Thad A. Eckman

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers: A government-sponsored revolving door?

BACKGROUND Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.

Teaching medication management skills to schizophrenic patients.

A behaviorally-oriented program for teaching medication management skills to psychiatrically disabled patients was field-tested in a broad range of inpatient and partial-hospitalization clinics representing a wide geographic distribution across the United States. Results indicated that medical practitioners and others in the allied health professions were able to implement the medication management program with a high degree of fidelity. Additionally, patients who participated in the study demonstrated significant gains in cognitive mastery of the program content, high levels of skill attainment, increased utilization of medication management skills, and a significant increase in medication compliance.

Substance abuse and the need for money management assistance among psychiatric inpatients

Patients who mismanage their funds may benefit from financial advice, case management or the involuntary assignment of a payee who restricts direct access to funds. Data from a survey of psychiatric inpatients at four VA hospitals (N = 236) was used to evaluate the relationship between substance abuse and clinician-rated need for money management assistance. Multivariate analytic techniques were used to control for sociodemographic factors and psychopathology. Alcohol and drug use severity both were modestly associated with need for assistance. The effect of substance use severity was greater in patients who were also diagnosed with a major mental illness. Clinicians indicated that 27 patients (11% of the sample) required an involuntary payee and 21 of the 27 (78%) had a Substance Abuse diagnosis. Only drug use severity was significantly associated with need for a payee. These data describe a substantial unmet need for money management assistance in psychiatric inpatients, particularly among those with substance abuse disorders. There is a need to examine the process by which the Social Security and Veterans Benefits Administrations assign payees to determine whether patients with co-morbid substance abuse are not being assigned a payee in spite of their discernible need for one.

Do patients who mismanage their funds use more health services

One rationale for establishing programs that help patients manage their funds is that such patients make extensive use of expensive inpatient services. We surveyed the money management habits of 406 inpatients and determined their use of Veterans Administration (VA) services and related costs over the subsequent year. In multivariate analyses, there was no statistically significant relationship between need for money management and service use or cost. The misspending of funds for drugs may precipitate hospitalization for some outpatients. However, in a sample of hospitalized patients, mismanagement of funds was not associated with longer length of stay or increased service use following discharge.

The Behavioral Analysis and Modification Project for Community Mental Health

The confluence of two innovative streams in psychology and psychiatry —the delivery of mental health services through comprehensive, community-based centers, and the development of behavioral analysis and therapy—led to an applied research project aimed at demonstrating the applicability of behavioral approaches to the needs of clients and clinicians in a typical community mental health center (CMHC). The Behavior Analysis and Modification (BAM) Project in CMHCs began slowly in 1970 with the building of a clinical-research foundation in the Ox-nard, California CMHC; accelerated during 1972–1975 when an NIMH research grant permitted the establishment and evaluation of systematic behavior therapies; and concluded in 1975–1979 with dissemination of six of the therapeutic methods that were experimentally validated to 40 other CMHCs across the nation. This chapter summarizes the procedures and results of the 9-year BAM Project.