Keith M. Miles

A comparative study of elderly patients with schizophrenia and bipolar disorder in nursing homes and the community

This study compared the functioning of 188 elderly schizophrenic and bipolar disorder patients living in nursing homes and the community. Residential status and diagnostic groups were compared on measures of symptomatology, cognitive impairment, functional impairment, and behavior problems. In general, the diagnostic groups differed in symptoms, while most differences in living setting were related to cognition, functioning, and behavior. Nursing home status was significantly associated with more severe overall symptom ratings, worse cognitive impairment, greater functional impairment, more aggressive behaviors, and marital status of having never married. Self-care skills, community living skills, and marital status were most uniquely predictive of nursing home residence. However, cognitive deficits were strongly predictive of both self-care and community living skills, explaining approximately half of the variance in these variables. The implications of these findings for the treatment of elderly patients with schizophrenia and other severe mental illnesses are discussed.

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial behavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems.

Design and sample characteristics of the PRISM-E multisite randomized trial to improve behavioral health care for the elderly.

Objective: To describe the design of the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study and baseline characteristics of the randomized primary care patients with mental health problems and at-risk alcohol use. Method: Adults aged 65 and older were screened at primary care clinics from 10 study sites throughout the United States. Those diagnosed for depression, anxiety, and/or at-risk alcohol consumption were randomized to either integrated or enhanced referral care. Results: Of the 23,828 participants, 14% had a positive assessment for depressive and/or anxiety disorders, and 6% had at-risk alcohol consumption diagnoses. Among patients with mental health diagnoses, there was a higher preponderance of younger ages, women, and ethnic minorities. Among patients with at-risk drinking, there was a higher preponderance of younger ages, Whites, and men. Discussion: These findings indicate the need for screening in primary care and for engaging older adults in treatment.

Mental health service use by elderly patients with bipolar disorder and unipolar major depression.

Symptoms, functioning, and mental health service use were compared in older out-patients with bipolar disorder and unipolar depression. Bipolar outpatients (n = 37, mean age = 69.7) had higher total symptom severity and positive symptom scores, more impaired community-living skills, and earlier age at onset of illness than patients with unipolar depression (n = 85, mean age = 70.9). Bipolar elderly patients used almost four times the total amount of mental health services and were four times more likely to have had a psychiatric hospitalization over the previous 6 months. These findings underscore the need for effective services for elderly patients with bipolar disorder, who account for a minority of patients with affective disorders, but use a disproportionate amount of costly services.

Functional impairments in elderly patients with schizophrenia and major affective illness in the community: Social skills, living skills, and behavior problems*

Despite recent advances in the psychosocial treatment of schizophrenia and other severe mental illnesses, little is known about the specific needs of elderly persons with these disorders. To address this gap in understanding, we examined the functional impairments of a sample of elderly patients with diagnoses of schizophrenia or schizoaffective disorder (N = 55), bipolar disorder (N = 39), or major depression (N = 90) who were living in the community and receiving mental health services. Functioning in four different areas was assessed: social skills, behavior problems, self-care skills, and community living skills. Diagnostic group comparisons indicated that the schizophrenia-schizoaffective disorder group had worse functioning than the other groups across all of the different domains. The clinical and research implications of the findings for the development of psychosocial interventions for elderly persons with schizophrenia are discussed.

Enhanced skills training and health care management for older persons with severe mental illness

This report describes a combined skills training (ST) and health management (HM) intervention for older adults with severe mental illness (SMI) and one-year pilot study outcomes. Findings are reported for twelve older persons with SMI (age 60+) who received ST+HM and twelve who received only HM. ST addressed interpersonal and independent living skills. HM included promotion of preventive health care. ST+HM was associated with improved social functioning and independent living skills, whereas functioning remained constant or declined for the HM only group. Both groups receiving HM demonstrated increased use of preventive health services and identification of previously undetected medical disorders.

Are Nursing Homes Appropriate for Older Adults with Severe Mental Illness? Conflicting Consumer and Clinician Views and Implications for the Olmstead Decision

Objectives: In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs.

Correlates of co-occurring depressive symptoms and alcohol use in an older primary care clinic population

ABSTRACT Objective: This report describes the prevalence and correlates of co-occurring depressive symptoms and alcohol use in an older Veterans Affairs primary care clinic population. Methods: Participants include 8,782 older primary care patients (age 65 +) who responded to a self-report, mailed survey. Patients were classified into six mutually exclusive groups based upon screening indicators for problem drinking (quantity/frequency questions) and depressive symptoms (General Health Questionnaire). Groups included: (a) neither problem drinking nor depressive symptoms (n = 6,415, 73.0%); (b) at-risk alcohol use (n = 761; 8.7%); (c) heavy alcohol use (n = 201; 2.3%); (d) depressive symptoms (n = 1,234, 14.1%); (e) depressive symptoms and at-risk alcohol use (n = 120; 1.4%); and (f) depressive symptoms and heavy alcohol use (n = 51; 0.6%). Chi-square and ANOVA were used to test for equality of demographic and clinical characteristics across groups. Results: 12.9% of patients reported alcohol use consistent with problem drinking (including 10.0% with at-risk alcohol use and 2.9% with heavy alcohol use) and 16.1% screened positive for possible depressive symptoms (including 2.0% with co-occurring at-risk or heavy alcohol use). The combination of heavy alcohol use and depressive symptoms was associated with the highest rates of death and suicidal ideation; living alone; being divorced, separated, or widowed; and regular cigarette smoking. The presence of depressive symptoms (regardless of amount of alcohol use) was associated with worse perceived health, and perceived lack of social support. Finally, individuals with at-risk alcohol use alone were younger and had better perceived health compared to those with non-problem alcohol use or no alcohol use. However, there were no differences between those with at-risk drinking and depressive symptoms and those with depressive symptoms alone. Conclusions: Self-reported heavy alcohol use combined with depressive symptoms identifies a subgroup of older primary care patients at especially high risk with respect to suicidal ideation and poor mental and physical well-being. In contrast, older adults with depressive symptoms and self-reported “at-risk” alcohol use were not differentiated from older persons with depressive symptoms reporting non-problematic or nonuse of alcohol.