Means of suicide among adults with schizophrenia across the life span.

BACKGROUND AND HYPOTHESES: Adults with schizophrenia have increased risk of suicide with highest risk among younger adults. We investigated whether means of suicide among these adults were different from the general population. STUDY DESIGN: This retrospective longitudinal analysis used the National Death Index to characterize means of suicide among 4 cohorts of Medicare patients with schizophrenia (2007-2016) by age: 18 to 34, 35 to 44, 45 to 54, and aged 55+ years. Means of suicide were categorized by age at death and sex. Adjusted hazard ratios were calculated for common means. Mortality rates per 100,000 person-years were estimated by age group stratified by sex, and standardized to the general population by age, sex, and race-ethnicity using standardized mortality ratios. STUDY RESULTS: 668,836 adults were included with 2218 suicide decedents: 1444 men and 774 women. The most common means of suicide was poisoning (36.8 %), with a significant sex difference by means: 55.9 % of women died by poisoning, 13.8 % by firearms, 11.0 % by hanging and 9.4 % by jumping, while among men suicide by poisoning (26.6 %), firearms (25.5 %), and hanging (24.2 %) were similar, followed by jumping (12.0 %). Suicide by poisoning among the schizophrenia cohort was 10 times that of the general population, while suicide by firearm was twice that of the general population. CONCLUSIONS: Means of suicide differed for patients with schizophrenia compared to the general population: poisoning was the most common means among men and women with schizophrenia, while firearms accounted for over half of all suicides in the general U.S.

Ethnoracial Variation in Risk for Psychotic Experiences.

BACKGROUND & HYPOTHESIS: Psychotic disorders are inequitably distributed by race in the United States, although it is not known whether this is due to assessment biases or inequitable distributions of risk factors. Psychotic experiences are subclinical hallucinations and delusions used to study the etiology of psychosis, which are based on self-report and therefore not subject to potential clinician biases. In this study, we test whether the prevalence of psychotic experiences (PE) varies by race and if this variance is explained by socioenvironmental risk factors. STUDY DESIGN: Data on demographics, PE, and socioenvironmental risk factors were collected through the National Survey of Poly-victimization and Mental Health, a national probability sample of US young adults. Logistic regression analyses were used to determine whether PE prevalence varied by race/ethnicity and, if so, whether this was attenuated with inclusion of indicators of income, education, urban/rural living, discrimination, and trauma exposure. STUDY RESULTS: Black and Hispanic respondents reported PE at significantly greater rates than White or "other" ethnoracial groups, with hallucinations more commonly reported by Hispanic respondents. PE were significantly associated with police violence exposure, discrimination, adverse childhood experiences, and educational attainment. These factors statistically explained ethnoracial differences in the likelihood of overall PE occurrence and of nearly all PE subtypes. CONCLUSIONS: Previously observed racial differences in psychosis extend beyond clinical schizophrenia, and therefore, are unlikely to be explained entirely by clinician biases. Instead, racial disparities in PE appear to be driven by features of structural racism, trauma, and discrimination.

Engagement of individuals with serious mental illness in outpatient mental health services and telehealth use during the COVID-19 pandemic.

Questions remain regarding whether the transition and continued use of telehealth was associated with changes in treatment engagement among patients with serious mental illness (SMI). Using NYS Medicaid claims, we identified 116,497 individuals with SMI receiving outpatient mental health services from September 1, 2019-February 28, 2021 and a comparison cohort of 101,995 from September 1, 2017-February 28, 2019 to account for unmeasured and seasonal variation. We characterized engagement in three 6-month increments (T0-T1-T2) using clinically meaningful measures of high, partial, low, and none. Subgroup differences were compared, and telehealth users were compared to those with only in-person visits. Engagement, as characterized, was largely maintained during COVID. The 19.0 % with only in-person visits during COVID had different characteristics than telehealth users. Telehealth use was greater among younger people by T2 (33.1 %), women (57.7 %), non-Hispanic White people (38.9 %), and those with MDD (18.0 %), but lower among non-Hispanic Black people, in NYC, and those with schizophrenia or SUD. Most telehealth users were highly engaged (77.1 %); most using only in-person services had low engagement (47.5 %). The shift to telehealth preserved access to many outpatient services for this SMI population. Exploring reasons for not using telehealth may identify opportunities to increase care access.

Variation in Psychotropic Medication Prescription for Adults With Schizophrenia in the United States.

OBJECTIVE: Variation in prescription of psychotropic medications to patients with schizophrenia spectrum disorders may underlie health inequities. Using a national U.S. Medicaid sample, the authors examined prescription patterns of psychotropic medications commonly used for managing schizophrenia. METHODS: Data from the 2011-2012 Medicaid Analytic eXtract were examined for demographic predictors of and variation across states in psychotropic medication prescription among adult patients diagnosed as having schizophrenia spectrum disorders (N=357,914). Percentages of patients in each state who filled prescriptions of at least 15 days of any antipsychotic, clozapine, antidepressant, benzodiazepine, mood stabilizer, or long-acting injectable (LAI) antipsychotic medication were determined after adjustment for demographic and clinical covariates. Multivariate regressions of clinical and demographic factors predicting prescription patterns were conducted. RESULTS: Prescribing patterns for all types of psychotropic medications varied across states. Clozapine and LAI prescriptions showed the most dramatic differences across states and among patients with different demographic characteristics. Across states, adjusted proportions of prescriptions ranged from 4% to 22% for LAIs and from 1% to 11% for clozapine. Non-Hispanic Blacks and people of other race-ethnicities were more likely than non-Hispanic Whites to fill prescriptions for LAIs, and non-Hispanic Whites were more likely than individuals from other racial-ethnic groups to fill prescriptions for clozapine and all other medications. CONCLUSIONS: Considerable variation in prescribing patterns of LAIs and clozapine by race-ethnicity and across states suggests uneven quality of care for individuals with schizophrenia spectrum disorders in the United States. A better understanding of what causes this variation could inform policy makers to improve treatment for this vulnerable population.

An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care.

Importance: Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis. Objective: To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis. Design, Setting, and Participants: This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis. Exposures: Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral). Main Outcomes and Measures: Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC. Results: The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group. Conclusions and Relevance: In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

Violence risk assessment for young adults receiving treatment for early psychosis.

AIM: Although the absolute risk of violence is small for individuals with mental illnesses, a specific subgroup of individuals who appear to be at increased risk for violence includes young people experiencing emerging or early psychosis. Prior research has identified risk factors for violence in this population, though no prior studies using a formal risk assessment tool have been identified. This study used the Historical Clinical Risk Management-20, version 3 (HCR-20) to identify risk of future violence among a sample of young adults with early psychosis and relevant predictors of risk unique to this population. METHODS: The HCR-20 was administered to a sample of young adults with early psychosis (N = 53) enrolled at one OnTrackNY site, part of a statewide program providing early intervention services to young adults presenting with a first episode of non-affective psychosis. A Confirmatory Factor Analysis (CFA) was conducted to explore the relative importance of the HCR-20 items for this population. RESULTS: The average age of participants was 21.9 years (SD 3.6 years) and most were male (69.8%, n = 37). Most patients were assessed to be at low risk for future violence based on the Case Prioritization summary risk rating (67.9%, n = 36). The CFA identified 4 items that were not of relative predictive value in identifying the risk of violence in this sample: history of substance use (item H5), history of major mental disorder (item H6), living situation (item R2), and personal support (item R3). CONCLUSION: This study presents a formal approach to assessing violence risk in a population at elevated risk of violence, demonstrates the feasibility of using a standardized risk assessment tool in early intervention services, and identifies factors of particular importance associated with predicting violence in this population. Future research should implement violence risk assessment with a structured tool such as the HCR-20 and assess its accuracy in predicting future violent behavior in this setting.

Association Between Psychotropic Medication Polypharmacy and an Objective Measure of Balance Impairment Among Middle-Aged Adults: Results from the US National Health and Nutrition Examination Survey.

OBJECTIVE: Psychotropic medications (e.g., antidepressants, anxiolytics, and neuroleptics) are increasingly prescribed with two or more taken concurrently (polypharmacy), and have been associated with an increased risk of falling. The aim of this study was to examine the association between psychotropic medication use and balance impairment using an objective balance measure. METHODS: We derived data from participants aged 40 years and older in the US National Health and Nutrition Examination Survey (1999/00-2003/04) who completed the Modified Clinical Trial of Sensory Interaction and Balance and indicated current medications (n = 3090). Balance impairment was defined as failing the Modified Clinical Trial of Sensory Interaction and Balance condition 4 (standing on foam surface, eyes closed). Medication use included specific psychotropic classes, a count of psychotropic medications, and a count of non-psychotropic medications taken concurrently. Nested multiple logistic regression assessed relationships between medication use and balance impairment, adjusting for covariates and complex sampling. RESULTS: One third of participants had balance impairment. After accounting for medical comorbidities, there was no relationship between individual classes of psychotropic medications and balance impairment. After adjusting for all covariates, there was a dose-response relationship between the number of psychotropic medications taken and balance impairment, with every additional medication associated with a 35% higher odds (odds ratio = 1.35; 95% confidence interval 1.07-1.70). In comparison, there was no increase in the odds of balance impairment associated with each additional medication taken for participants only taking non-psychotropic medications. CONCLUSIONS: Psychotropic medication polypharmacy is associated with an increased odds of balance impairment. Clinicians should exercise caution when prescribing combinations of psychotropic medications, and refer to physical therapy for assessment and treatment if balance impairment is detected.

Heterogeneity of Treatment Effects of Long-Acting Injectable Antipsychotic Medications.

OBJECTIVE: To investigate subgroup responses to long-acting injectable (LAI) medications haloperidol decanoate (HD) and paliperidone palmitate (PP) in a randomized controlled trial that found no difference between the treatments on the primary outcome of efficacy failure. METHODS: A Comparison of Long-Acting Injectable Medications for Schizophrenia (ACLAIMS) enrolled 311 participants from March 2011 to July 2013 meeting DSM-IV-TR criteria for diagnoses of schizophrenia or schizoaffective disorder at risk of relapse due to medication nonadherence or substance abuse. Participants were randomly assigned to double-blinded treatment with HD or PP and followed for up to 2 years. A committee blinded to treatment assignment adjudicated efficacy failure on the basis of participants' meeting at least 1 of these criteria: psychiatric hospitalization, crisis stabilization, increased outpatient visits, could not discontinue oral antipsychotic, discontinued assigned LAI due to inadequate therapeutic benefit, or ongoing or repeated need for adjunctive oral antipsychotic medication. Survival analyses examined modification of treatment effects on efficacy failure by age, sex, race, substance abuse, baseline symptom severity, and baseline adherence. Mixed-effect linear models and analysis of covariance examined this modification on safety outcomes. RESULTS: An interaction between age and treatment (P = .009) revealed younger participants assigned HD had longer time to efficacy failure than those assigned PP. Interactions were not significant between treatment group and sex, race, substance use disorder, baseline symptom severity, or baseline adherence. An interaction of treatment and age on akathisia (P = .047) found an advantage for PP that was larger among younger persons. An advantage for HD on serum prolactin levels was larger among younger women (P = .033). CONCLUSIONS: Among younger persons, HD was associated with lower rates of efficacy failure than PP. Age effects on adverse effects were mixed. Age-related heterogeneity of antipsychotic treatment effects warrants further investigation and consideration in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01136772.

Identifying clinical net benefit of psychotropic medication use with latent variable techniques: Evidence from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

BACKGROUND: Poor medication adherence is common among individuals with Bipolar Disorder (BD). Understanding the sources of heterogeneity in clinical net benefit (CNB) and how it is related to psychotropic medications can provide new insight into ways to improve adherence. METHODS: Data come from the baseline assessments of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Latent class analysis identified groups of CNB, and validity of this construct was assessed using the SF-36. Adherence was defined as taking 75% or more of medications as prescribed. Associations between CNB and adherence were tested using multiple logistic regression adjusting for sociodemographic characteristics. RESULTS: Five classes of CNB were identified: High (24%), Moderately high (12%), Moderate (26%), Moderately low (27%) and Low (12%). Adherence to psychotropic medications did not differ across classes (71% to 75%, χ2 = 3.43, p = 0.488). Medication regimens differed by class: 57% of the High CNB were taking ≤2 medications, whereas 49% of the Low CNB were taking ≥4. CNB classes had good concordance with the SF-36. LIMITATIONS: Missing data limited measures used to define CNB. Participants' perceptions of their illness and treatment were not assessed. CONCLUSIONS: This novel operationalization of CNB has construct validity as indicated by the SF-36. Although CNB and polypharmacy regimens are heterogeneous in this sample, adherence is similar across CNB. Studying adherent individuals, despite suboptimal CNB, may provide novel insights into aspects influencing adherence.

The relationship between childhood poverty, military service, and later life depression among men: Evidence from the Health and Retirement Study.

BACKGROUND: Childhood poverty has been associated with depression in adulthood, but whether this relationship extends to later life major depression (MD) or is modified by military service is unclear. METHODS: Data come from the Health and Retirement Study (HRS) 2010 wave, a longitudinal, nationally representative study of older adults. Men with data on military service and childhood poverty were included (N=6330). Childhood poverty was assessed by four indicators (i.e., parental unemployment, residential instability) experienced before age 16. Military service was categorized as veteran versus civilian, and during draft versus all-volunteer (after 1973) eras. Past year MD was defined by the Composite International Diagnostic Inventory. RESULTS: Four in ten men ever served, with 13.7% in the all-volunteer military. Approximately 12% of civilians, 8% draft era and 24% all-volunteer era veterans had MD. Childhood poverty was associated with higher odds of MD (Odds Ratio (OR): 2.38, 95% Confidence Interval (CI): 1.32-4.32) and higher odds of military service (OR: 2.58, 95% CI: 1.58-4.21). Military service was marginally associated with MD (OR: 1.28, 95% CI: 0.98-1.68) and did not moderate the association between childhood poverty and MD. LIMITATIONS: Self-report data is subject to recall bias. The HRS did not assess childhood physical and emotional abuse, or military combat exposure. CONCLUSIONS: Men raised in poverty had greater odds of draft and all-volunteer military service. Early-life experiences, independent of military service, appear associated with greater odds of MD. Assessing childhood poverty in service members may identify risk for depression in later life.