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ABSTRACT: The need for accurate and reliable information about income and resources available to individuals with psychiatric disabilities is critical for the assessment of need and evaluation of programs designed to alleviate financial hardship or affect finance allocation. Measurement of finances is ubiquitous in studies of economics, poverty, and social services. However, evidence has demonstrated that these measures often contain error. We compare the 1-week test-retest reliability of income and finance data from 24 adult psychiatric outpatients using assessment-as-usual (AAU) and a new instrument, the Timeline Historical Review of Income and Financial Transactions (THRIFT). Reliability estimates obtained with the THRIFT for Income (0.77), Expenses (0.91), and Debt (0.99) domains were significantly better than those obtained with AAU. Reliability estimates for Balance did not differ. THRIFT reduced measurement error and provided more reliable information than AAU for assessment of personal finances in psychiatric patients receiving Social Security benefits. The instrument also may be useful with other low-income groups.
The Journal of nervous and mental disease 01/2013; 201(1):56-9. · 1.77 Impact Factor
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ABSTRACT: Integrating information technology into healthcare has the potential to bring treatment to hard-to-reach people. Individuals with serious mental illness (SMI), however, may derive limited benefit from these advances in care because of lack of computer ownership and experience. To date, conclusions about the computer skills and attitudes of adults with SMI have been based primarily on self-report. In the current study, 28 psychiatric outpatients with co-occurring cocaine use were interviewed about their computer use and opinions, and 25 were then directly observed using task analysis and think aloud methods as they navigated a multi-component health informational website. Participants reported low rates of computer ownership and use, and negative attitudes towards computers. Self-reported computer skills were higher than demonstrated in the task analysis. However, some participants spontaneously expressed more positive attitudes and greater computer self-efficacy after navigating the website. Implications for increasing access to computer-based health information are discussed.
Psychiatric Quarterly 06/2012; · 1.26 Impact Factor
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Marc I Rosen
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ABSTRACT: How addicts manage their funds can be understood from the studies of impulsive spending, contingency management, self-reported expenditures, behavioral economics, and anthropology.
To show how these differing perspectives can provide theoretical explanations for substance abuse, they were applied to the question of when extra "windfall" funds are spent on substances of abuse. Treatment implications of these perspectives were examined.
Relevant literature was reviewed.
Behavioral economics and related approaches provide the basis for money-management-based interventions targeting substance abuse, informed configuration of reinforcers to compete with substances, and therapeutically framing the choice between abstinence and substance use.
A cross-discipline consideration of how addicts manage their funds has the potential to inform and improve substance abuse treatment.
The American Journal of Drug and Alcohol Abuse 01/2012; 38(1):2-7. · 1.55 Impact Factor
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ABSTRACT: Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes.
The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious.
A literature review was conducted and randomized clinical trials describing ACT's impact on substance use were reviewed.
Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better.
Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.
Journal of the American Psychiatric Nurses Association 01/2011; 17(1):45-50.
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ABSTRACT: Patients with concomitant psychiatric and substance use disorders are commonly assigned representative payees or case managers to help manage their funds, but money management has not been conceptualized as a theory-based treatment. This randomized clinical trial was conducted to determine the effect of a money management-based therapy, advisor-teller money manager (ATM), on substance abuse or dependence.
Ninety patients at a community mental health center who had a history of cocaine or alcohol abuse or dependence were assessed after random assignment to 36 weeks of ATM (N=47) or a control condition in which use of a financial workbook was reviewed (N=43). Patients assigned to ATM were encouraged to deposit their funds into a third-party account, plan weekly expenditures, and negotiate monthly budgets. Substance use calendars and urine toxicology tests were collected every other week for 36 weeks and again 52 weeks after randomization.
Patients assigned to ATM had significantly more negative toxicologies for cocaine metabolite over time than patients in the control group, and treating clinicians rated ATM patients as significantly more likely to be abstinent from illicit drugs. Self-reported abstinence from alcohol did not significantly differ between groups. Unexpectedly, patients assigned to ATM were more likely to be assigned a representative payee or a conservator than control participants during the follow-up period (ten of 47 versus two of 43). One patient in ATM assaulted the therapist when his check had not arrived.
ATM is an efficacious therapy for the treatment of cocaine abuse or dependence among people with concomitant psychiatric illness but requires protection of patient autonomy and staff safety.
Psychiatric services (Washington, D.C.) 07/2010; 61(7):707-13. · 2.81 Impact Factor
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Marc I Rosen
The Journal of Rehabilitation Research and Development 01/2010; 47(5):xv-xxii. · 1.78 Impact Factor
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ABSTRACT: Prospective memory is defined as the ability to "remember to remember" something at a future time despite intervening distractions and may be particularly important in remembering to take prescribed medication among people infected with HIV. Ninety-seven HIV-positive participants in a clinical trial had their adherence measured by electronic pillcaps and were administered neuropsychological screening tests and the memory for intentions screening test (MIST). Factor analysis of the MIST and other neuropsychological measures identified four factors. Two were derived from MIST subscales and accounted for approximately 50% of the variance in cognitive functioning. Only one factor was significantly correlated with adherence, and this was a MIST factor. In this preliminary study, the MIST assessed a memory function that (a) could be distinguished from traditional retrospective recall and executive functioning and (b) was correlated with antiretroviral adherence.
Archives of Clinical Neuropsychology 08/2009; 24(6):547-54. · 2.18 Impact Factor
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ABSTRACT: Money management has been implemented, often in bundled interventions, as a strategy to counteract spending of public support checks and other funds on drugs and alcohol. The authors conducted a randomized controlled trial of a voluntary money management program as an adjunctive treatment for patients in treatment for mental illness, substance use disorders, or both. In the advisor-teller money manager (ATM) intervention, a money manager stores patients' checkbooks and automated bank cards, trains patients to manage their own funds, and links spending to activities related to their treatment goals.
Eighty-five veterans with recent use of alcohol or cocaine were randomly assigned to 36 weeks of the ATM intervention or a control intervention (completion of a simple financial workbook).
With ATM, 75% of veterans gave their checkbook to their money manager to hold, and participants attended significantly more therapy sessions than those assigned to the control therapy (mean of 20.6 versus 8.1 sessions). Although participants assigned to ATM did not show significantly greater improvement over time on the primary outcomes (self-reported abstinence from alcohol and cocaine and negative urine tests for cocaine metabolite), they reduced their Addiction Severity Index drug and alcohol use composite scale scores more rapidly than the control group. High rates of abstinence in both groups created a ceiling effect, limiting the power to detect improved abstinence rates.
In this relatively small trial, ATM, a money management intervention, showed promise in engaging patients, improving their money management, and improving some substance abuse outcomes.
Psychiatric services (Washington, D.C.) 05/2009; 60(4):498-504. · 2.81 Impact Factor
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ABSTRACT: It is largely unknown how frequently low-abundance HIV drug-resistant variants at levels under limit of detection of conventional genotyping (<20% of quasi-species) are present in antiretroviral-experienced persons experiencing virologic failure. Further, the clinical implications of low-abundance drug-resistant variants at time of virologic failure are unknown.
Plasma samples from 22 antiretroviral-experienced subjects collected at time of virologic failure (viral load 1380 to 304,000 copies/mL) were obtained from a specimen bank (from 2004-2007). The prevalence and profile of drug-resistant mutations were determined using Sanger sequencing and ultra-deep pyrosequencing. Genotypes were interpreted using Stanford HIV database algorithm. Antiretroviral treatment histories were obtained by chart review and correlated with drug-resistant mutations. Low-abundance drug-resistant mutations were detected in all 22 subjects by deep sequencing and only in 3 subjects by Sanger sequencing. In total they accounted for 90 of 247 mutations (36%) detected by deep sequencing; the majority of these (95%) were not detected by standard genotyping. A mean of 4 additional mutations per subject were detected by deep sequencing (p<0.0001, 95%CI: 2.85-5.53). The additional low-abundance drug-resistant mutations increased a subject's genotypic resistance to one or more antiretrovirals in 17 of 22 subjects (77%). When correlated with subjects' antiretroviral treatment histories, the additional low-abundance drug-resistant mutations correlated with the failing antiretroviral drugs in 21% subjects and correlated with historical antiretroviral use in 79% subjects (OR, 13.73; 95% CI, 2.5-74.3, p = 0.0016).
Low-abundance HIV drug-resistant mutations in antiretroviral-experienced subjects at time of virologic failure can increase a subject's overall burden of resistance, yet commonly go unrecognized by conventional genotyping. The majority of unrecognized resistant mutations correlate with historical antiretroviral use. Ultra-deep sequencing can provide important historical resistance information for clinicians when planning subsequent antiretroviral regimens for highly treatment-experienced patients, particularly when their prior treatment histories and longitudinal genotypes are not available.
PLoS ONE 01/2009; 4(6):e6079. · 4.09 Impact Factor
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ABSTRACT: It is unknown whether impulsivity is associated with risky sexual behavior in dually diagnosed clients.
Impulsivity in 51 sexually-active, dually diagnosed clients was assessed by the Barrett Impulsivity Scale, Delayed Discounting Questionnaire, and Wisconsin Card-Sorting Task, and a path analysis of relationship to self-reported risk behaviors was conducted.
Recent cocaine use was correlated with risky sexual behaviors and a preference for immediate over larger, delayed rewards trended towards a correlation.
The association between impulsivity and risky sexual behavior among substance users appears to extend to the dually diagnosed. Implications for HIV prevention are discussed.
The American Journal of Drug and Alcohol Abuse 01/2009; 35(5):325-8. · 1.55 Impact Factor
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ABSTRACT: Clients dually diagnosed with psychiatric and substance abuse disorders may be adversely affected if they mismanage their Social Security or public support benefits. Assistance managing funds, including assignment of a representative payee, is available but there are no objective assessments of money mismanagement. In this study, a Structured Clinical Interview for Money Mismanagement was administered twice at 1-week intervals to 46 clients receiving disability payments and was compared with clinician's judgment that the client was incapable of managing funds, the frequent basis for payee assignment by the Social Security Administration and Veterans Affairs. Clinician's judgment and structured interview were concordant on 71% of capability judgments. The interview had high test-retest reliability and was correlated with self-reported money mismanagement and global assessment of functioning scale scores, but clinician judgment was not associated with these measures. Results suggest that the interview is sensitive in detecting money mismanagement and raises questions concerning the validity of clinicians' judgments.
The Journal of nervous and mental disease 08/2008; 196(7):576-9. · 1.77 Impact Factor
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Social security bulletin 02/2007; 67(1):53-62.
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ABSTRACT: Contingency management (CM) based interventions that reinforce adherence to prescribed medications have shown promise in a variety of disadvantaged populations. Fifty-six participants with histories of illicit substance use who were prescribed antiretroviral medication but evidenced suboptimal adherence during a baseline assessment were randomly assigned to 16 weeks of weekly CM-based counseling or supportive counseling, followed by 16 additional weeks of data collection and adherence feedback to providers. The CM intervention involved review of data generated by electronic pill-bottle caps that record bottle opening (MEMS) and brief substance abuse counseling. CM participants were reinforced for MEMS-measured adherence with drawings from a bowl for prizes and bonus drawings for consecutive weeks of perfect adherence. Potential total earnings averaged $800. Mean MEMS-measured adherence to the reinforced medication increased from 61% at baseline to 76% during the 16-week treatment phase and was significantly increased relative to the supportive counseling group (p = 0.01). Furthermore, mean log-transformed viral load was significantly lower in the CM group. However, by the end of the 16-week follow-up phase, differences between groups in adherence and viral load were no longer significantly different. Proportions of positive urine toxicology tests did not differ significantly between the two groups at any phase. A brief CM-based intervention was associated with significantly higher adherence and lower viral loads. Future studies should evaluate methods to extend effects for longer term benefits.
AIDS PATIENT CARE and STDs 02/2007; 21(1):30-40. · 2.41 Impact Factor
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ABSTRACT: Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse.
Participants in this observational 12-month cohort study (n=1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned.
At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participants not assigned payees but showed no greater reduction in substance use.
Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment.
Drug and Alcohol Dependence 02/2007; 86(2-3):115-22. · 3.38 Impact Factor
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ABSTRACT: To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use.
Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill.
Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months.
Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings.
Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits.
In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.
Health Services Research 03/2006; 41(1):173-91. · 2.16 Impact Factor
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ABSTRACT: Clients disabled by psychiatric illness may be assigned mental health clinicians as payees. We compared client-payee interactions among 42 clients with clinician-payees, 20 whose payees were family or friends and nine with attorney-payees. Compared to clients with attorney-payees, clients with clinician-payees felt more satisfied and more involved in their money management, and had had more contacts with their payees in the previous month. Clients' satisfaction with family/friend payees was similar to that with clinician payees. In multivariate analyses, whether or not the payee had had training about mental illness accounted for 33% of the variance in satisfaction with the payee.
Community Mental Health Journal 07/2005; 41(3):291-306. · 1.03 Impact Factor
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ABSTRACT: Electronic caps, pill caps that record the date and time of pill bottle opening provide an objective measure of adherence to prescribed medication. A promising intervention to improve adherence, cue-dose training, involves reviewing patients' pill cap-generated reports concerning their medication-taking and offering individualized recommendations for remembering to take medications at specific times of day. In this preliminary study, 79 patients prescribed the antihyperglycemic medication metformin had adherence assessed during a 4-week baseline period. Adherence, defined as proportion of prescribed doses taken within a predetermined 4-h window, was measured using electronic MEMS caps. Those who had less than 80% baseline adherence (n = 33) were randomly assigned to either receive 4 months of cue-dose training (n = 16) or to a control group (n = 17). Cue-dose training was associated with significantly better adherence to metformin (mean improvement of 15%). The effects of cue-dose training on adherence to other antihyperglycemic medication did not reach statistical significance. Glycosylated hemoglobin (a measure of blood sugar control) did not differ between groups. Data from nine patients who reviewed pill cap-generated data with their primary care providers suggested that both patients and providers found the discussion moderately helpful and not at all uncomfortable.
Behaviour Research and Therapy 05/2004; 42(4):409-22. · 3.30 Impact Factor
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ABSTRACT: 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.
Administration and Policy in Mental Health 12/2003; 31(2):131-40. · 2.09 Impact Factor
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ABSTRACT: The goal of this study was to determine if neuropsychological function is associated with adherence to prescribed medication. Altogether, 79 patients with type II diabetes at a VA primary care clinic had adherence to the antihyperglycemic drug metformin measured with MEMS caps over a 4-week period. They completed several tests of neuropsychological function: Mini-Mental Status Exam (MMSE), Trails A and B, Stroop, Digit Span, Digit Symbol, and Grooved Pegboard. In separate multivariate analyses, Stroop word score and time to complete Trails B were independently associated with adherence, as was age. Secondary analyses of the relationship between neuropsychological variables and other adherence-related measures were conducted. Low scores on the MMSE and non-Caucasian ethnicity were associated with missed appointments. None of the neuropsychological variables were associated with glycosylated hemoglobin. These results suggest that cognitive abilities should be considered when counseling patients concerning their adherence.
Journal of Behavioral Medicine 09/2003; 26(4):349-60. · 3.10 Impact Factor
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Psychiatric Services 03/2003; 54(2):171-3. · 2.38 Impact Factor
