Eric P. Slade

Measures and Predictors of Community-Based Employment and Earnings of Persons With Schizophrenia in a Multisite Study

OBJECTIVE Data from a national study of persons with schizophrenia-related disorders were examined to determine clinical factors and labor-market conditions related to employment outcomes. METHODS Data were obtained from the U.S. Schizophrenia Care and Assessment Program, a naturalistic study of more than 2,300 persons from organized care systems in six U.S. regions. Data were collected via surveys and from medical records and clinical assessments at baseline and for three years. Outcome measures included any community-based (nonsheltered) employment, 40 or more hours of work in the past month, employment at or above the federal minimum wage, days and hours of work, and earnings. Bivariate and multiple regression analyses of data from more than 7,000 assessments tested relationships between outcomes and sociodemographic, clinical, and local labor market characteristics. RESULTS The employment rate was 17.2%; only 57.1% of participants who worked reported 40 or more hours of past-month employment. The mean hourly wage was

The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States.

7.05, and mean monthly earnings were

Impacts of age of onset of substance use disorders on risk of adult incarceration among disadvantaged urban youth: a propensity score matching approach.

494.20. Employment rates and number of hours worked were substantially below those found in household surveys or in baseline data from trials of employment programs but substantially higher than those found in a recent large clinical trial. Strong positive relationships were found between clinical factors and work outcomes, but evidence of a relationship between local unemployment rates and outcomes was weak. CONCLUSIONS Work attachment and earnings were substantially lower than in previous survey data, not very sensitive to labor market conditions, and strongly related to clinical status.

Effects of School-Based Mental Health Programs on Mental Health Service Use by Adolescents at School and in the Community

Problems related to mental illness are increasingly becoming the focal point of public concern over the safety and performance of schools, yet little is known about the availability and quality of school-based mental health services in the United States. In this article it is estimated that approximately 50% of US middle and high schools have any mental health counseling services available onsite and approximately 11% have mental health counseling, physical examinations, and substance abuse counseling available on-site. There are substantial differences in mental health counseling availability by region, urbanicity, and school size, with rural schools, schools in the Midwest and South regions, and small schools being least likely to offer mental health counseling. Multivariate estimates suggest that disparities between schools in the availability of mental health counseling and related health services may be partly explained by differences in access to Medicaid for financing of health services provided at school.

Trends in the Duration of Emergency Department Visits, 2001–2006

BACKGROUND Age of onset of substance use disorders in adolescence and early adulthood could be associated with higher rates of adult criminal incarceration in the U.S., but evidence of these associations is scarce. METHODS Propensity score matching was used to estimate the association between adolescent-onset substance use disorders and the rate of incarceration, as well as incarceration costs and self-reported criminal arrests and convictions, of young men predominantly from African American, lower income, urban households. Age of onset was differentiated by whether onset of the first disorder occurred by age 16. RESULTS Onset of a substance use disorder by age 16, but not later onset, was associated with a fourfold greater risk of adult incarceration for substance related offenses as compared to no disorder (0.35 vs. 0.09, P=0.044). Onset by age 16 and later onset were both positively associated with incarceration costs and risk of arrest and conviction, though associations with crime outcomes were more consistent with respect to onset by age 16. Results were robust to propensity score adjustment for observable predictors of substance use in adolescence and involvement in crime as an adult. CONCLUSION Among young men in this high risk minority sample, having a substance use disorder by age 16 was associated with higher risk of incarceration for substance related offenses in early adulthood and with more extensive criminal justice system involvement as compared to having no disorder or having a disorder beginning at a later age.

The relationship between per capita income and diffusion of medical technologies

Many schools provide counseling to adolescents with behavioral and emotional problems on-site, but little is known about the use of school-based counseling services in the United States, and it is unclear whether these services complement or substitute for counseling services available outside of school. In this study data on mental health services offered in schools are used to estimate the probability of receiving emotional counseling at school and elsewhere. Where mental health services were available on-site, students were substantially more likely to see a counselor in the previous year, controlling for mental health status, health insurance coverage, and other factors. The effects of availability were greater for students enrolled in special education programs than for other students. However, these data also suggest that, relative to other schools, schools offering on-site mental health counseling do not increase or reduce use of counseling services outside of school on average.

Access to new medications to treat schizophrenia

OBJECTIVE This study estimated trends in the duration of emergency department visits from 2001 to 2006 and compared duration by presenting complaint-mental health related or non-mental health related. METHODS Data on visits (N=193,077) were from the National Hospital Ambulatory Medical Care Survey Emergency Department databases. Visits were classified as mental health visits if the primary reason for the visit was a common mental health symptom or disorder, a problem related to substance use, suicidal behaviors, or a need for counseling. Regression models were adjusted for year, diagnosis type, discharge status, payment source, demographic characteristics, receipt of medical care during the visit, mode of arrival, and immediacy of need for treatment. RESULTS The duration of all emergency department visits increased at an annual rate of 2.3%. Trends were similar for mental health visits and non-mental health visits. Throughout the period the average duration of mental health visits exceeded the average duration of non-mental health visits by 42% (p<.001). This difference was related to the longer durations of mental health visits ending in transfer and visits by persons with serious mental illness or substance use disorders. CONCLUSIONS From 2001 to 2006, the duration of emergency department visits made by patients presenting with mental health complaints and visits made by all other patients increased at similar rates. However, the longer visits for certain groups of mental health patients suggest that emergency departments incur higher costs in connection with the delivery of services to persons in need of acute stabilization.

Time to discontinuation of first- and second-generation antipsychotic medications in the treatment of schizophrenia

It is commonly known that per capita income is correlated with the level of health care spending and that technology is a major factor in explaining the increase in health care spending. This study examines differences in the rate of diffusion of medical technologies in Organization for Economic Cooperation and Development countries between 1975 and 1995. We find that the importance of income in explaining the long-term availability of a technology generally declines over time and becomes insignificant for some technologies. In other words, more affluent countries are earlier adopters of new technologies, but access to technology becomes less dependent on income over time. The evidence also suggests that the effects of reimbursement incentives are greater for purchases of diagnostic technologies than for lifesaving technologies and that reimbursement incentive effects are less significant for older technologies.

Antidepressant prescribing patterns among VA patients with schizophrenia.

Between 1989 and 1997, the Food and Drug Administration approved four new-generation antipsychotic medications for use in the treatment of schizophrenia. This article examines factors associated with the use of new antipsychotic medications as compared with traditional antipsychotic medications from patient interviews, medical records, and a physician survey administered at schizophrenia treatment sites around the country as part of the Schizophrenia Care and Assessment Program. The following variables were significantly associated with a higher probability of receiving an atypical antipsychotic medication in multiple regression analysis atP<.05: female, younger age, younger age of onset, non-African American, having a higher Positive and Negative Syndrome Scale-Negative Syndrome subscale score. Some physician characteristics were statistically significant in the bivariate results but not in the multivariate analyses. Access to new atypical antipsychotic medications is dependent on more than clinical characteristics. In particular, barriers to access may exist for African Americans. Physician access to information about advances in drug therapies also may play a substantial role in the rate of diffusion of new medications.

Estimation of antipsychotic effects on hospitalization risk in a naturalistic study with selection on unobservables.

BACKGROUND Continuous adherence to antipsychotic treatment is critical for individuals with schizophrenia to benefit optimally, yet studies have shown rates of antipsychotic discontinuation to be high with few differences across medications. We investigated discontinuation of selected first- and second-generation antipsychotics among individuals with schizophrenia receiving usual care in a VA healthcare network in the U.S. mid-Atlantic region. METHODS We identified 2138 VA patients with schizophrenia who initiated antipsychotic treatment with one of five non-clozapine second-generation antipsychotics or either of the two most commonly prescribed first-generation agents between 1/2004 and 9/2006. The dependent variable was duration of continuous antipsychotic possession from the index prescription until the first gap of more than 45 days between prescriptions. We used the Cox proportional hazards model to compare the hazard of discontinuation among the seven antipsychotics controlling for patient demographic and clinical characteristics. The reference group was olanzapine. RESULTS The majority of patients (84%) discontinued their index antipsychotic during the follow-up period (up to 33 months). In multivariable analysis, only risperidone had a significantly greater hazard of discontinuation compared to olanzapine (Adjusted hazard ratio=1.15, 95% CI: 1.02-1.30, p=.025). Younger age, non-white race, homelessness, substance use disorder, recent inpatient mental health hospitalization, and prescription of another antipsychotic were also associated with earlier discontinuation. CONCLUSIONS Examination of a usual care sample of individuals with schizophrenia revealed short durations of antipsychotic use, with only risperidone having a shorter time to discontinuation than olanzapine. These findings demonstrate that current antipsychotic agents have limited overall acceptability by patients in usual care.