Long-Term Follow-Up of a Randomized Trial of Supported Employment for SSDI Beneficiaries With Mental Illness.

OBJECTIVE: In this study, the authors assessed the long-term impact of the Mental Health Treatment Study (MHTS), a randomized controlled trial testing the effects of providing 2 years of employment services based on the evidence-based individualized placement and support model to Social Security Disability Insurance (SSDI) recipients with serious mental illness. Treatment recipients also received systematic medication management, supplemental health care supports, and short-term relief from medical continuing disability review by the Social Security Administration (SSA). METHODS: MHTS site data for 2,160 participants were linked to SSA administrative data from 2011 to 2015, 1 to 5 years after the original study concluded. Univariate and multivariate models were used to assess the MHTS effects on employment, earnings, and disability benefit suspension-termination up to 7 years after services ended. RESULTS: The analyses showed that the treatment group was more likely than the control group to work, and average earnings among the treatment group increased more over time than earnings among the control group. Disability benefit suspension/termination did not differ between groups. CONCLUSIONS: Providing the demonstration's package of services and support to SSDI beneficiaries with psychiatric disabilities for up to 2 years may have a long-term impact on employment and earnings. Under the SSDI program as currently structured, however, even after receiving 2 years of evidence-based supported employment and high-quality mental health services, SSDI beneficiaries with psychiatric conditions are unlikely to achieve economic independence within 5 years.

Incentivizing healthy lifestyle behaviors to reduce cardiovascular risk in people with serious mental illness: An equipoise randomized controlled trial of the wellness incentives program.

BACKGROUND: Medicaid recipients with serious mental illness die 25-30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers). METHODS: Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months. DISCUSSION: New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation.

Use of Academic Detailing With Audit and Feedback to Improve Antipsychotic Pharmacotherapy.

OBJECTIVE: Second-generation antipsychotics vary in their propensity to cause serious cardiometabolic side effects. In addition, use of two or more antipsychotics (polypharmacy) may lead to additive side effects and has not been shown to be consistently more effective than monotherapy. This study examined the use of academic detailing with audit and feedback to improve antipsychotic prescribing practices, including antipsychotic polypharmacy and utilization of medication with high or low risk of cardiometabolic side effects ("high risk" or "low risk," respectively). METHODS: Four intervention sessions were provided over two years to psychiatric care providers at community mental health centers. Segmented regression within the general estimating equation model framework used Medicaid pharmacy claims to examine prescribing patterns before and after the intervention among all beneficiaries (67,721 person-months) over a five-year period. RESULTS: After the intervention, 10.9% of beneficiaries with antipsychotic claims were on polypharmacy, compared with 13.1% before the invention. Use of high-risk and low-risk antipsychotics did not change. The final adjusted polypharmacy model showed that antipsychotic polypharmacy decreased among young adults and adults ages 40 or older compared with beneficiaries ages 30-39 (ß=-.02, p=.04, and ß=-.02, p=.007, respectively). The raw proportion of beneficiaries on high- and low-risk agents did not change, although final adjusted models demonstrated changes in use of high- and low-risk agents by diagnosis and risk group. CONCLUSIONS: Polypharmacy decreased among young and older adults after academic detailing with audit and feedback. Although further research is needed, this low-intensity intervention may help mental health systems reduce antipsychotic polypharmacy.

Cognitive Predictors of Work Among Social Security Disability Insurance Beneficiaries With Psychiatric Disorders Enrolled in IPS Supported Employment.

BACKGROUND: Impaired cognitive functioning is a significant predictor of work dysfunction in schizophrenia. Less is known, however about relationships of cognition and work in people with less severe disorders with relatively normal cognitive functioning. METHODS: This secondary analysis evaluated cognitive predictors of work in Social Security Disability Insurance (SSDI) beneficiaries with a recent work history who were randomized to receive mental health services, supported employment, and freedom from work disincentives over a 2-year study period in the Mental Health Treatment Study. Of the 1045 participants randomized to the treatment package, 945 (90.4%) received a cognitive assessment at study entry. Competitive work activity was evaluated using a computer-assisted timeline follow-back calendar at baseline and quarterly for 24 months. RESULTS: Mood disorders were the most common psychiatric diagnoses (64.9%), followed by schizophrenia or schizoaffective disorder (35.1%). Tobit regression analyses predicting the average number of hours worked per week, controlling for demographic characteristics, diagnosis, and work history indicated that the cognitive composite score (P < .01) and verbal learning subscale scores (P < .001) were associated with fewer hours of weekly work over the study period. CONCLUSIONS: Cognitive functioning predicted work over 2 years in SSDI beneficiaries with mood or schizophrenia-spectrum disorders who were receiving supported employment and mental health interventions, despite a relative absence of cognitive impairment in the study participants. The findings suggest cognitive functioning contributes to competitive work outcomes in persons with psychiatric disorders who have relatively unimpaired cognitive abilities, even under optimal conditions of treatment and vocational support.

Using a Learning Collaborative Strategy With Office-based Practices to Increase Access and Improve Quality of Care for Patients With Opioid Use Disorders.

OBJECTIVES: Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont. METHODS: We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology. RESULTS: Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%). CONCLUSIONS: Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers.

INTRODUCTION: Smoking cessation pharmacotherapy is underutilized by people with mental illnesses, who smoke at high rates and die prematurely of smoking-related diseases. Educational outreach can improve prescribing, but distances impede widespread use of this practice. Little research has assessed whether videoconference can effectively deliver educational outreach. We conducted a randomized, controlled trial of in-person versus videoconference educational outreach for smoking cessation pharmacotherapy across a state mental health system. METHODS: We randomly assigned clinics to receive in-person or videoconference educational outreach with audit and feedback for cessation pharmacotherapy. Prescribers completed brief questionnaires before and after the intervention. With segmented regression analysis of interrupted time series, we evaluated prescribing trends in Medicaid pharmacy claims for nicotine replacement therapy (NRT) and varenicline, with interaction terms for the effect of intervention type (in-person vs. videoconference). RESULTS: With interaction terms in the model, filled NRT prescriptions increased after the intervention compared to before (p < .01). The pattern of fills after the intervention were different at centers receiving in-person compared to videoconference educational outreach (p < .02) without clearly favoring one over the other. Additionally, filled varenicline prescriptions increased after the intervention compared to before (p = .04), but type of intervention delivery did not influence varenicline fills. Prescriber satisfaction with the educational intervention was high and prescriber attitudes became more positive in both groups. CONCLUSION: This study suggests that single session educational outreach with audit and feedback can increase cessation pharmacotherapy utilization, and that videoconference delivery could be an effective, scalable approach to improve workforce capacity in systems serving mentally ill smokers.

Next-generation psychiatric assessment: Using smartphone sensors to monitor behavior and mental health.

OBJECTIVE: Optimal mental health care is dependent upon sensitive and early detection of mental health problems. We have introduced a state-of-the-art method for the current study for remote behavioral monitoring that transports assessment out of the clinic and into the environments in which individuals negotiate their daily lives. The objective of this study was to examine whether the information captured with multimodal smartphone sensors can serve as behavioral markers for one's mental health. We hypothesized that (a) unobtrusively collected smartphone sensor data would be associated with individuals' daily levels of stress, and (b) sensor data would be associated with changes in depression, stress, and subjective loneliness over time. METHOD: A total of 47 young adults (age range: 19-30 years) were recruited for the study. Individuals were enrolled as a single cohort and participated in the study over a 10-week period. Participants were provided with smartphones embedded with a range of sensors and software that enabled continuous tracking of their geospatial activity (using the Global Positioning System and wireless fidelity), kinesthetic activity (using multiaxial accelerometers), sleep duration (modeled using device-usage data, accelerometer inferences, ambient sound features, and ambient light levels), and time spent proximal to human speech (i.e., speech duration using microphone and speech detection algorithms). Participants completed daily ratings of stress, as well as pre- and postmeasures of depression (Patient Health Questionnaire-9; Spitzer, Kroenke, & Williams, 1999), stress (Perceived Stress Scale; Cohen et al., 1983), and loneliness (Revised UCLA Loneliness Scale; Russell, Peplau, & Cutrona, 1980). RESULTS: Mixed-effects linear modeling showed that sensor-derived geospatial activity (p < .05), sleep duration (p < .05), and variability in geospatial activity (p < .05), were associated with daily stress levels. Penalized functional regression showed associations between changes in depression and sensor-derived speech duration (p < .05), geospatial activity (p < .05), and sleep duration (p < .05). Changes in loneliness were associated with sensor-derived kinesthetic activity (p < .01). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Smartphones can be harnessed as instruments for unobtrusive monitoring of several behavioral indicators of mental health. Creative leveraging of smartphone sensing could provide novel opportunities for close-to-invisible psychiatric assessment at a scale and efficiency that far exceeds what is currently feasible with existing assessment technologies.

Antipsychotic Cardiometabolic Side Effect Monitoring in a State Community Mental Health System.

Antipsychotic medications can cause serious cardiometabolic side effects. No recent research has broadly evaluated monitoring and strategies to improve monitoring in U.S. public mental health systems. To address this knowledge gap, we evaluated education with audit and feedback to leaders to improve cardiometabolic monitoring in a state mental health system. We used Chi square statistics and logistic regressions to explore changes in monitoring recorded in randomly sampled records over 2 years. In 2009, assessment of patients on antipsychotics was 29.6 % for cholesterol, 40.4 % for glucose, 29.1 % for triglycerides, 54.3 % for weight, 33.6 % for blood pressure, and 5.7 % for abdominal girth. In 2010, four of ten mental health centers improved their rate of adult laboratory monitoring. Overall monitoring in the state did not increase. Education for prescribers with audit and feedback to leaders can improve monitoring in some settings, but more intensive and/or prolonged interventions may be required.

Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems.

Despite increased awareness of the benefits of integrated services for persons with co-occurring substance use and psychiatric disorders, estimates of the availability of integrated services vary widely. The present study utilized standardized measures of program capacity to address co-occurring disorders, the dual diagnosis capability in addiction treatment and dual diagnosis capability in mental health treatment indexes, and sampled 256 programs across the United States. Approximately 18 % of addiction treatment and 9 % of mental health programs met criteria for dual diagnosis capable services. This is the first report on public access to integrated services using objective measures.

Organizational capacity to address co-occurring substance use and psychiatric disorders: assessing variation by level of care.

OBJECTIVES: There is widespread recognition that services to persons with co-occurring substance use and psychiatric disorders should be accessible, yet most persons with these disorders do not receive care for both problems. Estimates of available services vary widely and have not examined potential variation by level of care. METHODS: The present study samples 180 community addiction treatment programs and utilizes a standardized observational assessment of these programs using the dual diagnosis capability of addiction treatment (DDCAT) index. By level of care, the sample consisted of 53 outpatient programs, 50 intensive outpatient programs, and 77 residential programs. RESULTS: Overall, approximately 81.1% of programs across levels of care offered addiction-only services, 18.3% dual diagnosis capable services, and less than 1% dual diagnosis enhanced services. Relative to residential and intensive outpatient programs, outpatient programs were more likely to have greater dual diagnosis capability (dual diagnosis capable services). Outpatient programs scored significantly higher on the DDCAT dimensions associated with program policies and continuity of care. Specific DDCAT benchmark items revealing detailed differences were found in these dimensions and specific assessment and treatment practices. Access to physician-prescriber or to psychotropic medications did not differ by level of care. CONCLUSIONS: The findings suggest that across levels of care, addiction-treatment systems and programs must continue to improve capacity for patients with co-occurring disorders. The application of a standardized, objective, and observational instrument may be useful to guide and measure the effectiveness of these efforts.

Client predictors of employment outcomes in high-fidelity supported employment: a regression analysis.

Research on vocational rehabilitation for clients with severe mental illness over the past 2 decades has yielded inconsistent findings regarding client factors statistically related to employment. The present study aimed to elucidate the relationship between baseline client characteristics and competitive employment outcomes-job acquisition and total weeks worked during an 18-month follow-up-in Individual Placement and Support (IPS). Data from 4 recent randomized controlled trials of IPS were aggregated for within-group regression analyses. In the IPS sample (N = 307), work history was the only significant predictor for job acquisition, but receiving Supplemental Security Income-with or without Social Security Disability Insurance-was associated with fewer total weeks worked (2.0%-2.8% of the variance). In the comparison sample (N = 374), clients with a diagnosis of mood disorder or with less severe thought disorder symptoms were more likely to obtain competitive employment. The findings confirm that clients with severe mental illness interested in competitive work best benefit from high-fidelity supported employment regardless of their work history and sociodemographic and clinical background, and highlight the needs for changes in federal policies for disability income support and insurance regulations.

The long-term impact of employment on mental health service use and costs for persons with severe mental illness.

OBJECTIVE: Stable employment promotes recovery for persons with severe mental illness by enhancing income and quality of life, but its impact on mental health costs has been unclear. This study examined service cost over ten years among participants in a co-occurring disorders study. METHODS: Latent-class growth analysis of competitive employment identified trajectory groups. The authors calculated annual costs of outpatient services and institutional stays for 187 participants and examined group differences in ten-year utilization and cost. RESULTS: A steady-work group (N=51) included individuals whose work hours increased rapidly and then stabilized to average 5,060 hours per person over ten years. A late-work group (N=57) and a no-work group (N=79) did not differ significantly in utilization or cost outcomes, so they were combined into a minimum-work group (N=136). More education, a bipolar disorder diagnosis (versus schizophrenia or schizoaffective disorder), work in the past year, and lower scores on the expanded Brief Psychiatric Rating Scale predicted membership in the steady-work group. These variables were controlled for in the outcomes analysis. Use of outpatient services for the steady-work group declined at a significantly greater rate than it did for the minimum-work group, while institutional (hospital, jail, or prison) stays declined for both groups without a significant difference. The average cost per participant for outpatient services and institutional stays for the minimum-work group exceeded that of the steady-work group by $166,350 over ten years. CONCLUSIONS: Highly significant reductions in service use were associated with steady employment. Given supported employment's well-established contributions to recovery, evidence of long-term reductions in the cost of mental health services should lead policy makers and insurers to promote wider implementation.

Increased risk of nursing home admission among middle aged and older adults with schizophrenia.

OBJECTIVE: Cross-sectional data indicate that persons with serious mental illness have increased risk of institution-based care, yet little is known about the long-term course of nursing home placement for persons with schizophrenia. This study describes nursing home entrance over a 10-year period among community residing Medicaid enrollees with schizophrenia compared with Medicaid enrollees with no mental illness. METHODS: The authors analyzed claims of 7,937 New Hampshire Medicaid beneficiaries aged 40 and older. Claims were followed annually from 1996 to 2005 to determine nursing home admission. Schizophrenia was identified from International Classification of Diseases: 9th Edition codes and used to model nursing home admission controlling for medical severity, physical disability, sex, and age. Cox proportional hazard models were run for the entire sample and then separately for middle-aged (40-64 years) and older-aged (65 years and older) subgroups. RESULTS: Persons with schizophrenia enter nursing homes earlier (median age 65) than persons with no mental illness (median age: 80). The greatest relative disparity occurs at middle age (40-64 years), where nursing home admission risk was 3.90 (95% confidence interval = 2.86-5.31) times greater for persons with schizophrenia than for persons with no mental illness. CONCLUSIONS: Middle-aged persons with schizophrenia have almost four times greater likelihood of early institutionalization in nursing homes compared with their same age peers with no mental illness. Efforts to prevent/reduce unwarranted nursing home admission among persons with schizophrenia should focus on health status in the fifth decade of life.

Can SSDI and SSI beneficiaries with mental illness benefit from evidence-based supported employment?

OBJECTIVE: Individuals with psychiatric disabilities are the fastest-growing subgroup of Social Security Administration disability beneficiaries and have negligible rates of return to competitive employment. Nevertheless, a new approach to vocational rehabilitation, termed supported employment, has increased the optimism regarding employment for this population. METHODS: Aggregating data from four randomized controlled trials of evidence-based supported employment for persons with severe mental illness, the investigators compared 546 Social Security Administration disability beneficiaries with 131 nonbeneficiaries. Three employment measures were examined: job acquisition, weeks worked, and job tenure. RESULTS: Beneficiaries receiving supported employment had better employment outcomes than those receiving other vocational services. Similar results were found for nonbeneficiaries. Overall, nonbeneficiaries had better employment outcomes than beneficiaries. However, the effect sizes measuring the improved outcomes with supported employment were similar for beneficiaries (d=.52-1.10) and nonbeneficiaries (d=.78-.89). CONCLUSIONS: Evidence-based supported employment could enable many Social Security Administration beneficiaries with psychiatric disabilities to attain competitive employment even though receipt of disability benefits operates as a barrier to employment.

Effect of benefits counseling services on employment outcomes for people with psychiatric disabilities.

OBJECTIVE: This study examined the impact of specialized benefits counseling services on levels of competitive employment for people with psychiatric disabilities receiving Social Security Administration (SSA) disability benefits in Vermont. METHODS: Beneficiaries who had a psychiatric disability and who received specialized benefits counseling (N = 364) were compared with matched contemporaneous and historical control participants over four years, two years before and two years after the initiation of the intervention. Study participants were consumers of vocational rehabilitation services, and the outcome measure was quarterly earnings from state unemployment insurance program records. Benefits counseling included general education regarding SSA disability programs, the various work incentives available under those programs, and other federal and state public benefits; individualized research and counseling regarding enrollees' current benefits packages; assistance in managing benefits through the transition to employment; and provision of information to supporting professionals. RESULTS: Participants who received specialized benefits counseling achieved significantly greater improvements in earnings. The benefits counseling group increased its adjusted average earnings by 1,256 dollars per year in comparison with the two control groups. CONCLUSIONS: Specialized benefits counseling appears to be an important employment support for Social Security Administration disability beneficiaries who have psychiatric disabilities.

Improving mental health assessment and service planning practices for older adults: a controlled comparison study.

This study evaluated the effectiveness of a guided assessment and service planning intervention in improving the clinical practices of non-physician community mental health providers caring for older persons. Thirteen agencies, 44 clinicians, and 100 consumers (age 60 and older) were assigned to the intervention or a comparison group receiving usual care. Baseline interviews of clinicians and chart reviews found that clinicians' routine evaluation and service planning practices showed inattention to key domains such as substance abuse (over 33% of clinicians), suicide risk and dangerous behaviors (over 40%), and caregiver burden and risk of neglect or abuse (over 75%). At 1-year follow-up, the intervention was associated with increased rates of routine assessments of major symptom, functioning, and support domains. There was also significant improvement in the specificity of treatment planning within the intervention condition. Implications for quality improvement are discussed.

A method for analyzing longitudinal outcomes with many zeros.

Health care utilization and cost data have challenged analysts because they are often correlated over time, highly skewed, and clumped at 0. Traditional approaches do not address all these problems, and evaluators of mental health and substance abuse interventions often grapple with the problem of how to analyze these data in a way that accurately represents program impact. Recently, the traditional 2-part model has been extended to mixed-effects mixed-distribution model with correlated random effects to deal simultaneously with excess zeros, skewness, and correlated observations. We introduce and demonstrate this new method to mental health services researchers and evaluators by analyzing the data from a study of assertive community treatment (ACT). The response variable is the number of days of hospitalization, collected every 6 months over 3 years. The explanatory variable is group: ACT vs. standard case management. Diagnosis (schizophrenia vs. bipolar disorder), time, and the baseline values of hospital days are covariates. Results indicate that clients in the ACT group have a higher probability of hospital admission, but tend to have shorter lengths of stay. The mixed-distribution model provides greater specification of a model to fit these data and leads to more refined interpretation of the results.

Benzodiazepine prescription practices and substance abuse in persons with severe mental illness.

BACKGROUND: Benzodiazepines have many benefits for persons with severe mental disorders, but they may also lead to or exacerbate substance abuse. An American Psychiatric Association taskforce established practice guidelines in 1990 to assist physicians in managing these and other potential side effects of benzodiazepine use. The objectives of this study were to determine the prevalence of benzodiazepine use among persons with psychiatric disorders and to evaluate compliance with published prescribing guidelines. METHOD: We studied benzodiazepine use among New Hampshire Medicaid beneficiaries aged 18 to 64 years with ICD-9 diagnoses that were grouped under the headings "schizophrenia," "bipolar disorder," "major depression," and "other psychiatric disorders" from Jan. 1995 through Dec. 1999. Rates and length of use, frequency of high-potency/fast-acting prescriptions, and diazepam-equivalent dosages were compared for those with and without retrospectively determined evidence of substance abuse, substance dependence, or a procedure code indicating treatment for a substance use disorder (SUD). RESULTS: Five-year prevalence of benzodiazepine use for persons with and without SUD was 63% versus 54% for schizophrenia, 75% versus 58% for bipolar disorder, 66% versus 49% for major depression, and 48% versus 40% for other psychiatric disorders. Differences were statistically significant over 5 years and in 1999 (p <.0001). Among persons with major depression or other psychiatric disorders, those with comorbid SUD were more likely to use fast-acting/high-potency benzodiazepines; there were no such differences for those with schizophrenia or bipolar disorder. Persons with bipolar disorder or other psychiatric disorders and SUD received significantly higher diazepam-equivalent dosages than did those without SUD. CONCLUSION: Contrary to published guidelines, rates of benzodiazepine use are higher among Medicaid beneficiaries with severe mental illness and co-occurring SUD than among persons with severe mental illness alone. Additional research and possibly a reassessment of prescribing guidelines are recommended.

Electron paramagnetic resonance assessment of brain tissue oxygen tension in anesthetized rats.

UNLABELLED: The adequacy of cerebral tissue oxygenation (PtO(2)) is a central therapeutic end point in critically ill and anesthetized patients. Clinically, PtO(2) is currently measured indirectly, based on measurements of cerebrovascular oxygenation using near infrared spectroscopy and experimentally, using positron emission tomographic scanning. Recent developments in electron paramagnetic resonance (EPR) oximetry facilitate accurate, sensitive, and repeated measurements of PtO(2). EPR is similar to nuclear magnetic resonance but detects paramagnetic species. Because these species are not abundant in brain (or other tissues) in vivo, oxygen-responsive paramagnetic lithium phthalocyanine crystals implanted into the cerebral cortex are used for the measurement of oxygen. The line widths of the EPR spectra of these materials are linear functions of PtO(2). We used EPR oximetry in anesthetized rats to study the patterns of PtO(2) during exposure to various inhaled and injected general anesthetics and to varying levels of inspired oxygen. Rats anesthetized with 2.0 minimum alveolar anesthetic concentration isoflurane maintained the largest PtO(2) (38.0 +/- 4.5 mm Hg) and rats anesthetized with ketamine/xylazine had the smallest PtO(2) (3.5 +/- 0.3 mm Hg) at a fraction of inspired oxygen (FIO(2)) of 0.21, P < 0.05. The maximal PtO(2) achieved under ketamine/xylazine anesthesia with FIO(2) of 1.0 was 8.8 +/- 0.3 mm Hg, whereas PtO(2) measured during isoflurane anesthesia with FIO(2) of 1.0 was 56.3 +/- 1.7 mm Hg (P < 0.05). These data highlight the experimental utility of EPR in measuring PtO(2) during anesthesia and serve as a foundation for further study of PtO(2) in response to physiologic perturbations and therapeutic interventions directed at preventing cerebral ischemia. IMPLICATIONS: Using in vivo electron paramagnetic resonance oximetry, we studied the patterns of cerebral tissue oxygenation (PtO(2)) during exposure to various inhaled and injected general anesthetics, and to varying levels of inspired oxygen. These data show that inhaled anesthetics result in larger levels of PtO(2) in the brain than do several injectable anesthetics. The results highlight the experimental utility of electron paramagnetic resonance in measuring PtO(2) during anesthesia and serve as a foundation for further study of PtO(2) in response to physiologic perturbations and therapeutic interventions directed at preventing cerebral ischemia.

Substitution between Formal and Informal Care for Persons with Severe Mental Illness and Substance Use Disorders.

BACKGROUND: Persons with severe mental illness (SMI) often get extensive informal care from family members and friends as well as substantial amounts of formal treatment from paid professionals. Both sources of care are well documented, but very little is known about how one affects the other. AIMS OF THE STUDY: This analysis estimates the extent of substitution between direct care provided by family and friends and formal treatment for people with severe mental illness and substance use disorders. Separate estimates are generated for short-term and long-term effects. METHODS: Data are from a randomized clinical trial conducted at seven mental health centers in New Hampshire between 1989 and 1995. The study includes detailed data for 193 persons with dual disorders measured at study entry and every six months for three years. Hours of informal care were compared with total treatment costs within each six-month period to measure short-term effects. Average amount of informal care over three years represented long-term caregiving practices. Measures of informal care are from interviews with informal caregivers. Treatment costs are based on combined data from management information systems, Medicaid claims, hospital records, and self reports. We used mixed effects repeated measures regression to estimate longitudinal effects and a multiple imputation technique to test the sensitivity of results to missing data. RESULTS: In the short-term, persons with bipolar disorder used significantly more formal care as informal care increased (complementarity). The relationship between short-term informal and formal care was significantly weaker for persons with schizophrenia. For both diagnostic groups there was a long-term substitution effect; a 4-6% increase in informal care hours was associated with an approximate 1% decrease in formal care costs. DISCUSSION: Although they must be confirmed by further research, these findings suggest that there is a significant and strong relationship between care given by family and friends and that supplied by formal treatment providers. The analysis indicates that the short-term relationship between informal care and formal treatment tends to be complementary, but differs according to diagnosis. Long-term effects, which are possibly related to changing role perceptions, show substitution between the two forms of care. Missing data for family care hours in some time periods was a concern in this study. However, the consistency in results between the analyses that used imputed data and the model using only original data increase our confidence in the findings. Although there may be some endogeneity between formal and informal care in other treatment settings we believe the unique characteristics of the service-rich environment in which this study was conducted limit that concern here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The amount of care provided by informal caregivers has a significant impact on formal treatment costs. Models of care that explicitly acknowledge the interplay between the two types of care are needed to ensure efficient combinations of formal and informal care. IMPLICATIONS FOR HEALTH POLICY FORMULATION: How to best to encourage informal support, without overburdening caregivers, is a key challenge facing policy makers and providers of mental health services. The merits of various approaches to reducing caregiver burden is a subject that needs more attention from researchers. In the interim, the demands on informal caregivers may mount as efforts to reduce health care spending continue. IMPLICATIONS FOR FURTHER RESEARCH: Informal care is not often included in economic evaluations of mental health treatment. Although additional research is needed to understand better the mechanisms by which informal care and formal treatment are related, we believe our results offer a strong argument for including measures of informal care in future economic evaluations.