ABSTRACT
BACKGROUND: The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. OBJECTIVES: To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. DESIGN: Randomized trial. SUBJECTS: Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). MEASURES: The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. RESULTS: Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by $1,171 (P <0.001) per patient, but lowered inpatient costs by $3,027 (P = 0.017), for an overall savings of $1,856 (P = 0.156). Inpatient savings were attributable to fewer bed days of care (3.30 days; P = 0.016) rather than fewer admissions. Patients with 1 or more pre-enrollment and postenrollment hospitalizations had the greatest overall savings ($6,015; P = 0.069). CONCLUSIONS: UPBEAT appears to accelerate the transition from inpatient to outpatient care for acute nonpsychiatric admissions. Care coordination and increased access to ambulatory psychiatric services produces similar improvement in mental health and general health status as usual care.
Subject(s)
Alcoholism/complications , Alcoholism/diagnosis , Anxiety Disorders/complications , Anxiety Disorders/diagnosis , Continuity of Patient Care/organization & administration , Depressive Disorder/complications , Depressive Disorder/diagnosis , Geriatric Assessment , Geriatric Psychiatry/organization & administration , Hospitals, Veterans/statistics & numerical data , Mass Screening/organization & administration , Mental Health Services/organization & administration , Patient Care Team/organization & administration , United States Department of Veterans Affairs/statistics & numerical data , Aged , Alcoholism/therapy , Analysis of Variance , Anxiety Disorders/therapy , Comorbidity , Cost-Benefit Analysis , Depressive Disorder/therapy , Female , Follow-Up Studies , Health Status , Hospitals, Veterans/economics , Humans , Male , Mental Health , Middle Aged , Outcome Assessment, Health Care , Program Evaluation , Psychiatric Status Rating Scales , United States , United States Department of Veterans Affairs/economics , VeteransABSTRACT
This is the first study to test concurrently the effectiveness of four treatment programs for patients with serious mental illness. Three-year outcome data on utilization and functioning demonstrated important positive changes for seriously mentally ill veterans enrolled in specialized, enhanced inpatient and community case management treatment programs, when compared to patients in an enhanced day treatment program or traditional standard care.
Subject(s)
Case Management , Community Mental Health Services , Day Care, Medical , Patient Admission , Psychotic Disorders/rehabilitation , Veterans/psychology , Adult , Aged , Chronic Disease , Female , Follow-Up Studies , Humans , Male , Middle Aged , Outcome and Process Assessment, Health Care , Psychotic Disorders/psychologyABSTRACT
Treatment outcomes in later-life schizophrenia are poorly understood and of serious concern for clinicians and mental health policy makers. Age-group differences were examined for 499 male veterans with severe schizophrenia enrolled in enhanced treatment programs at 12 Veterans Affairs hospitals. Participants were separated into three age groups (20-39 years, 40-59 years, 60 years and above), with the following outcomes assessed at enrolment and 1 and 3 years afterwards: psychiatric symptomatology, global functioning, impairment in Instrumental Activities of Daily Living (IADL), and hospital use. All three age groups experienced significant improvement in psychiatric symptoms over time. The oldest group fared worse than younger patients in terms of global functioning and generally required more inpatient services and assistance with IADL. Innovative programming is needed to meet the special needs of the growing population of older adults with schizophrenia.
Subject(s)
Schizophrenia/drug therapy , Veterans , Adult , Age Factors , Aged , Aged, 80 and over , Geriatric Psychiatry , Humans , Longitudinal Studies , Male , Middle Aged , Prognosis , Schizophrenia/pathology , Treatment OutcomeSubject(s)
Mental Disorders/therapy , Mental Health Services/economics , Veterans/psychology , Aged , Alzheimer Disease/economics , Alzheimer Disease/psychology , Alzheimer Disease/therapy , Budgets , Continuity of Patient Care/economics , Cost Allocation , Dementia/economics , Dementia/psychology , Dementia/therapy , Female , Health Services for the Aged/economics , Humans , Male , Mental Disorders/economics , Mental Disorders/psychologyABSTRACT
The efficacy of three different residential therapeutic communities for male veterans addicted to heroin was studied, comparing 181 subjects who were randomly assigned to one of the communities with 166 subjects briefly hospitalized only for the treatment of withdrawal symptoms. At two-year follow-up, subjects from both a professionally staffed community and a peer confrontation community were found significantly more likely than the withdrawal-only group to be working or attending school and less likely to have been convicted of a crime. An eclectic program employing both professionals and paraprofessionals was not found to exceed the withdrawal-only group on any of the major outcome variables. The two relatively successful communities, although different in structure and style, were both perceived by their residents to have greater program clarity, order, staff control, and orientation to personal problems than the unsuccessful program.
Subject(s)
Heroin Dependence/therapy , Therapeutic Community , Adult , Attitude to Health , Clinical Trials as Topic , Follow-Up Studies , Heroin Dependence/psychology , Heroin Dependence/rehabilitation , Hospitalization , Humans , Male , Outcome and Process Assessment, Health Care , Prospective Studies , Residential Facilities , Sensitivity Training Groups , Substance Withdrawal Syndrome/prevention & controlABSTRACT
During a 2-year follow-up interview, 272 male veteran heroin addicts reported their recent heroin use and provided a urine sample. Eighty-four percent of those reporting no heroin use in the 3 months preceding the interview, and 78% of those declaring no use in the previous week had urines found negative for opiates. The subjective impressions of the interviewers were useful in predicting the veracity of the self-reports. Subjects who had been in longer-term treatment, especially therapeutic communities, were more likely to report heroin use truthfully.
Subject(s)
Heroin Dependence/psychology , Truth Disclosure , Adult , Follow-Up Studies , Heroin/urine , Heroin Dependence/therapy , Humans , Interview, Psychological , Male , Self Disclosure , Therapeutic Community , Veterans/psychologyABSTRACT
This study compares the efficacy of three residential therapeutic communities and an outpatient methadone maintenance program for 585 male veterans addicted to heroin. Subjects were randomly assigned to the treatment modalities. More than 93% of the subjects completed both six- and 12-month questionnaires. In this report, the treatment settings, characteristics of the sample, assignment protocol, and pattern of treatment entry and first-year follow-up results are outlined. The various clinical demands that affected the research protocol, the degree to which the randomization was compromised, and the implications for the analysis of outcome are discussed. One year after admission to the study, subjects who had been in a therapeutic community for longer than seven weeks or in methadone treatment were more likely to be employed or attending school, and less likely to be in jail, using heroin, or to have been convicted of a serious crime, than subjects who received no treatment at all beyond a short detoxification period. Those who spent less than seven weeks in a therapeutic community were doing no better than subjects in the no treatment group.