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Biomedical subjects

Robert A Rosenheck

Publications and source records attributed to Robert A Rosenheck.

At least 19 recordsLinked to original sources
PubMed2007

New insights into the efficacy of naltrexone based on trajectory-based reanalyses of two negative clinical trials.

BACKGROUND: The heterogeneity of clinical findings in studies evaluating the efficacy of naltrexone in the treatment of alcohol dependence has led to growing efforts to explore novel approaches to data analysis. The objective of this study was to identify distinct trajectories of daily drinking over time in two negative clinical trials and to determine whether naltrexone affected the probability to follow a particular trajectory. METHODS: The Veterans Affairs (VA) Cooperative Study #425 and the Women's Naltrexone Study failed to demonstrate efficacy on primary outcome variables. Separately for each study, we analyzed daily indicators of any drinking and heavy drinking using a semiparametric group-based approach. RESULTS: We estimated three distinct trajectories of daily drinking (both any and heavy drinking) which we described as "abstainer," "sporadic drinker," and "consistent drinker." Naltrexone doubled the odds of following the abstainer trajectory instead of the consistent drinker trajectory but did not significantly change the odds of following the abstainer trajectory as contrasted with the sporadic drinker trajectory. CONCLUSIONS: Naltrexone may have a clinically meaningful effect for alcohol-dependent patients with a high chance of consistent drinking, even in studies where it failed to show efficacy in planned analyses.

Adult↗
PubMed2007

Factors associated with receipt of pension and compensation benefits for homeless veterans in the VBA/VHA Homeless Outreach Initiative.

Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.

Adult↗
PubMed2007

Impact of supported housing on clinical outcomes: analysis of a randomized trial using multiple imputation technique.

In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) Program to provide integrated clinical and housing services to homeless veterans with psychiatric and/or substance abuse disorders at 19 sites. At four sites, 460 subjects were randomly assigned to one of the three groups: (1) HUD-VASH, with both Section 8 vouchers and intensive case management; (2) case management only; and (3) standard VA care. A previous publication found HUD-VASH resulted in superior housing outcomes but yielded no benefits on clinical outcomes. Since many participants missed prescheduled visits during the follow-up period and follow-up rates were quite different across the groups, we reanalyzed these data using multiple imputation statistical methods to account for the missing observations. Significant benefits were found for HUD-VASH in drug and alcohol abuse outcomes that had not previously been identified.

Alcoholism↗
PubMed2007

Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina.

OBJECTIVE: This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina. METHODS: Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years. RESULTS: In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003-2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services. CONCLUSIONS: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.

Ambulatory Care Facilities↗
PubMed2007

Generic fluoxetine and choice of antidepressant medication.

OBJECTIVE: In 2002 generic fluoxetine, the first generic product in a relatively expensive medication class, became available at Veterans Affairs medical centers at only 5% of its previous cost. This study examined whether its availability was associated with an increase in use compared with other medications. METHODS: All new starts of 15 antidepressants during fiscal year (FY) 2001 (before generic fluoxetine became available) and FY2003 were identified from administrative records, and the change in proportions of new starts across years was examined. RESULTS: Altogether, 55,673 patients had a new start on antidepressants in FY2001 and 48,002 had a new start in FY2003. The percentage of fluoxetine prescriptions (both branded and generic) rose only 1.2%--from 8.3% in FY2001 to 9.5% in FY2003. CONCLUSIONS: Only a small increase was found in the rate of new starts of fluoxetine in the year after its release as a low-cost generic. There appear to be untapped opportunities to realize savings for antidepressants with appropriate administrative mechanisms and incentives.

Choice Behavior↗
PubMed2007

Factors associated with stigma among caregivers of patients with bipolar disorder in the STEP-BD study.

OBJECTIVE: Little is known about the factors contributing to mental illness stigma among caregivers of people with bipolar disorder. METHODS: A total of 500 caregivers of patients participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study were interviewed in a cross-sectional design on measures of stigma, mood, burden, and coping. Relatives and friends with bipolar disorder were assessed on measures of diagnosis and clinical status, determined by a days-well measure derived from psychiatrist ratings of DSM-IV episode status. Because patients' clinical status varied widely, separate models were run for patients who were euthymic for at least three-fourths of the past year (well group) and for those who met criteria for an affective episode for at least one-fourth of the previous year (unwell group). Stepwise multiple regression was used to identify patient, illness, and caregiver characteristics associated with caregiver stigma. RESULTS: In the unwell group, greater mental illness stigma was associated with bipolar I (versus II) disorder, less social support for the caregiver, fewer caregiver social interactions, and being a caregiver of Hispanic descent. In the well group, greater stigma was associated with being a caregiver who is the adult child of a parent with bipolar disorder, who has a college education, who has fewer social interactions, and who cares for a female bipolar patient. CONCLUSIONS: Mental illness stigma was found to be prevalent among caregivers of persons with bipolar disorder who have active symptoms as well as for caregivers of those who have remitted symptoms. Stigma is typically associated with factors identifying patients as "different" during symptomatic periods. Research is needed to understand how the stigma experienced by caregivers during stable phases of illness differs from the stigma experienced during patients' illness states.

Adolescent↗
PubMed2006

Disability benefits and clinical outcomes among homeless veterans with psychiatric and substance abuse problems.

This study examined the relationship between disability payment status and clinical outcomes among 305 homeless veterans entering VA treatment. Disability status and clinical outcomes were characterized using self-report data at program entry, and quarterly for 2 years thereafter. Seeking or already receiving disability benefits at program entry was not associated with any of the 8 clinical outcomes examined. Those seeking or receiving disability benefits during the 2 years that followed showed more serious mental health problems and lower levels of mental health functioning, but no greater risk of substance use or not being employed nor worse housing outcomes than those who remained uninterested in applying for disability benefits. This study does not, therefore, support the notion that disability orientation results in poorer clinical outcomes, at least not among homeless veterans.

Adult↗
PubMed2006

A comparison of outcomes among patients with schizophrenia in two mental health systems: a health state approach.

This paper introduces a health state modeling approach using clustering and Markov analysis to compare short- and long-term outcomes among health care populations. We provide a comparison to more conventional mixed effects regression methods and show that discrete state modeling offers a richer portrait of patient outcomes than the standard univariate techniques. We demonstrate our approach using primary data from a three year observational study of patients treated for schizophrenia at a VA Medical Center (VA) and in a Community Mental Health Center (CMHC) in the same urban community. Randomly selected samples of outpatients treated for schizophrenia or schizoaffective disorder were interviewed every six months using standardized psychiatric assessments such as the Positive and Negative Syndrome Scale (PANSS). Items from the PANSS were used to define 7 discrete health states representing different levels of severity and diverse mixtures of psychiatric symptoms. Conventional analysis showed that VA patients exhibited increasingly severe symptoms, while CMHC patients remained more stable over the study period. Health state analysis reinforced these results but also identified which subpopulations of VA patients were deteriorating. In particular they showed that there was little change over time among VA patients in the best and worst health states. Instead the deterioration was caused by VA patients with: a) mild symptoms and hallucinations and b) serious positive and negative symptoms, being more likely to enter a state with severe positive and negative symptoms accompanied by moderate general distress.

Adult↗
PubMed2006

A national study of violent behavior in persons with schizophrenia.

CONTEXT: Violent behavior is uncommon, yet problematic, among schizophrenia patients. The complex effects of clinical, interpersonal, and social-environmental risk factors for violence in this population are poorly understood. OBJECTIVE: To examine the prevalence and correlates of violence among schizophrenia patients living in the community by developing multivariable statistical models to assess the net effects of psychotic symptoms and other risk factors for minor and serious violence. DESIGN: A total of 1410 schizophrenia patients were clinically assessed and interviewed about violent behavior in the past 6 months. Data comprise baseline assessments of patients enrolled in the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness. SETTING AND PATIENTS: Adult patients diagnosed as having schizophrenia were enrolled from 56 sites in the United States, including academic medical centers and community providers. MAIN OUTCOME MEASURES: Violence was classified at 2 severity levels: minor violence, corresponding to simple assault without injury or weapon use; and serious violence, corresponding to assault resulting in injury or involving use of a lethal weapon, threat with a lethal weapon in hand, or sexual assault. A composite measure of any violence was also analyzed. RESULTS: The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. "Positive" psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while "negative" psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization. CONCLUSIONS: Particular clusters of symptoms may increase or decrease violence risk in schizophrenia patients. Violence risk assessment and management in community-based treatment should focus on combinations of clinical and nonclinical risk factors.

Adult↗
PubMed2006

The mental health of children exposed to maternal mental illness and homelessness.

In recent years a number of reports have documented an increase in the number of homeless families in the US. Using a sample of 195 mothers who were veterans of the US armed forces we assessed the association of maternal homelessness and clinical status, with measures of children's mental health, school enrollment and attendance. Although maternal homelessness had no significant association with children's reported emotional problems it had a profound effect on school enrollment and attendance. Mothers' mental health status, history of incarceration and cumulative history of trauma, as well as children's exposure to trauma and their self-esteem were the factors most strongly associated with measures of children's emotional problems. The study suggests that preventive interventions are needed to minimize the effects of exposure to trauma, both in the community and at home, as well as family interventions to address both the mother's and child's emotional and physical needs. A longitudinal study is needed to understand better the association between residential instability and children's mental health.

Adolescent↗
PubMed2006

Use of nationwide outcomes monitoring data to compare clinical outcomes in specialized mental health programs and general psychiatric clinics in the Veterans Health Administration.

There has been a growing interest in the implementation of evidence-based specialized mental health programs. However, there has been little study of the effectiveness of these programs in comparison with standard mental health care in real world mental health systems. This study used a national sample of patients from the Veterans Health Administration to compare changes in mental health status in various specialized mental health outpatient programs and in general psychiatric clinics. Hierarchical linear models were used to compare the association of both regularity and intensity of care in six specialized mental health programs with GAF change scores in patients treated in general psychiatric clinics. While improvements were observed in all programs, two specialized programs performed better overall than general psychiatric care, one was not significantly different, and three had poorer outcomes than general psychiatric clinics. Programmatic differences in target populations accompanied by imperfect risk adjustment for population differences most likely explain why these results differ from those observed in clinical trials. While the analytic strategies demonstrated here may have wider applicability to comparative performance assessment, this study provides a cautionary tale concerning the limits of conclusions that can be drawn from large scale outcomes monitoring efforts.

Aged↗
PubMed2006

Case-finding for depression among medical outpatients in the Veterans Health Administration.

OBJECTIVES: We sought to determine the rates and predictors of screening, screening positive, follow-up evaluation, and subsequent diagnosis of depression among medical outpatients. RESEARCH DESIGN: This was a cross-sectional study using chart-review data from the Department of Veterans Affairs (VA) 2002 External Peer Review Program merged with administrative data. SUBJECTS AND MEASURES: We studied a national sample of VA medical outpatients with no depression diagnosis or mental health visits in the past 6 months (n = 21,489) and used chart-review and administrative data to follow the chain of events from depression screening to diagnosis. RESULTS: Overall, 84.9% of eligible patients (n = 18,245) were screened for depression in the past year. Of the 8.8% who screened positive, only 54.0% received follow-up evaluation and, of these, 23.6% (n = 204) subsequently were diagnosed with a depressive disorder (representing 1.1% of the originally screened sample). Patients who were younger, unmarried, and had more medical comorbidities were less likely to be screened; however, if screened, they were more likely to screen positive. Male gender and greater medical comorbidity were associated with decreased odds of follow-up evaluation after a positive screen. At the facility level, likelihood of depression screening was inversely associated with spending on teaching and research but positively associated with spending on mental health care. CONCLUSIONS: VA's depression case-finding activities yielded relatively few positive cases, raising questions about cost-effectiveness. Targeted strategies may increase the value of case-finding among patients at greatest risk for depression and at more academically affiliated medical centers. Targeted efforts also are needed to ensure proper follow-up evaluation of suspected cases, particularly among male patients and those with increased medical comorbidity.

Academic Medical Centers↗
PubMed2006

Unforeseen inpatient mortality among veterans with schizophrenia.

BACKGROUND: Patients with schizophrenia have co-occurring medical conditions, like other patients, but may lack the capacity to provide good self-care or to work with their providers to ensure appropriate medical treatment. We hypothesized that death among patients with schizophrenia occurs more frequently after minimal care of comorbid conditions. METHODS: All patients who died in veterans affairs (VA) hospitals during FY02 were categorized as to type of death: unforeseen (age <80 years, 1-2 inpatient days past year), cancer, organ failure (heart, lungs, kidneys), frailty (dementias, hip fractures, dehydration, etc.), or other deaths. Logistic regression explored factors in unforeseen death. RESULTS: During the year, 27,798 patients died in VA facilities; 3% had schizophrenia (n = 943). Roughly two-thirds of all deaths were from cancer or organ failure, 11% frailty, 9% other, and 8% met criteria for unforeseen death. Among patients with schizophrenia, however, 20% fell into the unforeseen death category. In an adjusted model, schizophrenia was associated with a 2-fold increased risk of unforeseen death compared with any other category (odds ratio = 2.4, 95% confidence interval 1.6-3.4). Unforeseen death was less likely among patients with substance abuse diagnoses in the year before death and more likely when patients had no outpatient medical care. CONCLUSIONS: VA patients with schizophrenia were more likely to die as inpatients with little previous-year care compared with other inpatient decedents without schizophrenia. Outreach efforts may be necessary to engage patients with schizophrenia in treatment of potentially life-threatening conditions.

Adult↗
PubMed2006

Risk of nursing home admission in association with mental illness nationally in the Department of Veterans Affairs.

OBJECTIVE: We sought to determine whether patients with mental health diagnoses in the Department of Veterans Affairs (VA) are more likely to be admitted to nursing homes and to identify sociodemographic, utilization, and clinical characteristics, especially indicators of mental illness severity, associated with nursing home admission among mentally ill patients. METHODS: Patients receiving treatment in the VA system nationally during FY 2000 and having no evidence of nursing home utilization during FY 1999 or FY 2000 were followed through FY 2003 using administrative claims data. Three-year incidence rates and unadjusted odds ratios were estimated for each diagnosis. Logistic regression was used to examine the correlates of admission among mentally patients, including analyses stratified by age. RESULTS: Of 3,952,229 VA patients with no prior nursing home use, 15.2% received a mental health diagnosis, of which, 4.6% were eventually admitted to a nursing home. Among mentally ill patients, risk of admission was highest for those with any inpatient medical/surgical days (odds ratio [OR] = 2.28), followed by 3+ outpatient medical visits (OR = 1.48), inpatient mental health days (OR = 1.31), and outpatient mental health visits (OR = 1.09). Patients diagnosed with dementia were 58% more likely to be admitted. Patients diagnosed schizophrenia (OR = 1.26), other psychosis (OR = 1.15), and personality disorder (OR = 1.14) had the next highest probabilities. Elderly patients with bipolar disorder (OR = 1.28) were also more likely to enter. CONCLUSION: Although factors leading to nursing home entry among the mentally ill are similar to those driving entry in the general population, those with more severe mental health problems are still more likely to be admitted.

Adult↗
PubMed2006

Substance use in persons with schizophrenia: baseline prevalence and correlates from the NIMH CATIE study.

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

Antipsychotic Agents↗
PubMed2006

Effect of Social Security payments on substance abuse in a homeless mentally ill cohort.

OBJECTIVES: To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use. DATA SOURCES/STUDY SETTING: Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill. DESIGN: Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months. DATA COLLECTION METHODS: Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings. PRINCIPAL FINDINGS: Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits. CONCLUSIONS: In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.

Adult↗