Linda K. Frisman

A Comparison of Clozapine and Haloperidol in Hospitalized Patients with Refractory Schizophrenia

BACKGROUND Clozapine, a relatively expensive antipsychotic drug, is widely used to treat patients with refractory schizophrenia. It has a low incidence of extrapyramidal side effects but may cause agranulocytosis. There have been no long-term assessments of its effect on symptoms, social functioning, and the use and cost of health care. METHODS We conducted a randomized, one-year, double-blind comparative study of clozapine (in 205 patients) and haloperidol (in 218 patients) at 15 Veterans Affairs medical centers. All participants had refractory schizophrenia and had been hospitalized for the disease for 30 to 364 days in the previous year. All patients received case-management and social-rehabilitation services, as clinically indicated. RESULTS In the clozapine group, 117 patients (57 percent) continued their assigned treatment for the entire year, as compared with 61 (28 percent) of the patients in the haloperidol group (P<0.001). As judged according to the Positive and Negative Syndrome Scale of Schizophrenia, patients in the clozapine group had 5.4 percent lower symptom levels than those in the haloperidol group at all follow-up evaluations (mean score, 79.1 vs. 83.6; P=0.02). The differences on a quality-of-life scale were not significant in the intention-to-treat analysis, but they were significant among patients who did not cross over to the other treatment (P=0.003). Over a one-year period, patients assigned to clozapine had fewer mean days of hospitalization for psychiatric reasons than patients assigned to haloperidol (143.8 vs. 168.1 days, P=0.03) and used more outpatient services (133.6 vs. 97.9 units of service, P=0.03). The total per capita costs to society were high --

The proportion of veterans among homeless men.

58,151 in the clozapine group and

Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions.

60,885 in the haloperidol group (P=0.41). The per capita costs of antipsychotic drugs were

Validity of Self-Reported Drug Use Among People with Co-Occurring Mental Health and Substance Use Disorders

3,199 in the clozapine group and

Rural and urban differences in patients with a dual diagnosis.

367 in the haloperidol group (P<0.001). Patients assigned to clozapine had less tardive dyskinesia and fewer extrapyramidal side effects. Agranulocytosis developed in three patients in the clozapine group; all recovered fully. CONCLUSIONS For patients with refractory schizophrenia and high levels of hospital use, clozapine was somewhat more effective than haloperidol and had fewer side effects and similar overall costs.

A Comparison of Prebooking and Postbooking Diversion Programs for Mentally Ill Substance-Using Individuals With Justice Involvement

This study used data from four surveys conducted in 1986/87 to identify age-race cohorts of homeless men in which veterans are overrepresented. The overall proportion of veterans among homeless men (41%) was somewhat higher than that in the general population (34%). This overrepresentation is largely attributable to the disproportionate representation of veterans in the youngest age cohort (20 to 34 years) of homeless White men. Veterans in this group are 4.76 times more likely to be homeless than nonveterans. Other national data on this cohort reveal higher rates of unemployment, substance abuse, and antisocial personality among veterans than among nonveterans.

Outcomes of Trauma Treatment Using the TARGET Model

Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.

ISSUES IN ESTIMATING THE COST OF INNOVATIVE MENTAL HEALTH PROGRAMS

Abstract Objectives: The validity of self-reports of drug use from individuals who abuse substances has been questioned. Results from studies examining the accuracy of such self-reports have been mixed, indicating the need for closer examinations of the factors associated with concordance between self-reported drug use and results of urine screens. Methods: As part of a larger study examining the effectiveness of interventions for people with co-occurring mental health and substance use disorders, we examined the agreement between self-report and urine screens for recent drug use. Results: Overall, the concordance between self-report and results from urine screens was high (80-84% agreement overall and 75–79% for the subset where the urine screen indicated recent drug use). Estimates for the likelihood of use of marijuana and cocaine within the past 30 days were 15% and 32%, respectively, based on urine screens, 25% and 35% based on self-report, and 28% and 43% based on information from both sources combined. About 1/3 of individuals who had at least one positive urine screen misrepresented their drug use at least once. Such misrepresentation tended to increase with time in the study. Conclusions: The relatively high concordance rates between self-report and urine screens indicate that situations can be structured so that individuals with co-occurring mental health and substance use disorders report instances of substance use accurately most of the time. Given the observed increase in failure to report use through time, the utility of biological markers may be more valuable as clients develop relationships with clinicians.

Partner Relationships and HIV Risk Behaviors among Women Offenders

OBJECTIVES To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas. METHODS Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life. RESULTS Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness. CONCLUSIONS Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.

Ethnic differences in the effects of spiritual well-being on long-term psychological and behavioral outcomes within a sample of homeless women.

Eight programs are described representing a variety of approaches to diversion in terms of point of criminal justice intervention (prebooking or postbooking), degree of criminal justice coercion, type of linkages provided to community-based treatment, and approaches to treatment retention. The authors also describe the characteristics of almost 1000 study participants who were diverted into these programs over an 18-month period and examine the extent to which systematic differences are observed between prebooking and postbooking subjects, as well as among sites in each of the diversion types. Results suggest that prebooking and postbooking diversion subjects were similar on most mental health indicators, but differed substantially on measures of social functioning and substance use and criminality, with postbooking subjects scoring worse on social functioning and reporting more serious substance use and criminal histories. Variability among sites was also observed, indicating differences in local preferences for the types of individuals deemed appropriate for diversion.