Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System.

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

Access to Direct-Acting Antiviral Treatment for Hepatitis C Virus Among Veterans With Serious Mental Illness.

OBJECTIVE: This study examined whether serious mental illness is associated with initiating and with completing sofosbuvir-based treatment for hepatitis C virus (HCV) among veterans who started treatment after the Veterans Health Administration (VHA) received expanded funding for HCV care. METHODS: Administrative health care data from fiscal years 2016-2017 revealed 4,288 treatment-naïve patients with HCV, of whom 1,311 had initiated sofosbuvir-based treatment. Dependent variables were initiation and completion of ≥8 weeks of sofosbuvir treatment. Associations with serious mental illness were estimated with adjusted odds ratios from multivariable logistic regression analyses. RESULTS: No statistically significant differences were found in the proportion of veterans with and veterans without serious mental illness who initiated (p=0.628) or completed ≥8 weeks (p=0.301) of sofosbuvir treatment. CONCLUSIONS: Veterans with and without serious mental illness initiated and completed sofosbuvir treatment at similar rates. The VA should continue to provide equitable access to HCV treatments and support medication adherence.

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer-prescriber communication patterns.

OBJECTIVE: The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample. METHODS: Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns. RESULTS: The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction. CONCLUSIONS: Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation. PRACTICE IMPLICATIONS: Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Glucose control and medication adherence among veterans with diabetes and serious mental illness: does collocation of primary care and mental health care matter?

OBJECTIVE: Persons with serious mental illness (SMI) may benefit from collocation of medical and mental health healthcare professionals and services in attending to their chronic comorbid medical conditions. We evaluated and compared glucose control and diabetes medication adherence among patients with SMI who received collocated care to those not receiving collocated care (which we call usual care). RESEARCH DESIGN AND METHODS: We performed a cross-sectional, observational cohort study of 363 veteran patients with type 2 diabetes and SMI who received care from one of three Veterans Affairs medical facilities: two sites that provided both collocated and usual care and one site that provided only usual care. Through a survey, laboratory tests, and medical records, we assessed patient characteristics, glucose control as measured by a current HbA1c, and adherence to diabetes medication as measured by the medication possession ration (MPR) and self-report. RESULTS: In the sample, the mean HbA1c was 7.4% (57 mmol/mol), the mean MPR was 80%, and 51% reported perfect adherence to their diabetes medications. In both unadjusted and adjusted analyses, there were no differences in glucose control and medication adherence by collocation of care. Patients seen in collocated care tended to have better HbA1c levels (ß = -0.149; P = 0.393) and MPR values (ß = 0.34; P = 0.132) and worse self-reported adherence (odds ratio 0.71; P = 0.143), but these were not statistically significant. CONCLUSIONS: In a population of veterans with comorbid diabetes and SMI, patients on average had good glucose control and medication adherence regardless of where they received primary care.

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D.

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Predictors of mortality in patients with serious mental illness and co-occurring type 2 diabetes.

Persons with serious mental illness (SMI) have higher rates of chronic medical conditions such as type 2 diabetes and mortality than the general population. We assessed demographic and health related factors in the prediction of all-cause mortality among SMI patients with diabetes and a comparison group of diabetic patients without SMI. From 1999 to 2002, 201 patients with type 2 diabetes and SMI were recruited from community mental health centers and 99 persons with type 2 diabetes and no identified mental illness were recruited from nearby primary clinics. Deaths over an average seven-year period after baseline assessment were identified using the Social Security Administration's Death Master File. Twenty-one percent in each group died over follow-up. Age, smoking status, duration of diabetes, and diabetes-related hospitalization in the 6months prior to baseline assessment predicted mortality in all patients. Among the non-SMI patients, those who were prescribed insulin had over a four-fold greater odds of mortality whereas this association was not found in the SMI patients. Diabetes likely contributes to mortality in persons with SMI. Providers need to be especially vigilant regarding mortality risk when patients require hospitalization for diabetes and as their patients age. Smoking cessation should also be aggressively promoted.

Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: a review of the literature.

Disengagement from mental health services can lead to devastating consequences for individuals with schizophrenia and other serious mental illnesses who require ongoing treatment. We review the extent and correlates of dropping out of mental health treatment for individuals with schizophrenia and suggest strategies for facilitating treatment engagement. Although rates vary across studies, reviews of the literature suggest that up to one-third of individuals with serious mental illnesses who have had some contact with the mental health service system disengage from care. Younger age, male gender, ethnic minority background, and low social functioning have been consistently associated with disengagement from mental health treatment. Individuals with co-occurring psychiatric and substance use disorders, as well as those with early-onset psychosis, are at particularly high risk of treatment dropout. Engagement strategies should specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Interventions to enhance engagement in mental health treatment range from low-intensity interventions, such as appointment reminders, to high-intensity interventions, such as assertive community treatment. Disengagement from treatment may reflect the consumer's perspective that treatment is not necessary, is not meeting their needs, or is not being provided in a collaborative manner. An emerging literature on patient-centered care and shared decision making in psychiatry provides suggestive evidence that efforts to enhance client-centered communication and promote individuals' active involvement in mental health treatment decisions can also improve engagement in treatment.

Quality of life in individuals with serious mental illness and type 2 diabetes.

Diabetes is a pervasive metabolic disease that disproportionately affects persons with serious mental illness. The authors studied the effect of diabetes on quality of life in a sample of 369 adult outpatients with schizophrenia or major mood disorder, 201 of whom had type 2 diabetes. Patients with diabetes reported greater impairment in both physical and mental-health quality of life than those without diabetes. The diabetes patients also reported less satisfaction with health but not with other life domains. Medical providers need to be attentive to the burden of disease experienced by patients with both serious mental illness and diabetes.

Quality of diabetes care among adults with serious mental illness.

OBJECTIVE: The study compared the quality of care for type 2 diabetes delivered to two groups with type 2 diabetes--adults with serious mental illness and those with no serious mental illness--in a range of community-based clinic settings. METHODS: Cross-sectional analyses of medical chart data from 300 patients (201 with serious mental illness and 99 without serious mental illness) were used to examine indicators of the quality of care established by the Diabetes Quality Improvement Project. Recommended services assessed included glycosylated hemoglobin examination, eye and foot examinations, blood pressure check, and urine and lipid profiles. Self-report data were used to compare receipt of provider-delivered diabetes education and receipt of cues regarding self-management of diabetes for the two study groups. RESULTS: Evidence of lower quality of diabetes care was found for persons with serious mental illness as reflected by their receipt of fewer recommended services and less education about diabetes, compared with those without serious mental illness. Although participants with serious mental illness were less likely to receive cues from providers regarding the need for glucose self-monitoring, they were as likely as those without serious mental illness to receive cues regarding diet and medication adherence. CONCLUSIONS: Although participants with serious mental illness received some services that are indicated in quality-of-care standards for diabetes, they were less likely to receive the full complement of recommended services and care support, suggesting that more effort may be required to provide optimal diabetes care to these vulnerable patients.

Clozapine utilization and outcomes by race in a public mental health system: 1994-2000.

OBJECTIVE: This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing. METHOD: Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database. RESULTS: A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041). CONCLUSION: Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.

An assessment of the independent effects of olanzapine and risperidone exposure on the risk of hyperlipidemia in schizophrenic patients.

BACKGROUND: The newer antipsychotic agents exhibit a superior safety profile compared with conventional antipsychotic agents in terms of extrapyramidal symptoms. Previous studies have suggested an association between olanzapine treatment and hyperlipidemia. We evaluated this association using a large health care database. METHODS: The study was derived from the England and Wales-based General Practice Research Database, composed of 3.5 million subjects followed up between June 1, 1987, and September 24, 2000. A total of 18 309 individuals diagnosed as having schizophrenia were identified. A 6:1 matched nested case-control design was used. Conditional logistic regression was used to derive adjusted odds ratios (ORs), controlling for sex, age, and other medications and disease conditions influencing lipid levels. Antipsychotic drug exposure was defined as the receipt of at least 1 prescription for an antipsychotic medication within the 3 months before the date of diagnosis of hyperlipidemia. RESULTS: There were 1268 incident cases of hyperlipidemia in the cohort, matched to 7598 control subjects. Olanzapine use was associated with nearly a 5-fold increase in the odds of developing hyperlipidemia compared with no antipsychotic exposure (OR, 4.65; 95% confidence interval [CI], 2.44-8.85) (P<.001) and more than a 3-fold increase compared with those receiving conventional agents (OR, 3.36; 95% CI, 1.77-6.39) (P<.001). Risperidone was not associated with increased odds of hyperlipidemia compared with no antipsychotic exposure (OR, 1.12; 95% CI, 0.60-2.11) (P =.72) or conventional antipsychotic exposure (OR, 0.81; 95% CI, 0.44-1.52) (P =.52). CONCLUSIONS: We observed a strong association between olanzapine exposure and hyperlipidemia in schizophrenic patients. The possible metabolic consequences of olanzapine use should be given serious consideration by treating physicians.

Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study.

OBJECTIVE: To quantify the association between olanzapine and diabetes. DESIGN: Population based nested case-control study. SETTING: United Kingdom based General Practice Research Database comprising 3.5 million patients followed between 1987 and 2000. PARTICIPANTS: 19 637 patients who had been diagnosed as having and treated for schizophrenia. 451 incident cases of diabetes were matched with 2696 controls. MAIN OUTCOME MEASURES: Diagnosis and treatment of diabetes. RESULTS: Patients taking olanzapine had a significantly increased risk of developing diabetes than non-users of antipsychotics (odds ratio 5.8, 95% confidence interval 2.0 to 16.7) and those taking conventional antipsychotics (4.2, 1.5 to 12.2). Patients taking risperidone had a non-significant increased risk of developing diabetes than non-users of antipsychotics (2.2, 0.9 to 5.2) and those taking conventional antipsychotics (1.6, 0.7 to 3.8). CONCLUSION: Olanzapine is associated with a clinically important and significant increased risk of diabetes.