Mustafa Karakus

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

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

7.05, and mean monthly earnings were

Assisting Social Security Disability Insurance Beneficiaries With Schizophrenia, Bipolar Disorder, or Major Depression in Returning to Work

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.

Depression and the Onset of Chronic Illness in Older Adults: A 12-Year Prospective Study

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.

Economic Grand Rounds: Financing First-Episode Psychosis Services in the United States

OBJECTIVE People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Implications of Middle School Behavior Problems for High School Graduation and Employment Outcomes of Young Adults: Estimation of a Recursive Model

The relationship between depression and development of chronic illness among older adults is not well understood. This study uses data from the Health and Retirement Study to evaluate the relationship between depression at baseline and new onset of chronic illnesses including cancer, heart problems, arthritis, and diabetes. Analysis controlling for demographics (age, gender, race, education), health risk indicators (BMI and smoking), functional limitations (gross motor index, health limitations for work), and income show that working-age older people (ages 50–62) with depression at baseline are at significantly higher risk to develop diabetes, heart problems, and arthritis during the 12-year follow-up. No significant association was found between depression and cancer. Prevention efforts aimed at chronic illnesses among the elderly should recognize the mind–body interaction and focus on preventing or alleviating depression.

Enhancing the Net Benefits of Disseminating Efficacious Prevention Programs: A Note on Target Efficiency with Illustrative Examples

Adequate financing is essential to implementing services for individuals experiencing a first episode of a psychotic illness. Recovery After an Initial Schizophrenia Episode (RAISE), a project sponsored by the National Institute of Mental Health, is providing a practical test of the implementation and effectiveness of first-episode services in real-world settings. This column describes approaches to financing early intervention services that are being used at five of 18 U.S. sites participating in a clinical trial of a team-based, multielement RAISE intervention. The authors also describe new options for financing that will become available as the Affordable Care Act (ACA) is implemented more fully. The ACA will rationalize coverage of first-episode services, but the all-important Medicaid provisions will also require individual state action to implement services optimally.

Do Not Turn Out the Lights on the Public Mental Health System When the ACA is Fully Implemented

The potentially serious adverse impacts of behavior problems during adolescence on employment outcomes in adulthood provide a key economic rationale for early intervention programs. However, the extent to which lower educational attainment accounts for the total impact of adolescent behavior problems on later employment remains unclear. As an initial step in exploring this issue, we specify and estimate a recursive bivariate probit model that (1) relates middle school behavior problems to high school graduation and (2) models later employment in young adulthood as a function of these behavior problems and of high school graduation. Our model thus allows for both a direct effect of behavior problems on later employment as well as an indirect effect that operates via graduation from high school. Our empirical results, based on analysis of data from the National Educational Longitudinal Study, suggest that the direct effects of externalizing behavior problems on later employment are not significant but that these problems have important indirect effects operating through high school graduation.

“Big Eight” Recommendations for Improving the Effectiveness of the U.S. Behavioral Health Care System

We consider the implementation, in a non-research setting, of a new prevention program that has previously been evaluated in a randomized trial. When the target population for the implementation is heterogeneous, the overall net benefits of the implementation may differ substantially from those reported in the economic evaluation of the randomized trial, and from those that would be realized if the program were implemented within a selected subgroup of the target population. This note illustrates a simple and practical approach to targeting that can combine risk-factor results from the literature with the overall cost-benefit results from the program’s randomized trial to maximize the expected net benefit of implementing the program in a heterogeneous population.

GENDER-SPECIFIC PATTERNS OF EMPLOYMENT AND EMPLOYMENT TRANSITIONS FOR PERSONS WITH SCHIZOPHRENIA: EVIDENCE FROM THE SCHIZOPHRENIA CARE AND ASSESSMENT PROGRAM (SCAP)

When all of the insurance and health care reforms of the ACA are fully implemented, some public financing needs for behavioral health services will remain. This commentary outlines a number of the residual functions of the public mental health system in an ACA world, and it identifies opportunities for expansions of service areas not covered by traditional insurance or the health delivery reforms for behavioral health services within the scope of the ACA.