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Biomedical subjects

Robert Rosenheck

Publications and source records attributed to Robert Rosenheck.

At least 19 recordsLinked to original sources
PubMed2006

Does assigning a representative payee reduce substance abuse?

BACKGROUND: Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse. METHODS: Participants in this observational 12-month cohort study (n=1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned. RESULTS: At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participants not assigned payees but showed no greater reduction in substance use. CONCLUSIONS: Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment.

Adult↗
PubMed2006

Baseline neurocognitive deficits in the CATIE schizophrenia trial.

Neurocognition is moderately to severely impaired in patients with schizophrenia. However, the factor structure of the various neurocognitive deficits, the relationship with symptoms and other variables, and the minimum amount of testing required to determine an adequate composite score has not been determined in typical patients with schizophrenia. An 'all-comer' approach to cognition is needed, as provided by the baseline assessment of an unprecedented number of patients in the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) schizophrenia trial. From academic sites and treatment providers representative of the community, 1493 patients with chronic schizophrenia were entered into the study, including those with medical comorbidity and substance abuse. Eleven neurocognitive tests were administered, resulting in 24 individual scores reduced to nine neurocognitive outcome measures, five domain scores and a composite score. Despite minimal screening procedures, 91.2% of patients provided meaningful neurocognitive data. Exploratory principal components analysis yielded one factor accounting for 45% of the test variance. Confirmatory factor analysis showed that a single-factor model comprised of five domain scores was the best fit. The correlations among the factors were medium to high, and scores on individual factors were very highly correlated with the single composite score. Neurocognitive deficits were modestly correlated with negative symptom severity (r=0.13-0.27), but correlations with positive symptom severity were near zero (r<0.08). Even in an 'all-comer' clinical trial, neurocognitive deficits can be assessed in the overwhelming majority of patients, and the severity of impairment is similar to meta-analytic estimates. Multiple analyses suggested that a broad cognitive deficit characterizes this sample. These deficits are modestly related to negative symptoms and essentially independent of positive symptom severity.

Adult↗
PubMed2006

Treatment of female veterans with posttraumatic stress disorder: the role of comfort in a predominantly male environment.

This study examines the role of women's comfort in coming for treatment of posttraumatic stress disorder in a predominantly male environment. Consecutive admissions (N = 224) to the Department of Veterans Affairs (VA)'s Women's Stress Disorder Treatment Teams were enrolled in an outcome study from July 1998 through June 2000. Women reported that they were somewhat comfortable in coming to the VA for their mental health care. For women who had no prior experience with the VA, comfort increased with their exposure to the treatment program. Further, for this group of women, comfort level was related significantly to their commitment to working in therapy and the regularity of their attendance in treatment over time. There were no significant changes in comfort level for women who had prior contact with the VA. Comfort level was unrelated to satisfaction and only minimally related to clinical outcomes. The primary role of women's comfort level, therefore, appeared to be as a facilitator of their participation in the therapeutic process.

Adaptation, Psychological↗
PubMed2006

An examination of fulfilled housing preferences and quality of life among homeless persons with mental illness and/or substance use disorders.

This study examined the types of housing features considered important to a sample of homeless persons diagnosed with a mental illness and/or substance use disorder and the relationship between the degree to which important features were obtained in subsequent housing and subjective quality of life, clinical and housing outcomes at 3-month and 1-year follow-up periods. After controlling for significant clinical and sociodemographic covariates, results from regression analyses indicate that the degree to which a client's individual housing preferences were realized in dwellings is significantly associated with greater quality of life in the future, but not clinical outcomes or housing tenure.

Adult↗
PubMed2006

Impact of medical comorbidity on the quality of schizophrenia pharmacotherapy in a national VA sample.

BACKGROUND: More than half of patients with schizophrenia have comorbid chronic medical illness. During the past decade, several studies have evaluated the quality of the medical treatment of these conditions. This work examines the impact of comorbid medical conditions on the quality of schizophrenia pharmacotherapy in the Department of Veterans Affairs (VA). METHODS: Data for this study came from national VA administrative databases. All VA outpatients diagnosed with schizophrenia during fiscal year 2002 were identified, and the presence of 9 chronic medical conditions was determined by ICD-9 codes. Measures of quality of schizophrenia pharmacotherapy were based on the Schizophrenia Patient Outcomes Research Team (PORT) and included the proportion of patients who received any antipsychotic medications, multiple antipsychotic medications, atypical antipsychotic medications, and dosages in compliance with PORT recommendations. Multivariate logistic regression analysis was used to determine the effects of comorbid medical illness on these measures. RESULTS: Overall, 92.2% of the patients were prescribed an antipsychotic medication. Patients with 6 of the 9 chronic medical conditions were significantly less likely to be prescribed antipsychotic medications, and the odds of this treatment decreased with increasing medical complexity. 63.8% received doses which were within the recommended PORT guidelines. CONCLUSIONS: In a large national sample of veterans with schizophrenia, several chronic medical conditions were associated with a decreased likelihood of being prescribed an antipsychotic medication, suggesting less intensive schizophrenia treatment. Patients with medical comorbidity who were treated with antipsychotic medications were as likely to receive doses within the PORT guidelines as schizophrenic patients without medical comorbidity.

Adult↗
PubMed2006

Specificity of patients' satisfaction with the delivery and outcome of treatment.

This study investigated the hypotheses that the general disposition to be satisfied is more influential than the nature of service delivery in determining satisfaction with treatment, and that there is a specificity to satisfaction with the delivery of care and with clinical outcome of care that makes their ratings distinct. Data were obtained by questionnaire at intake into treatment and 4 months later from 154 male veterans. There were statistically significant relationships between the general disposition to be satisfied and satisfaction with treatment, but they had only a trivial effect on the relationships between treatment satisfaction and other variables. There was, however, a specificity to satisfaction ratings such that a major feature of the delivery of care, the experience of friendliness and caring from staff, was related more highly to satisfaction with care than to satisfaction with outcome, while measures of clinical outcome were related more highly to satisfaction with outcome than to satisfaction with care. A general disposition to be satisfied, therefore, appears not to have a major biasing effect on satisfaction with treatment. Further, patients appear to make valid differentiations between satisfaction with the delivery of care and the clinical outcome of care when their attention is focused specifically on satisfaction with these features.

Attention↗
PubMed2006

Barriers to employment for people with schizophrenia.

OBJECTIVE: There is growing interest in identifying and surmounting barriers to employment for people with schizophrenia. The authors examined factors associated with participation in competitive employment or other vocational activities in a large group of patients with schizophrenia who participated in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, a multisite clinical trial comparing the effects of first- and second-generation antipsychotics. METHOD: Baseline data on more than 1,400 patients with a diagnosis of schizophrenia were collected before their entry into the CATIE study. Multinomial logistic regression was used to examine the relationship between participation in either competitive employment or other vocational activities and sociodemographic characteristics, schizophrenia symptoms, neurocognitive functioning, intrapsychic functioning, availability of psychosocial rehabilitation services, and local unemployment rates. RESULTS: Altogether, 14.5% of the patients reported participating in competitive employment in the month before the baseline assessment, 12.6% reported other (noncompetitive) employment activity, and 72.9% reported no employment activity. Participation in either competitive or noncompetitive employment was associated with having less severe symptoms, better neurocognitive functioning, and higher scores on a measure of intrapsychic functioning that encompassed motivation, empathy, and other psychological characteristics. Competitive employment, in contrast to other employment or no employment, was negatively associated with receipt of disability payments as well as with being black. Greater access to rehabilitation services was associated with greater participation in both competitive and noncompetitive employment. CONCLUSIONS: Overall employment of persons with schizophrenia seems to be impeded by clinical problems, including symptoms of schizophrenia and poorer neurocognitive and intrapsychic functioning. However, participation in competitive employment may be specifically impeded by the potentially adverse incentives of disability payments and by race and may be promoted by the availability of rehabilitation services.

Adult↗
PubMed2005

The role of loss of meaning in the pursuit of treatment for posttraumatic stress disorder.

Clinical observation and theory suggest that people who have difficulty coping with their exposure to traumatic events often experience a loss of meaning to their lives. This article examines the contribution of loss of meaning to seeking help from clergy and/or mental health providers. Results support the hypotheses that veterans who have suffered a greater loss of meaning are more likely to seek help from clergy and from VA mental health professionals. We suggest that veterans who seek help from clergy are particularly desirous of achieving a restoration of meaning that is specific to their loss, and that this quest sustains a continued pursuit of mental health treatment, especially among those who seek help from the VA.

Adult↗
PubMed2005

The role of war-zone trauma and PTSD in the etiology of antisocial behavior.

Historically, successful reintegration of war veterans into civilized society has been an enduring concern of nations. Data from the National Vietnam Veterans Readjustment Study were used to develop and evaluate an etiological model of postwar antisocial behavior. Two initial models specified causal paths among five sets of variables, ordered according to their historical occurrence: (a) premilitary risk factors, (b) military traumas and disciplinary actions, (c) the homecoming reception, (d) postmilitary PTSD and substance abuse, and (e) postmilitary antisocial behavior. PTSD and substance abuse were omitted in one model and included in the other. The initial models were refined and then cross-validated, leading to the specification of replicated models with highly satisfactory fit and parsimony. Comparison of the two models suggested that (1) premilitary experiences and behavior exert the largest effects on postmilitary antisocial behavior, and that (2) PTSD plays a necessary mediational role for the effects of war-zone traumatic exposure on postmilitary antisocial behavior.

Adult↗
PubMed2005

Cost-sharing requirements and access to mental health care among medicare enrollees with schizophrenia.

OBJECTIVE: This study explored the association between Medicare cost-sharing requirements and the probability of use of various mental health outpatient services among Medicare enrollees with schizophrenia. METHODS: Multivariate logistic regression was used to estimate the probability of use of each of seven types of services over six months. Patients were recruited from public and private mental health treatment provider organizations in six states. The analyses included 1,088 Medicare enrollees, of whom approximately 55 percent were also enrolled in Medicaid. RESULTS: Medicare-only patients (with greater cost-sharing) were 25 to 45 percent less likely to have used rehabilitation services, individual therapy with nonpsychiatrist mental health providers, and case management. No association was found between Medicaid enrollment and probability of service use for medical clinic visits, group therapy, individual contact with a psychiatrist, or receipt of second-generation antipsychotics. CONCLUSIONS: Among Medicare enrollees with schizophrenia, gaps in Medicare coverage may be more problematic for rehabilitation, case management, and contact with nonpsychiatrist providers. Local public and private subsidies for mental health treatment may compensate for some of the gaps in coverage. However, such subsidies are not universally or uniformly provided.

Adult↗
PubMed2005

Measuring outcome priorities and preferences in people with schizophrenia.

BACKGROUND: Measures have not taken account of the relative importance patients place on various outcomes. AIMS: To construct and evaluate a multidimensional, preference-weighted mental health index. METHOD: Each of over 1200 patients identified the relative importance of improvement in six domains: social life, energy, work, symptoms, confusion and side-effects. A mental health index was created in which measures of well-being in these six domains were weighted for their personal importance. RESULTS: The strongest preference was placed on reducing confusion and the least on reducing side-effects. There was no significant difference between the unweighted and preference-weighted mental health status measures and they had similar correlations with global health status measures. Patients with greater preference for functional activities such as work had less preference for medical model goals such as reducing symptoms and had less symptoms. CONCLUSIONS: A preference-weighted mental health index demonstrated no advantage over an unweighted index.

Adult↗
PubMed2005

The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans.

This study evaluated the efficacy of adding contingency management techniques to vocational rehabilitation (VR) to improve treatment outcome as measured by entry into competitive employment. Nineteen dually diagnosed veterans who entered VR in the Veterans' Administration's compensated work therapy (CWT) program were randomly assigned to CWT (n = 8) or to CWT with enhanced incentives (n = 11). Over the first 16 weeks of rehabilitation, those in the incentives condition could earn up to dollar 1,006 in cash for meeting two sets of clinical goals: (a) remaining abstinent from drugs and alcohol and (b) taking steps to obtain and maintain a competitive job. Results indicate that relative to participants in the CWT-only group, those in the incentives condition engaged in more job-search activities, were more likely to remain abstinent from drugs and alcohol, were more likely to obtain competitive employment, and earned an average of 68% more in wages. These results suggest that rehabilitation outcomes may be enhanced by restructuring traditional work-for-pay contingencies to include direct financial rewards for meeting clinical goals.

Diagnosis, Dual (Psychiatry)↗
PubMed2005

Undiagnosed hyperglycemia in patients treated with atypical antipsychotics.

BACKGROUND: The use of atypical antipsychotics has been associated with abnormalities of glucose metabolism in patients with schizophrenia. This study was designed to determine the proportion of undiagnosed hyperglycemia in patients receiving a broad range of atypical antipsychotics. METHOD: All outpatients treated at an urban Veterans Affairs medical center who received a prescription for clozapine, risperidone, olanzapine, quetiapine, or ziprasidone were identified, and an attempt was made to obtain a fasting plasma glucose (FPG) test. Testing took place October 2000 to November 2002. Patients previously diagnosed as diabetic were excluded. RESULTS: Of the 647 patients who received antipsychotic prescriptions and were not diagnosed as diabetic, 494 (76.4%) had a random glucose result, while 153 (23.6%) had an FPG result. Within the FPG group, 107 (69.9%) had a normal FPG level, while 46 (30.1%) had an abnormally elevated FPG. There were no differences between these 2 groups in terms of race/ethnicity, age, body mass index, or comorbid diagnoses. However, significantly more patients receiving clozapine were found to have occult hyperglycemia (p = .001); no significant differences in the percentage of patients with FPG levels > or = 100 mg/dL and those with FPG levels < 100 mg/dL were observed for any of the other medications. CONCLUSION: Hyperglycemia is common in patients treated with atypical antipsychotics and thought to be euglycemic. Screening for elevated FPG is indicated for patients receiving atypical antipsychotics.

Ambulatory Care↗
PubMed2005

Declining access to alcohol and drug abuse services among veterans in the general population.

Although the Veterans Health Administration has been committed to preserving its capacity to provide specialized substance abuse (SA) services, administrative data from the late 1990s point to reduced access. To explore the possible effects of reduced access to Veterans Affairs services on veterans in the general population, we examined data from the National Household Survey of Drug Abuse from 1994 to 2001. Although the data are not longitudinal at the level of individuals, the annual nature of these surveys makes it possible to chart aggregate changes in clinical needs and service use over time. The results indicate that, whereas veterans' needs for SA services remained high and were consistent across these years, the proportion of veterans in treatment decreased. The proportion of nonveterans receiving SA treatment also decreased but not as steeply as that of veterans. This trend parallels declining delivery of specialized alcohol and drug abuse services within the Veterans Health Administration, although they do not prove a causal relationship.

Adult↗
PubMed2004

CALCYON gene variation, schizophrenia, and cocaine dependence.

Calcyon is a brain-specific D1 dopamine receptor-interacting protein, with a potential role in D1-mediated physiological processes, including motor control, reward mechanisms, and cognitive processes. Our objective was to investigate the relationship between polymorphism of the CALCYON gene and (1) schizophrenia and (2) cocaine dependence in African-American (AA) and European-American (EA) subjects. Two single nucleotide polymorphisms (SNPs) at the CALCYON locus were genotyped in 70 AA and 206 EA individuals with schizophrenia and 90 AA and 118 EA individuals with cocaine dependence. The control group was comprised of 46 AA and 207 EA subjects screened to exclude those with psychiatric or substance use disorders. The specific polymorphisms studied were markers +295214G/A and +297151T/G. Comparisons of allele and haplotype frequencies between cases and controls were performed with the Fisher's Exact Test. Linkage disequilibrium (LD) between these two SNPs was calculated with the 3LOCUS program. No alleles or haplotypes were found to be associated with schizophrenia or cocaine dependence either in AA or EA subjects. The markers +295214G/A and +297151T/G are in the same haplotype block in all subgroups. Allele and haplotype frequencies differed significantly between EA and AA subjects. These results suggest that these two genetic variants in the CALCYON gene do not play a major role in predisposition to either schizophrenia or cocaine dependence in AA or EA subjects. Furthermore, these findings begin to establish a haplotype map for this gene in the AA and EA populations.

Black or African American↗
PubMed2004

Age effects on antidepressant-induced manic conversion.

BACKGROUND: Antidepressant drug therapy can precipitate mania in vulnerable individuals, but little is known about the effects of age on this phenomenon. OBJECTIVE: To pharmacoepidemiologically evaluate the risk of conversion to mania by antidepressant class and patient age. DESIGN, SETTING, AND PATIENTS: Using an administrative national database of more than 7 million privately insured individuals, linked outpatient and pharmacy claims were analyzed for mental health users aged 5 to 29 years (N = 87,920). MAIN OUTCOME MEASURES: The proportion and cumulative hazard of manic conversion were analyzed by antidepressant class and subject age among children, adolescents, and young adults with an anxiety or nonbipolar mood disorder in the United States between January 1, 1997, and December 31, 2001. Manic conversion was defined as a new diagnosis of bipolar illness. RESULTS: During median follow-up of 41 weeks (range, 8-251 weeks), manic conversion occurred in 4786 patients (5.4%). Multivariate analyses using time-dependent Cox proportional hazards models indicated that an increased risk of manic conversion was associated with antidepressant category vs no antidepressant exposure (hazard ratios: 2.1 for selective serotonin reuptake inhibitors, P<.001; 3.8 for "other" antidepressants, P<.001; and 3.9 for tricyclic antidepressants, P =.002). Antidepressant x age interactions revealed inverse age effects for selective serotonin reuptake inhibitors and other antidepressants (beta = -.05; P<.001 for both) but not for tricyclic antidepressants (beta = -.02; P =.25). Peripubertal children exposed to antidepressants were at highest risk of conversion (number needed to harm: 10 [95% confidence interval, 9-12] among 10- to 14-year-olds vs 23 [95% confidence interval, 21-25] among 15- to 29-year-olds). CONCLUSIONS: Patient age is an effect modifier on the risk of antidepressant-associated manic conversion. Treatment with antidepressants is associated with highest conversion hazards among children aged 10 to 14 years.

Adolescent↗
PubMed2004

Measuring quality of pharmacotherapy for depression in a national health care system.

OBJECTIVES: This article examines the use of antidepressant medication in the treatment of major depression in the Department of Veterans Affairs (VA) during the 2001 fiscal year and considers the relationship of patient, drug, provider, and facility to adherence to medication treatment guidelines. METHODS: Prescription drug records for all VA outpatients diagnosed with major depression (International Classification of Diseases, 9th edition, code 296.2 or 296.3) were collected for October 2000 through September 2001. Indicators were constructed that noted whether patients newly treated with antidepressants (i.e., with no prescription in the previous 8 weeks) received at least 180 days (continuation phase) of antidepressant drug treatment (84- and 140-day measures were also considered). Logistic regression with and without center fixed effects and generalized estimation equations were used to identify patient, drug, and facility characteristics that were associated with these treatment quality indicators. RESULTS: Of the 27,713 patients in the final sample, 54% received at least 181 days of treatment. This is higher than recent rates reported by Health Employer Data and Information Set (HEDIS) for the general population, although our measures and those used by HEDIS are not exactly the same. Women, married patients, older patients, and whites were more likely than others to have higher-quality antidepressant drug treatment. Contrary to previous research, we find few significant differences among specific antidepressant agents prescribed in this large sample. Comorbid substance abuse was associated with fewer days of treatment, whereas other psychiatric comorbidities increased the length of treatment. We found few differences resulting from provider type. Although significant differences among facilities were found in the unadjusted rates (similar to those used by HEDIS), these diminished greatly after controlling for relevant covariates. CONCLUSIONS: In the nation's largest mental health system, quality of pharmacotherapy for depression, at least by one standard measure, is relatively good. We found the specific antidepressant drug used has little impact on quality. In considering differences among facilities, we found that it is critical to control for relevant patient characteristics.

Adult↗