Incidence of diabetes mellitus in a population-based cohort of HIV-infected and non-HIV-infected persons: the impact of clinical and therapeutic factors over time.

AIMS: To examine incidence density rate and correlates of incident diabetes mellitus in a cohort of HIV-infected individuals compared with matched non-HIV-infected persons. METHODS: Data were obtained from the South Carolina Medicaid system and the enhanced HIV/AIDS Reporting System surveillance database for persons ≥ 18 years of age who had been attended to during the period 1994 to 2011. Time-dependent proportional hazards analysis and marginal structural models were used to analyse the data. RESULTS: A total of 13 632 individuals (6816, 1:1 matched HIV-infected and non-HIV-infected persons; median age 39 years; 57% male) contributed 88 359 person-years of follow-up. Incidence rate of diabetes was higher in the non-HIV-infected group compared with the HIV-infected group (13.60 vs. 11.35 per 1000 person-years). Multivariable hazards analysis suggested a significantly lower risk of incident diabetes among HIV-infected persons treated with combination antiretroviral therapy compared with the matched non-HIV-infected persons (adjusted hazards ratio 0.55; 95% CI 0.46-0.65). Among HIV-infected persons, marginal structural modelling suggested a significantly higher risk of diabetes with cumulative exposure to protease inhibitors over the observation period (adjusted relative risk 1.35; 95% CI 1.03-1.78), but this association was not significant for exposure to non-nucleoside reverse transcriptase inhibitors. Overall, female gender, older age, non-white race/ethnicity, and pre-existing hypertension, dyslipidaemia, obesity and hepatitis C infection were associated with higher risk of diabetes incidence. CONCLUSIONS: HIV infection may not be independently associated with increased risk of diabetes. Among HIV-infected persons, exposure to protease inhibitor-based regimens may increase the risk of diabetes. Healthcare providers should make every effort to use combination antiretroviral therapy regimens with a better cardiometabolic profile.

Issues and outcomes in integrated treatment programs for dual disorders.

In an integrated, dual disorder treatment program delivered at two sites, the authors address numerous barriers to delivering services to dually diagnosed consumers and employ a set of multidimensional indicators to assess outcome. Consumers who received services through the well-implemented, integrated services program for 12 months were functioning better in the community. There was a cost shifting from mental health to drug and alcohol services, as well as a one-third increase in the total costs of care by the end of the first year of treatment. Program implementation issues are described and the clinical management implications for more effectively serving dually diagnosed consumers through integrated treatment programs are discussed.

The reliability and validity of the SAS-SMI.

The reliability and validity of the SAS-SMI (Social Adjustment Scale for the Severely Mentally Ill) were assessed in three samples of 670 persons with severe mental illness from a public mental health system. The SAS-SMI retained comparable factor structures (Social, Family, Work, Residential Stability, Romantic Interest, and Personal Well-being) to its predecessor, the SAS-II, and yielded high item-to-scale internal consistency correlations, good interrater reliability, and comparable convergent and divergent validity. The SAS-SMI's performance across these dimensions makes it a potentially valuable tool in mental health services research investigations. Limitations and suggestions for further development are discussed.

Impact of robustness of program implementation on outcomes of clients in dual diagnosis programs.

Three types of treatment-behavioral skills training, a 12-step recovery model, and intensive case management-provided to 132 clients at four facilities were identified as being robustly or not robustly implemented, depending on whether core elements of these treatments were emphasized. Outcomes and costs of services to clients were examined over 18 months. Clients receiving robustly implemented behavioral skills training had significantly higher psychosocial functioning and lower costs for supportive services than those receiving nonrobustly implemented training. Clients receiving robustly implemented case management also exhibited significantly higher psychosocial functioning and lower costs for intensive services than those in the nonrobust intervention. To be effective, dual diagnosis programs should better manage the robustness of implementation of planned interventions.

The relative impact of treatment program 'robustness' and 'dosage' on client outcomes.

The relationship between two aspects of program quality (robustness of model implementation and service dosage), client outcomes of self-reported and observer-rated psychosocial functioning, and intensive mental health service utilization costs was examined for 132 persons with dual mental and substance disorders. Membership in the 'robustly implemented' behavioral skills intervention was significantly associated with higher levels of self-reported and observer-rated psychosocial functioning, while membership in the 'robustly implemented' 12-step group was significantly related to higher intensive mental health service costs. Dosage of supportive service exhibited a significant, positive relationship to lower intensive mental health service costs but not to functioning. Although the addition of qualitative data was useful in interpreting the findings from the main study analyses, it had no discernable statistical impact on the regression equations for three major outcome variables.

Effect of ethnic matching of young clients and mental health staff.

The results of an analysis of factors affecting service use among children and adolescents suggest that those served by an ethnically matched therapist stay in outpatient treatment longer and use less day treatment service, a more intensive level of care. These findings support efforts to increase the number and type of ethnic staff delivering children's mental health services and to expand the types of culturally competent services available to children with mental health problems and their families.

Qualitative analysis of three case management programs.

Most investigations of case management service programs for people with severe mental illness lack detail about the specialized interventions employed, their key differences, and the changes they undergo over time. Qualitative data are presented which describe and compare three service approaches, and their relationship to quantitative outcomes from a cost-effectiveness study of the three models. The organization and functioning of the PACT Adaptation Model were most conductive to enhancing client psychosocial functioning and significantly reducing intensive mental health service costs. Outcomes for the Clinical Team and Intensive Broker Models were less consonant with the qualitative findings.

Utilization management analysis for children's mental health services.

Efficient identification of high-cost child and adolescent consumers of public mental health services using existing utilization and cost data is illustrated, along with analyses that profile these high-cost consumers and demonstrate the effect on total service cost per client of providing case management. The results indicate that providing high levels of case management services is not correlated with reductions in total service costs and that there is a need in the service system for using high-cost case management review techniques to control service utilization and lower costs.

Dual diagnosis care for severe and persistent disorders. A comparison of three methods.

People with severe and persistent mental illnesses frequently suffer from addictive disorders as well. Managed care plans and at-risk providers who care for people with these conditions must understand, authorize, and provide evidence-based and cost-effective care. The authors of this article evaluated three specialized interventions for treating people with co-occurring severe mental illness and substance abuse. Treatment of both disorders was found to be essential. In addition, a behavioral skills training was found to improve outcomes and reduce total healthcare costs when compared with intensive case management and 12-Step recovery interventions. Supplemental supportive services further increase the overall value of care. Implications for managed care and at-risk providers are discussed.

Ethnic differences in the treatment of dual mental and substance disorders. A preliminary analysis.

Differences between white and ethnic client psychosocial functioning, psychiatric and substance abuse symptomatology, and service utilization costs from a longitudinal clinical trial examining the relative cost effectiveness of three specialized interventions for dual disorders are compared within the study sample and to the existing literature. Ethnic clients comprised 30% of the treated sample, had lower psychosocial functioning scores (rated and self-reported), and received less supportive treatment services during the first 6 months of the intervention program; however, their overall outcomes were equivalent to those of white clients at 6 months. There were no functioning or symptom outcome differences across the three treatment groups, but the 12-step group had the highest intensive and supportive service costs over time, and also the greatest reductions in intensive service costs after 6 months. Clinical issues are described and the clinical implications for more effectively serving dually diagnosed ethnic clients are outlined.

Analysis of three interventions for substance abuse treatment of severely mentally ill people.

Severely mentally ill people with co-occurring substance abuse disorders are difficult to treat and the course of their psychiatric treatment is worsened by substance abuse. Despite increased attention to the problem, few studies of specialized treatment are reported in the literature and most lack detail about the specialized interventions employed. Qualitative data, gathered as part of a larger study of the cost-effectiveness of three substance abuse interventions for severely mentally ill people, are presented which describe the interventions, their implementation in four community mental health centers over 18 months of the study, and their relationship to the quantitative outcomes. Illustrated is the difficulty of implementing innovative programs and the need for vigilance concerning program fidelity.

The utility of dual diagnosis services for consumers from nonwhite ethnic groups.

Differences in psychosocial functioning, symptoms, service use, and costs for 40 nonwhite consumers of mental health services and 92 white consumers were compared at baseline and six months in a controlled clinical trial of three dual diagnosis interventions. At six months nonwhite consumers had lower psychosocial functioning than white consumers as measured by self-report and clinicians' ratings. Nonwhite consumers received significantly less supportive treatment than white consumers. Qualitative data from staff interviews indicated that nonwhite consumers had inadequate community and family supports due to a variety of problems. Although the nonwhite consumers had outcomes similar to those of white consumers, the complex needs of the nonwhite consumers warrant additional staff resources and culturally sensitive services in dual diagnosis treatment programs.

Toward cost-effective care for persons with dual diagnoses.

Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.

Estimating the cost impact of three dual diagnosis treatment programs.

Specialized intervention programs for people with concurrent severe mental illness and substance abuse reduce the total costs of care. Compared to baseline, cost savings of over 40% were achieved by 18 months, primarily due to significant reductions in the use of acute and subacute mental health services and despite an increase in outpatient mental health services. There also was an observable impact on cost reductions in medical and criminal justice services without an increase in family costs over the same time period.

Emergency care avoidance: ethnic matching and participation in minority-serving programs.

Using data from a county level mental health service system, relationships were examined between ethnic matching, program involvement and emergency service use. When clients were matched with an ethnically similar clinician who was also proficient in their preferred language, they had fewer emergency service visits than did clients who were unmatched on the basis of ethnicity and language. Equally if not more significant than ethnicity or language matching was the client's program and the proportion of minority clients it served. Clients in programs serving a relatively large proportion of minority clients had fewer emergency service visits than those in programs serving a smaller proportion of minority clients. More research is needed to document the impact of matching along with greater attention to minority oriented programs.

Gender differences in the assessment of specialized treatments for substance abuse among people with severe mental illness.

A recent study examined the relative cost-effectiveness of three specialized interventions for treating people with both severe mental illness and substance abuse disorders: behavioral skills training, intensive case management, and 12-Step recovery. This article reports the changes in client psychosocial outcomes, psychiatric and substance abuse symptomatology, and service utilization and costs for the 31 women involved in the study, and compares these results to similar data on the men in the study sample and to the existing literature. Also presented are the most salient clinical impressions of the treating staff of issues affecting the course of treatment and outcomes for these women. Similarities were found in treated prevalence, service utilization, and related clinical issues in women with dual disorders compared to those reported in the existing psychiatric or substance abuse literature. Compared to men in the same sample, the women had higher functioning scores, more psychiatric symptomatology, and greater reductions in 24-hour acute or subacute treatment services used during the first six months of the specialized intervention programs. These results provide some insight into ways of serving dually diagnosed women more effectively in community-based treatment programs and of investigating these services more fruitfully.

Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders.

This study examines the rationale for and relative effectiveness of three intervention models for treating people with severe mental illness and substance abuse disorders: Twelve Step recovery, behavioral skills training, and intensive case management. Using clinical trial methods, 132 dually diagnosed clients were assigned to three service approaches. Changes in client psychosocial outcomes, and psychiatric and substance abuse symptomatology were tracked over a 24-month period. Differential effectiveness was evident, with clients in the behavioral skills group demonstrating the most positive and significant differences in psychosocial functioning and symptomatology, compared with the Twelve Step recovery approach. However, the case management intervention also resulted in several positive and important differences compared with the Twelve Step recovery approach. We also found significant changes over time, not only at 6 months but increasingly positive changes in psychosocial functioning at 12 and 18 months as well. These results underscore the need for clinical trials to further examine the relative cost effectiveness of treatment approaches for dually disordered clients and to incorporate means of assessing subgroup differences so that the interventions being tested can be further refined and targeted to a broad set of needs among the dually diagnosed.

Evaluating changes in symptoms and functioning of dually diagnosed clients in specialized treatment.

OBJECTIVE: The authors outline a minimal set of outcome indicators to assess the effects of specialized treatment for people with severe mental illness and substance use disorders and report on use of these indicators in a longitudinal study of such treatments. METHODS: A total of 147 clients with dual disorders participated in a controlled clinical trial of three interventions--behavioral skills training, case management, and 12-step recovery--in a county mental health program. The clients were assessed every six months over a two-year period using multidimensional self-report and observer-rated outcome measures encompassing psychosocial functioning, psychiatric and substance abuse symptoms, and service utilization. RESULTS: Client self-reports showed changes in psychosocial functioning, especially increased functioning in residential stability and work, and reductions in alcohol and drug symptoms and usage. Data on service utilization showed decreased use of acute and subacute mental health services and increased use of outpatient and case management services over time. Ratings by trained observers of psychiatric symptoms and psychosocial functioning improved dramatically. CONCLUSIONS: A minimal set of outcome indicators for clinical trials and demonstrations of interventions for clients with dual disorders should include client self-reports of social adjustment, life satisfaction, psychiatric and substance abuse symptoms, and current substance use; interviewers' ratings of psychosocial functioning and psychiatric symptoms; data on utilization of mental health treatment and support services; and data on clients' personal income, use of medical services, and contact with the criminal justice system.