Delirium and decisional incapacity in veterans with schizophrenia and medical illness.

OBJECTIVE: The objective was to examine the characteristics of Veterans with schizophrenia admitted for nonpsychiatric hospitalizations. METHOD: We conducted a review of the electronic medical record and data warehouse downloads of Veterans with schizophrenia admitted to nonpsychiatric services of a large, academic Veterans Affairs hospital between 2004 and 2009 on whom psychiatry was consulted. RESULTS: Seventy-four veterans were admitted 89 times. Their mean age was 62 years. Among these veterans, the most common reasons for nonpsychiatric admission were infection, cardiac disease or altered mental status. Thirty-three percent of consultations were for patients who required intensive care. Consultation was requested most frequently for assessing psychotropic medication, decision-making capacity or altered mental status, or for assistance with behavioral problems. Thirty-seven percent of patients were diagnosed with delirium, and 42% lacked decision-making capacity, mostly secondary to delirium. Twenty-seven percent of patients died during the study period. CONCLUSION: In an aging cohort of Veterans with schizophrenia, a substantial proportion of patients developed delirium, lost decision-making capacity and required intensive care during nonpsychiatric hospital admission.

End-of-life care for veterans with schizophrenia and cancer.

OBJECTIVE: This study compared the quality of end-of-life care between veterans with and without schizophrenia who died of cancer in the northwestern United States. METHODS: In this cross-sectional study, medical records of 60 veterans with schizophrenia and 196 with no major mental illness who died of cancer were compared on hospice enrollment, palliative and life-sustaining interventions, advance directives, and site of death. RESULTS: Among veterans with schizophrenia, 58% had an advance directive, 73% received an opiate before hospice enrollment, 63% had a physician order to forgo cardiopulmonary resuscitation, 55% were hospice enrolled, and 27% died in the hospital. Schizophrenia patients had longer hospice stays (107+/-144 versus 63+/-96 days, p=.05) and more physician orders for life-sustaining treatment (15% versus 5%, p=.006) compared with veterans without mental illness. CONCLUSIONS: On most measures, veterans with schizophrenia who died of cancer received comparable or better end-of-life care than veterans without mental illness.

Appreciation of research information in patients with bipolar disorder.

OBJECTIVE: Ethicists have debated whether patients with serious mental illness can appreciate the risks of research participation and make autonomous decisions. We compared the abilities of euthymic and manic bipolar patients to appreciate and make voluntary decisions regarding research participation. METHODS: Twenty-six subjects with mania and 25 euthymic subjects reviewed hypothetical consent forms for three research studies of varying risk. We assessed subjects' appreciation of: their diagnosis and need for treatment; the researcher's role; the risks of participation; and the degree of influence of family, the treating clinician, and payment on decisions to participate. RESULTS: Most subjects (92%) agreed they had bipolar disorder requiring medication treatment. Subjects were less likely to participate in riskier studies. About half of subjects erroneously believed that researchers would make decisions based solely on what would be the best care for them (therapeutic misconception); and in randomized medication trials, they mistakenly believed they had improved chances of receiving one treatment over another. There were no differences between mood groups on these measures. Over half of subjects (59%) indicated that their mental health provider might influence them to participate in a study even when they did not want to, but most rejected a role for family in decision making. Payment was rated as having little impact on decisions to participate in research. CONCLUSION: Mania does not substantially influence appreciation of research participation. Subjects with bipolar disorder, regardless of mood state, are at risk for therapeutic misconception and optimistic bias. Special protections may be needed when mental health professionals approach their own patients to participate in research.

Influence of mood state on capacity to consent to research in patients with bipolar disorder.

OBJECTIVES: Experts have debated the ability of patients with bipolar illness to consent to research participation when manic. We compared 25 euthymic bipolar and 26 manic bipolar patients in their understanding of three hypothetical studies of varying complexity. METHODS: Hypothetical studies were presented as written informed consent forms, which were reread up to three times. Questions included assessment of hypothetical study purposes, procedures, risks and benefits, and voluntariness of participation. RESULTS: After adjusting for educational level, subjects with mania had lower mean understanding scores for all three hypothetical studies compared to euthymic subjects on initial assessment. By the end of Trial 3 of each hypothetical study, there were no significant differences between groups. The proportion of subjects with mania who met predetermined pass criteria for sufficient understanding was lower than the proportion of euthymic subjects on initial assessment of the first hypothetical study, but not the other hypothetical studies (odds ratio = 0.24; 95% confidence interval = 0.07-0.8; p = 0.02). Both groups exhibited an increase in the pass proportion by the end of the third trial for each hypothetical study with no significant differences between groups. CONCLUSIONS: We conclude that subjects with mania exhibited significantly poorer levels of understanding of relevant information in hypothetical research consent forms compared to euthymic subjects when initially presented with research information. The improvement in manic patients' understanding scores with the iterative review of consent forms suggests that many manic patients may be able to consent to research protocols containing an educational intervention as a part of the informed consent process.

Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO.

OBJECTIVE: Little is known about how psychiatric disorders affect health care costs in Medicaid programs. The prevalence of psychiatric disorders and costs of care for members of a Medicaid health maintenance organization (HMO) who had psychiatric disorders were examined. METHODS: A cross-sectional, observational analysis of adult Medicaid beneficiaries over a 12-month period was conducted by using data from a health plan that has both an HMO and a behavioral health carve-out. Claims data were analyzed for 6,500 adults who were eligible for services in both plans and who received medical or behavioral health services during calendar year 2000. RESULTS: Thirty-nine percent of the 6,500 adults had a psychiatric diagnosis. Of this subset, 67.2 percent had received no specialty mental health care in the previous year. The presence of any psychiatric diagnosis significantly increased total health care costs by a factor of 2.24 ($6,995 compared with $3,121 for persons with no psychiatric diagnosis) and costs to the medical plan by a factor of 1.77 ($4,690 compared with $2,649). For beneficiaries with bipolar or psychotic diagnoses, higher health plan costs were due predominately to increases in pharmacy and specialty mental health costs. In contrast, higher costs for beneficiaries with depression, anxiety, or substance use diagnoses were attributable to greater use of general medical services. CONCLUSIONS: An analysis of claims data showed that adult Medicaid beneficiaries have exceptionally high rates of comorbid psychiatric conditions, which were associated with significantly higher medical and pharmaceutical costs. The high cost of these beneficiaries to the medical plan has policy implications in terms of the importance of addressing mental health issues in Medicaid general medical populations.

Association of interferon-alpha-induced depression and improved treatment response in patients with hepatitis C.

Thirty-nine patients with hepatitis C viral infection on interferon-alpha (IFN-alpha) therapy were monitored weekly using the Beck Depression Inventory (BDI). Thirteen of thirty-nine patients (33%) developed IFN-alpha-induced major depressive disorder (MDD). During the course of IFN-alpha therapy, patients who became depressed were treated with citalopram, a selective serotonin reuptake inhibitor (SSRI) antidepressant. Results indicated that: (1) IFN-alpha response rates were significantly higher in those patients who developed IFN-alpha-induced MDD than in those who did not (end-of-treatment response (ETR) rates: 61.5% versus 26.9% and sustained viral response (SVR) rates: 38.5% versus 11.5%), (2) male patients with ETR to IFN-alpha therapy were, on average, approximately 33 pounds lighter in body weight than male patients who did not respond, and (3) gender, race, past history of MDD, and past history of substance abuse were not significantly associated with ETR. In conclusion, our findings suggest that IFN-alpha-induced MDD may be a predictor of a positive response to IFN-alpha therapy, or an indication of optimal dosing.