David P. Folsom

Schizophrenia in homeless persons: a systematic review of the literature

Objective: This article systematically reviews studies of prevalence of schizophrenia in homeless persons.

Differences in Clinical Features and Mental Health Service Use in Bipolar Disorder Across the Lifespan

OBJECTIVE Because of the scarcity of research in geriatric bipolar disorder, the authors examined the prevalence, clinical features, and service use of persons with bipolar disorder among older adults treated in a large public mental health system. METHODS From San Diego Countys Adult and Older-Adult Mental Health Services database (N=34,970, fiscal year 2002-2003), the authors selected patients with bipolar disorder, divided them into three age-groups (young: age 18-39, middle-aged: age 40-59, and elderly: age 60+) and compared them on demographic, clinical, and mental health service use characteristics. RESULTS The authors identified 2,903 patients who received services for bipolar disorder at least once during the fiscal year, accounting for a slightly lower proportion of diagnosis among elderly patients (7.0%) than middle-aged (8.7%) or younger groups (8.3%). Elderly patients were less likely to have substance use disorder comorbidity, but more likely to have a cognitive disorder diagnosis and lower global functioning scores than their younger counterparts. Elderly bipolar patients were less likely than younger groups to use inpatient, outpatient, and emergency room psychiatric care, but more likely to use case-management and conservator services. DISCUSSION Bipolar disorder was only slightly less common among elderly patients in a large, public mental health system, compared to younger age-groups. Available clinical data revealed a mixed picture of bipolar disorder in late life, with more functional and cognitive impairment and less substance use disorder comorbidity and use of acute psychiatric services. Our findings suggest that older adults with bipolar disorder have unique mental health service needs.

Incarceration Among Adults Who Are in the Public Mental Health System: Rates, Risk Factors, and Short-Term Outcomes

OBJECTIVE Incarceration of people with mental illness has become a major social, clinical, and economic concern, with an estimated 2.1 million incarcerations in 2007. Prior studies have primarily focused on mental illness rates among incarcerated persons. This study examined rates of and risk factors for incarceration and reincarceration, as well as short-term outcomes after incarceration, among patients in a large public mental health system. METHODS The data set included 39,463 patient records combined with 4,544 matching incarceration records from the county jail system during fiscal year 2005-2006. Risk factors for incarceration and reincarceration were analyzed with logistic regression. Time after release from the index incarceration until receiving services was examined with survival analysis. RESULTS During the year, 11.5% of patients (N=4,544) were incarcerated. Risk factors for incarceration included prior incarcerations; co-occurring substance-related diagnoses; homelessness; schizophrenia, bipolar, or other psychotic disorder diagnoses; male gender; no Medicaid insurance; and being African American. Patients older than 45, Medicaid beneficiaries, and those from Latino, Asian, and other non-Euro-American racial-ethnic groups were less likely to be incarcerated. Risk factors for reincarceration included co-occurring substance-related diagnoses; prior incarceration; diagnosed schizophrenia or bipolar disorder; homelessness; and incarceration for three or fewer days. Patients whose first service after release from incarceration was outpatient or case management were less likely to receive subsequent emergency services or to be reincarcerated within 90 days. CONCLUSIONS Modifiable factors affecting incarceration risk include homelessness, substance abuse, lack of medical insurance, and timely receipt of outpatient or case management services after release from incarceration.

Increased Framingham 10-year risk of coronary heart disease in middle-aged and older patients with psychotic symptoms

OBJECTIVE The Framingham 10-risk of coronary heart disease (CHD) has been a widely studied estimate of cardiovascular risk in the general population. However, few studies have compared the relative risk of developing CHD in antipsychotic-treated patients with different psychiatric disorders, especially in older patients with psychotic symptoms. In this study, we compared the 10-year risk of developing CHD among middle-aged and older patients with psychotic symptoms to that in the general population. METHOD We analyzed baseline data from a study examining metabolic and cardiovascular effects of atypical antipsychotics in patients over age 40 with psychotic symptoms. After excluding patients with prior history of CHD and stroke, 179 subjects were included in this study. Among them, 68 had a diagnosis of schizophrenia, 42 mood disorder, 38 dementia, and 31 PTSD. Clinical evaluations included medical and pharmacologic treatment history, physical examination, and clinical labs for metabolic profiles. Using the Framingham 10-year risk of developing CHD based on the Framingham Heart Study (FHS), we calculated the risk CHD risk for each patient, and then compared relative risk in each psychiatric diagnosis to the risks reported in the FHS. RESULTS The mean age of entire sample was 63 (range 40-94) years, 68% were men. The Framingham 10-year risk of CHD was increased by 79% in schizophrenia, 72% in PTSD, 61% in mood disorder with psychosis, and 11% in dementia relative to the risk in general population from the FHS. CONCLUSIONS In this sample of middle-aged and older patients with psychotic symptoms, we found a significantly increased 10-year risk of CHD relative to the estimated risk from FHS, with the greatest increased risk for patients with schizophrenia and PTSD. Development of optimally tailored prevention and intervention efforts to decrease different risk components in these patients could be an important step to help decrease the risks of CHD and overall mortality in this vulnerable population.

Association of Posttraumatic Stress Disorder With Increased Prevalence of Metabolic Syndrome

Objective: Few studies have compared prevalence rates of metabolic abnormalities in antipsychotic-treated patients with different psychiatric disorders, including posttraumatic stress disorder (PTSD). In this study, we examined components of metabolic syndrome among middle-aged and older patients with psychiatric disorders. Method: In the study, 203 outpatients older than 40 years and with psychotic symptoms that needed antipsychotic treatment were enrolled. Among them, 65 had a diagnosis of schizophrenia, 56 had dementia, 49 had mood disorder, and 33 had PTSD. Clinical evaluations included medical history, use of psychotropic and other medications, adverse effects, physical examination, and clinical laboratory tests for metabolic profiles. Results: Overall, the prevalence rates of metabolic syndrome were 72% in patients with PTSD, 60% in those with schizophrenia, 58% in those with mood disorder, and 56% in those with dementia. There were significant differences in body mass index, diastolic blood pressure, waist circumference, and high-density lipoprotein cholesterol among the 4 diagnostic groups. Posttraumatic stress disorder, schizophrenia, and mood disorder groups had significantly higher body mass indexes compared with the dementia group. The PTSD group also had significantly higher diastolic blood pressure compared with the dementia and mood disorder groups. Conclusions: Posttraumatic stress disorder may be associated with worsened metabolic profile. The overall frequency of metabolic syndrome and its components in patients with PTSD taking antipsychotics seemed to be at least equivalent, if not slightly worse, compared with that in patients with schizophrenia, dementia, or a mood disorder.

Physical and mental health-related quality of life among older people with schizophrenia.

OBJECTIVE Since the time of Kraeplin, schizophrenia has been thought of as a disorder with progressive deterioration in functioning. An important aspect of functioning is both physical and mental health-related quality of life (HRQoL). The objective of this study was to examine the relationship of age to both mental and physical aspects of HRQoL in individuals with schizophrenia as compared to normal comparison subjects (NCs). METHODS Middle-aged and older community-dwelling patients with schizophrenia (N=486) were compared to NCs (N=101). Health related quality of life was measured using the SF-36 Physical Health and Mental Health Component scores. The relationship between age and HRQoL was examined using linear regressions. In addition, we performed exploratory analyses to examine the effects of confounding variables on this relationship, and to examine the effects of age on SF-36 subscales. RESULTS Patients with schizophrenia had lower SF-36 Physical and Mental Health Component scores than NCs, and these differences persisted after adjusting for the age difference between the two groups. The relationship between age and mental, but not physical, HRQoL was significantly different between the patients with schizophrenia and the NCs. Specifically, older age was associated with higher mental HRQoL among patients with schizophrenia, but not among the NCs. This difference remained significant after examining multiple potential confounding demographic and clinical variables. CONCLUSIONS This study found that older age was associated with greater mental health quality of life. Longitudinal studies are warranted to confirm our finding, and to examine potential mechanisms responsible for possible improvement in mental HRQoL with age.

Patterns of Public Mental Health Service Use by Age in Patients With Schizophrenia

OBJECTIVE Authors examined the relationship between age and use of public mental health services by adults with schizophrenia in a large mental health care system. METHODS The study sample included 4,975 patients treated for schizophrenia in San Diego Countys Adult Mental Health Services (AMHS) during fiscal year 1999-2000. They compared three age-groups: 18-44 years (young adults), 45-64 (middle-aged), and 65-or-older (elderly) on 1) the number of individuals treated for schizophrenia per 10,000 people in the county, and 2) the use of six different types of public mental health services, including hospitalization, emergency psychiatric unit, crisis house, outpatient clinic, day treatment, and case management. RESULTS Elderly patients with schizophrenia were underrepresented among AMHS users with a diagnosis of schizophrenia. The use of hospitalization, emergency room, crisis house, and day treatment was highest among young-adult patients and decreased with age. Outpatient treatment use was similar for young-adult and middle-aged patients and lower for elderly patients. The only type of service use that seemed to increase with age was case management. Even after controlling for gender, ethnicity, living situation, substance use disorder, and insurance status, most of the above-mentioned age-related differences in service use persisted. CONCLUSION Among patients with schizophrenia in a public mental health system, old age was associated with significantly lower use of all mental health services except case management. Research is needed to explore reasons for this differential use of services across age-groups.

Diagnostic variability for schizophrenia and major depression in a large public mental health care system dataset

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.

Integrated Medicine and Psychiatry Curriculum for Psychiatry Residency Training: A Model Designed to Meet Growing Mental Health Workforce Needs

Patients with chronic mental illness have significantly higher rates of medical comorbidity and resultant lower life expectancies when compared to the general population [1–3]. This survival discrepancy is not fully accounted for by the higher rate of suicide completion in these patients but, rather, is often attributable to mortality from cardiovascular, metabolic, and other systemic illness. Many such individuals are seen in community mental health settings and have poor access to primary health care. In some cases, the psychiatrist may become the “de facto primary care physician,”while providing some preventive health screening and treatment of general medical conditions. For those patients who are cared for by a primary care provider, the psychiatrist may support preventive medical recommendations with psychopharmacological interventions and the use of psychotherapies such as cognitive behavioral therapy, problem solving therapy, supportive psychotherapy, and motivational interviewing. Strong evidence calls for improved general medical care for people with severe mental illnesses. In a 17-year followup study of over 80,000 people in the USA, those with mental illness died an average of 8.2 years earlier than those without mental illness, with excess mortality primarily due to socioeconomic factors, poor access to effective primary and preventative care, and the burden of chronic health conditions [1]. Moreover, individuals with schizophrenia tend to die 20– 30 years earlier than the population average, even after excluding deaths by suicide [2]. Similarly, those with bipolar disorder have a twofold higher mortality rate than the general population [3]. Patients with major depression are also at higher risk of medical illness, such as diabetes mellitus and ischemic heart disease [4, 5]. The increased risk of diabetes mellitus, metabolic syndrome, cardiovascular disease, and stroke associated with atypical antipsychotics further underscores the need for the psychiatrist to engage in risk factor monitoring, risk reduction, and recognition and management of comorbid medical conditions in their patients [6–8]. Given the significantly increased mortality among psychiatric patients as a result of non-psychiatric medical conditions, it is essential we provide psychiatric training that mirrors significant changes to our mental health delivery system by way of the Patient Protection and Affordable Care Act. Psychiatry residents should receive training about collaborative and targeted preventive medical care, which better approximates current and real-world clinical practice guidelines found in patient-centered medical homes. We suggest one approach to accomplishing this is to provide residents with an Integrated Medicine and Psychiatry (IMAP) curriculum.

Medical Comorbidity in Geriatric Psychiatry

Received January 3, 2005; accepted January 6, 2005. From the University of California–San Diego (DPF) and Channing Laboratory, Boston, MA (OIO). Send correspondence to Olivia I. Okereke, M.D., Channing Laboratory, 3rd floor, 181 Longwood Avenue, Boston, MA 02115. e-mail: ookereke@partners.org. 2005 American Association for Geriatric Psychiatry This is the first time that The American Journal of Geriatric Psychiatry has published a special section focusing on comorbid medical and psychiatric conditions in older persons. This theme is particularly important, given the fact that, among older patients, comorbid medical conditions are the rule rather than the exception. For example, in the IMPACT study, which was an investigation of collaborative care for older patients with depression treated in primary care, the average patient had more than three comorbid medical conditions. The relationship between mental and physical health may bemore important in geriatric psychiatry and geriatrics than in any other area of medicine. In this month’s Journal, Kilbourne and colleagues address the overall burden of general-medical comorbidity among older patients with serious mental illness (SMI). Using a large Veterans Health Administration-based sample of over 8,000 subjects with schizophrenia, schizoaffective disorder, or bipolar disorder, they contrast the degree of medical comorbidity among those patients age 60 and older with that of young patients. The authors found that the prevalence estimates of cardiovascular morbidity (hypertension and ischemic heart disease were the two most frequent diagnoses) and endocrinemorbidity (diabetes and hyperlipidemia were the two most common) were each about 30% among older patients. Also, older people with SMI were more likely to be diagnosed with pulmonary conditions and cancers and had an overall higher total burden of medical comorbidity (i.e., three or more conditions) than younger individuals. These results stand in contrast to the finding that younger seriously mentally ill persons experience a higher burden of substance-abuse disorders, hepatic illnesses, and accidents or injuries. The authors highlight the need for further development of strategies to treat coexisting serious medical and psychiatric conditions in the geriatric population. Also in this issue, Kilbourne et al. examine the effect that depressive symptoms have on adherence to treatment for a specific chronic condition: diabetes. As the authors point out, diabetes is an excellent example of a chronic disease for assessment to advance our understanding of why patients with depression have worse medical outcomes than those without depression. Diabetes is common, particularly in older patients, and the treatment of diabetes often involves multiple medications. In this investigation, the authors found a relationship between depressive symptoms and some, but not all, measures of adherence to diabetes treatment. This study highlights the complexity of measuring adherence to medications: using pharmacy refill data and patient self-report, there appeared to be a lower rate of medication adherence in patients with greater depressive symptoms; however, when using provider-report and electronic monitoring caps, no relationship was found between adherence and depressive symptoms. As the authors conclude, this report suggests that physicians caring for people with diabetes should be aware that those patients with comorbid depression may have lower medication adherence and may benefit from extra efforts to improve treatment adherence.