Serious mental illness and risk of new HIV/AIDS diagnoses: an analysis of Medicaid beneficiaries in eight states.

OBJECTIVE: A longitudinal analysis was used to explore the relationship between diagnosis of serious mental illness and subsequent new diagnoses of HIV. METHODS: Logistic regression was used to predict HIV/AIDS diagnoses in 2002­2004 among Medicaid beneficiaries in eight states (N=6,417,676) who were without HIV in 2001. Results for beneficiaries with and without serious mental illness, a substance use disorder, and psychiatric comorbidities in 2001 were compared. RESULTS: After controlling for substance abuse or dependence and other factors, the analyses indicated that the odds of new HIV/AIDS diagnoses among beneficiaries with or without serious mental illness did not differ significantly. Compared with beneficiaries without a substance use disorder or serious mental illness, individuals with a substance use disorder but without serious mental illness were 3.1 times (OR=3.13, p<.001) more likely, and those with both substance abuse or dependence and serious mental illness were 2.1 times (OR=2.09, p<.001) more likely, to receive a new HIV diagnosis in 2002­2004. However, people with serious mental illness but without a substance use disorder in 2001 were 23% less likely (OR=.77, p<.001) than people without serious mental illness or a substance use disorder in 2001 to receive a new HIV diagnosis. CONCLUSIONS: After substance abuse or dependence was controlled for longitudinally, little independent association between serious mental illness and the risk of new HIV diagnoses was found. HIV-prevention services for low-income individuals should be delivered to all persons with serious mental illness, but especially those with comorbid substance use disorders.

Substance abuse and hospitalization for mood disorder among Medicaid beneficiaries.

OBJECTIVES: We compared the influence of substance abuse with that of other comorbidities (e.g., anxiety, HIV) among people with mood disorder (N=129,524) to explore risk factors for psychiatric hospitalization and early readmission within 3 months of discharge. METHODS: After linking Medicaid claims data in 5 states (California, Florida, New Jersey, New York, and Texas) to community-level information, we used logistic and Cox regression to examine hospitalization risk factors. RESULTS: Twenty-four percent of beneficiaries with mood disorder were hospitalized. Of these, 24% were rehospitalized after discharge. Those with comorbid substance abuse accounted for 36% of all baseline hospitalizations and half of all readmissions. CONCLUSIONS: Results highlight the need for increased and sustained funding for the treatment of comorbid substance abuse and mood disorder, and for enhanced partnership between mental health and substance abuse professionals.

Psychiatric rehospitalization among elderly persons in the United States.

OBJECTIVE: This study examined predictors of psychiatric rehospitalization among elderly persons. METHODS: Readmission within six months of an index hospitalization was modeled by using Medicare data on all hospitalizations with a primary psychiatric diagnosis in the first half of 2002 (N=41,839). Data were linked with state and community-level information from the U.S. census. RESULTS: Twenty-two percent of beneficiaries were rehospitalized for psychiatric reasons within six months of discharge. After the analyses adjusted for sociodemographic factors, readmission was most likely among persons with a primary diagnosis of schizophrenia (hazard ratio [HR]=2.63), followed by bipolar disorder (HR=2.51), depression (HR=1.75), and substance abuse (HR=1.38) (reference group was "other" psychiatric conditions). A baseline hospital stay of five or more days for an affective disorder was associated with a reduced readmission hazard (HR=.68, relative to shorter stays), yet the opposite was true for a nonaffective disorder (HR=1.26). For persons with nonaffective disorders, an elevated hazard of readmission was associated with comorbid alcohol dependence (HR=1.32), panic disorder (HR=1.76), borderline personality disorder (HR=2.33), and drug dependence (HR=1.17). However, for persons with affective disorders, having a personality disorder other than borderline personality disorder or dependent personality disorder (HR=1.27) and having an "other" anxiety disorder (HR=1.15) were significantly associated with an increased risk of rehospitalization. Obsessive-compulsive disorder increased the readmission hazard in both groups. CONCLUSIONS: Readmission risk factors may differ for affective disorders and nonaffective disorders. Very short hospitalizations were associated with increased risk of rehospitalization among persons with an affective disorder, which underscores the need for adequate stabilization of this group of patients during hospitalization. Results also highlight the specific types of comorbidities associated most strongly with rehospitalization risk.

Hospitalization for psychiatric illness among community-dwelling elderly persons in 1992 and 2002.

OBJECTIVE: The authors evaluated the evolution of inpatient care for psychiatric illness in 1992 and 2002 for senior community-dwelling Medicare beneficiaries. METHODS: National Medicare Provider Analysis and Review files for 1992 and 2002 were analyzed. RESULTS: From 1992 to 2002, rates of inpatient hospital use for treatment of psychiatric illness declined 28%, from 429 to 311 stays per 100,000 eligible beneficiaries, mostly because of reduced hospitalization for depression, and next, for substance use disorder. Inpatient care patterns for patients with schizophrenia and bipolar disorder changed little. Although stays were shorter in 2002 in general, rehospitalization rates remained the same in 2002 as they were in 1992. CONCLUSION: Trends in hospitalizations differed by diagnoses, which may be representative of general changes in treatment philosophy during the 1990s.

Medicare inpatient treatment for elderly non-dementia psychiatric illnesses 1992--2002; length of stay and expenditures by facility type.

We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.

Promoting consumer empowerment through entrepreneurship: a proposal.

In order to promote life control, this proposal suggests strategies to help people who use community mental health services to access small loans or "microcredit" for entrepreneurship in self-help groups.

Incarceration and hospital care.

Risk for jail or prison recidivism is well documented among incarcerated individuals with schizophrenia. However, it is less clear that risk is also high for psychiatric hospital readmission after accounting for mediating influences such as psychopathology severity, functioning level, substance misuse, and demographic characteristics. Relative to counterparts without prior time in jail, this study therefore assessed whether formerly incarcerated individuals with schizophrenia were more likely to repeatedly use hospital care after controlling for level of functioning and symptomatology. Among 315 inpatients, former inmates had a greater mean number of previous hospital stays than other patients (t = -2.13; df = 305; p = 0.03) and were more likely to visit the emergency room or be rehospitalized within 3 months of discharge (chi2 = 8.83; df = 1; p = 0.003). They were twice as likely to be readmitted, moreover, even after accounting in logistic regression for age, sex, race, global functioning, psychopathology severity, alcohol abuse or dependence, and drug abuse or dependence (OR = .49; CI = .26-.95). Implications for community care are discussed, and the suggestion is made that jail diversion programs should be renamed and refocused as "jail and hospital diversion."

Determinants of care satisfaction among inpatients with schizophrenia.

Satisfaction with inpatient psychiatry can promote positive treatment outcomes. Using information on 315 inpatients with schizophrenia, this study tested the hypothesis that some services promote more satisfaction than others. Relative to less satisfied counterparts, inpatients were more likely to approve of care if staff invested high levels of effort into education about: (1) control of symptoms with psychiatric medication, (2) adverse effects of stress on symptoms, and (3) social skills. Other services were appreciated less. In order to enhance intervention outcomes, the findings suggest that limited resources should be invested to a greater extent in practices that are valued most highly by patients.