Robin E. Clark

Substance abuse in schizophrenia: service utilization and costs

Utilization and cost of institutional and outpatient services were prospectively measured over 1 year for three groups of schizophrenic patients: current substance abusers, past substance abusers, and those without a history of substance abuse. Current abusers had significantly greater utilization and cost of institutional (hospital and jail) services. Current abusers also had greater utilization of emergency services. There were no significant differences between the groups in utilization and cost of other services, including psychosocial rehabilitation, outpatient treatment (case management, psychotherapy, and psychiatric visits), and housing supports. The implications for developing cost-effective treatments for dually diagnosed individuals are discussed.

Treatment of substance abuse in severely mentally ill patients

Substance abuse is the most common comorbid complication of severe mental illness. Current clinical research converges on several emerging principles of treatment that address the scope, pace, intensity, and structure of dual-diagnosis programs. They include a) assertive outreach to facilitate engagement and participation in substance abuse treatment, b) close monitoring to provide structure and social reinforcement, c) integrating substance abuse and mental health interventions in the same program, d) comprehensive, broad-based services to address other problems of adjustment, e) safe and protective living environments, f) flexibility of clinicians and programs, g) stage-wise treatment to ensure the appropriate timing of interventions, h) a longitudinal perspective that is congruent with the chronicity of dual disorders, and i) optimism.

The Hartford study of supported employment for persons with severe mental illness.

The authors compared 3 approaches to vocational rehabilitation for severe mental illness (SMI): the individual placement and support (IPS) model of supported employment, a psychosocial rehabilitation (PSR) program, and standard services. Two hundred four unemployed clients (46% African American, 30% Latino) with SMI were randomly assigned to IPS, PSR, or standard services and followed for 2 years. Clients in IPS had significantly better employment outcomes than clients in PSR and standard services, including more competitive work (73.9% vs. 18.2% vs. 27.5%, respectively) and any paid work (73.9% vs. 34.8% vs. 53.6%, respectively). There were few differences in nonvocational outcomes between programs. IPS is a more effective model than PSR or standard brokered vocational services for improving employment outcomes in clients with SMI.

Research on the individual placement and support model of supported employment.

This paper reviews research on the Individual Placement and Support (IPS) model of supported employment for people with severe mental illness. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disabilities to find and maintain competitive employment than rehabilitative day programs or than traditional, stepwise approaches to vocational rehabilitation. There is no evidence that the rapid-job-search, high-expectations approach of IPS produces untoward side effects. IPS positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. The cost of IPS is similar to the costs of other vocational services, and cost reductions may occur when IPS displaces traditional day treatment programs. Future research should be directed at efforts to enhance job tenure and long-term vocational careers.

Medicare and medicaid costs for schizophrenia patients by age cohort compared with costs for depression, dementia, and medically ill patients

OBJECTIVE The authors describe per-capita Medicaid and Medicare expenditures across age cohorts for individuals with schizophrenia and compare expenditures for patients with schizophrenia and those with depression, dementia, and non-psychiatric medical disorders. METHODS Medicaid and Medicare claims were identified for dually-eligible beneficiaries ages 19+ in New Hampshire during 1999 (schizophrenia: N=1,423; depression: N=2,219; dementia: N=1,942; medical disorders alone: N=4,260). Annual per-capita weighted average expenditures were calculated for inpatient, outpatient, home-health, nursing home, pharmacy, physician, and other services. RESULTS The greatest per-capita expenditures for individuals with schizophrenia were among older beneficiaries (

Expenditures of time and money by families of people with severe mental illness and substance use disorders.

39,154 for ages 65-74 and

Antisocial Personality, Psychopathy, and Violence in Persons with Dual Disorders A Longitudinal Analysis

43,461 for ages 75+), versus younger beneficiaries (

Health Care Utilization Patterns of Homeless Individuals in Boston: Preparing for Medicaid Expansion Under the Affordable Care Act

25,633 for ages 19-44 and

The Evidence Doesn’t Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine

31,529 for ages 45-64). Outpatient services were the highest expenditure among younger adults (ages 19-64), whereas nursing home services were the highest expenditure for ages 65+. Total expenditures for individuals with schizophrenia exceeded those for individuals with depression, dementia, or medical disorders across all age cohorts except age 45-64, where dementia expenditures were highest. Among individuals age 65-74, per-capita expenditures for schizophrenia were

Impact of Substance Disorders on Medical Expenditures for Medicaid Beneficiaries With Behavioral Health Disorders

11,304 higher than for depression and