Erik R. Vanderlip

National study of discontinuation of long-term opioid therapy among veterans

Summary Veterans on continuous opioids with lower doses were more likely to stop. Mental illness and substance use increased the likelihood of discontinuation. ABSTRACT Veterans have high rates of chronic pain and long‐term opioid therapy (LTOT). Understanding predictors of discontinuation from LTOT will clarify the risks for prolonged opioid use and dependence among this population. All veterans with at least 90 days of opioid use within a 180‐day period were identified using national Veteran’s Health Affairs (VHA) data between 2009 and 2011. Discontinuation was defined as 6 months with no opioid prescriptions. We used Cox proportional hazards analysis to determine clinical and demographic correlates for discontinuation. A total of 550,616 veterans met criteria for LTOT. The sample was primarily male (93%) and white (74%), with a mean age of 57.8 years. The median daily morphine equivalent dose was 26 mg, and 7% received high‐dose (>100 mg MED) therapy. At 1 year after initiation, 7.5% (n = 41,197) of the LTOT sample had discontinued opioids. Among those who discontinued (20%, n = 108,601), the median time to discontinuation was 317 days. Factors significantly associated with discontinuation included both younger and older age, lower average dosage, and having received less than 90 days of opioids in the previous year. Although tobacco use disorders decreased the likelihood of discontinuation, co‐morbid mental illness and substance use disorders increased the likelihood of discontinuation. LTOT is common in the VHA system and is marked by extended duration of use at relatively low daily doses with few discontinuation events. Opioid discontinuation is more likely in veterans with mental health and substance use disorders. Further research is needed to delineate causes and consequences of opioid discontinuation.

Treating complexity: Collaborative care for multiple chronic conditions

Abstract Individuals with co-morbid chronic medical illness and psychiatric illness are a costly and complex patient population, at high risk for poor outcomes. Health-risk behaviours (e.g. smoking, poor diet, and sedentary lifestyle), side effects from psychiatric medications, and poor quality medical care all contribute to poor outcomes. Individuals with major depression die, on average, 5 to 10 years before their age-matched counterparts. For individuals with severe mental illness such as bipolar disorder or schizophrenia, life expectancy may be up to 20 years shorter. As the majority of this premature mortality is due to cardiovascular disease, there is a critical need to engage these individuals around the care of chronic medical illness.

Exploring Primary Care Activities in ACT Teams

People with serious mental illness often receive inadequate primary and preventive care services. Federal healthcare reform endorses team-based care that provides high quality primary and preventive care to at risk populations. Assertive community treatment (ACT) teams offer a proven, standardized treatment approach effective in improving mental health outcomes for the seriously mentally ill. Much is known about the effectiveness of ACT teams in improving mental health outcomes, but the degree to which medical care needs are addressed is not established. The purpose of this study was to explore the extent to which ACT teams address the physical health of the population they serve. ACT team leaders were invited to complete an anonymous, web-based survey to explore attitudes and activities involving the primary care needs of their clients. Information was collected regarding the use of health screening tools, physical health assessments, provision of medical care and collaboration with primary care systems. Data was analyzed from 127 team leaders across the country, of which 55 completed the entire survey. Nearly every ACT team leader believed ACT teams have a role in identifying and managing the medical co-morbidities of their clientele. ACT teams report participation in many primary care activities. ACT teams are providing a substantial amount of primary and preventive services to their population. The survey suggests standardization of physical health identification, management or referral processes within ACT teams may result in improved quality of medical care. ACT teams are in a unique position to improve physical health care by virtue of having medically trained staff and frequent, close contact with their clients.

Presenting symptoms of women with depression in an obstetrics and gynecology setting.

OBJECTIVE: To describe the presenting symptoms of women with depression in two obstetrics and gynecology clinics, determine depression diagnosis frequency, and examine factors associated with depression diagnosis. METHODS: Data were extracted from charts of women screening positive for depression in a clinical trial testing a collaborative care depression intervention. Bivariate and multivariable analyses examined patient factors associated with the diagnosis of depression by an obstetrician–gynecologist (ob-gyn). RESULTS: Eleven percent of women with depression presented with a psychologic chief complaint but another 30% mentioned psychologic distress. All others noted physical symptoms only or presented for preventive care. Ob-gyns did not identify 60% of women with a depression diagnosis. Depression severity was similar in women who were or were not diagnosed by their ob-gyns. Bivariate analyses showed four factors significantly associated with depression diagnosis: reporting a psychologic symptom as the chief complaint or associated symptom (72% compared with 18.6%, P<.001), younger age (35.5 years compared with 40.8 years, P<.005), being within 12 months postpartum (13.9% compared with 2.8%, P<.005), and a primary care-oriented visit (72% compared with 30%, P<.001). Multivariable analysis showed that reporting a psychologic symptom (adjusted odds ratio [OR] 8.90, 95% confidence interval [CI] 4.15–19.10, P<.001), a primary care oriented visit (adjusted OR 2.46, 95% CI 1.14–5.29, P=.03), and each year of increasing age (adjusted OR 0.96, 95% CI 0.93–0.96, P=.02) were significantly associated with a depression diagnosis. CONCLUSION: The majority of women with depression presented with physical symptoms; most women with depression were not diagnosed by their ob-gyn, and depression severity was similar in those diagnosed and those not diagnosed. LEVEL OF EVIDENCE: III

Screening, Diagnosis, and Treatment of Dyslipidemia Among Persons With Persistent Mental Illness: A Literature Review

OBJECTIVE Cardiovascular disease is the most frequent cause of death of persons with severe and persistent mental illness, and there is evidence of a widening mortality gap with the general population. Modifiable risk factors for cardiovascular disease, including dyslipidemia, are frequently underrecognized and undertreated. This review provides practitioners with an update on screening, diagnosis, and referral or treatment of dyslipidemia in this population. METHODS A literature search in PubMed from 1990 to 2012 that used various combinations of the terms cholesterol, screening, diagnosis, treatment, and severe mental illnesses identified 74 clinically relevant articles for review, and reference lists guided further exploration of sources. Additional material was selected with a focus on emerging guidelines to create clinically relevant recommendations for practitioners. RESULTS Multiple barriers can prevent clinicians from obtaining samples from fasting patients, which can be detrimental to successful screening. Dyslipidemia can be successfully screened for with nonfasting total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides, with follow-up measurement of fasting low-density lipoprotein (LDL) cholesterol if total cholesterol is greater than 200 mg/dl or triglycerides are above 500 mg/dl. Compelling evidence supports pharmacologic treatment of dyslipidemia to reduce cardiovascular events among high-risk patients. CONCLUSIONS When obtaining samples from fasting patients is not feasible, use of samples from nonfasting patients can radically improve management of dyslipidemia among persons with severe and persistent mental illness. Common medications used to treat dyslipidemia are inexpensive, safe, and effective and could be more liberally employed to address comorbidities in this population.

Integrated Care: Nonfasting Screening for Cardiovascular Risk Among Individuals Taking Second-Generation Antipsychotics

Ischemic heart disease (IHD) is the leading cause of mortality among adults with severe mental illness. Although gains in reducing mortality from IHD through screening, risk reduction, and early intervention have been realized for the general public, rates of recognition and treatment among individuals with mental illness continue to be poor. Obtaining blood samples from patients who have been fasting for eight to 12 hours is challenging for adults with severe mental illness and presents an additional obstacle to screening and treatment. This column outlines newer guidelines for cholesterol and diabetes screening that provide valid alternatives to fasting blood draws, thereby significantly reducing this common barrier to recognition of leading risk factors for IHD.

Suggesting a Medical-Psychiatric Cohort for ACT Treatment: In Reply

active intervention to end a life that would otherwise continue. That is not a small difference, legally or morally. For the reasons suggested in the column, including the possibility that physician-assisted death would serve as a substitute for ongoing commitment to patients with difficultto-treat disorders, it would be most unfortunate for the United States and Canada to follow in the footsteps of those European countries that have legalized that option.

Systematic Literature Review of General Health Care Interventions Within Programs of Assertive Community Treatment

OBJECTIVE Assertive community treatment (ACT) is one of the few evidence-based practices for adults with severe mental illness. Interest has slowly waned for ACT implementation. Yet ACT remains an appealing services platform to achieve the triple aim of health care reform (improved health outcomes, reduced cost, and improved satisfaction) through integration of primary care and behavioral health services. This review highlights the evidence for ACT to improve general medical outcomes, reduce treatment costs, and increase access to treatment. METHODS Using a comprehensive list of relevant search terms, the authors performed a systematic literature database search for articles published through November 2015, resulting in ten articles for inclusion. RESULTS No studies reported on clinical outcomes of general medical comorbidities or on mortality of ACT clients. Half of the studies reporting utilization (three of six) found a decrease in emergency room usage, and three of four studies identified an increase in outpatient primary care visits. Most studies found no increase in overall medical care costs. Of the few studies reporting on quality of life, most found mild to moderate improvements. CONCLUSIONS To date, rigorous scientific examination of the effect of ACT on the general health of the populations it serves has not been undertaken. Given ACTs similarity to emerging chronic illness medical management models, the approach seems like a natural fit for improving general medical outcomes of persons with severe mental illnesses. More research is needed that investigates the current effect of ACT teams on general medical outcomes, treatment costs, and access to care.

Depression among patients with diabetes attending a safety-net primary care clinic: relationship with disease control.

BACKGROUND Depression and diabetes are highly comorbid, with depression increasing risk of diabetes-related complications and mortality. Few studies have examined the relationship between depression and diabetes in safety-net populations with high rates of trauma exposure, anxiety, and substance use disorders. METHODS Using a cross-sectional survey of 261 patients with diabetes attending safety-net clinics, associations between depression and key diabetes control parameters were examined in bivariate and multivariable analyses adjusting for relevant confounders and significant interactions. RESULTS Among the participants, 57% were men, 51% were white, and the average age was 57 years. Most respondents were unemployed (81%) and earned less than

Presenting symptoms of women with depression in an obstetrics and gynecology setting

10,000 per year (51%). Overall, 28% screened positive for depression, with a high overlap of posttraumatic stress (58%) and generalized anxiety (77%) symptoms. After adjustment for socioeconomic and clinical variables, depression was associated with higher mean body mass index (p = 0.01), severe obesity (body mass index ≥ 35kg/m(2)) (odds ratio = 2.34, 95% CI: 1.09-5.04, p = 0.03) and uncontrolled diastolic blood pressure (odds ratio = 2.49, 95% CI: 1.15-5.39, p = 0.02). There was a nonsignificant trend for those with depression to have worse control of blood glucose. Associations with depression and diabetes clinical outcomes were not significantly worsened in the presence of comorbid anxiety disorders. CONCLUSIONS Within a highly comorbid safety-net population, significant associations between depression and key diabetes outcomes remained after accounting for relevant covariates. Further research will help elucidate the relationship between depression and diabetes control measures in safety-net populations.