Longitudinal Patterns of Health System Retention Among Veterans with Schizophrenia or Bipolar Disorder
Center for Mental Healthcare and Outcomes Research, HSR&D, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114-1706, USA.Community Mental Health Journal (Impact Factor: 1.03). 05/2008; 44(5):321-30. DOI: 10.1007/s10597-008-9133-z
Inconsistent service use for schizophrenia and bipolar disorder is associated with poorer outcomes of care. We analyzed VHA National Psychosis Registry data for 164,150 veterans with these disorders to identify characteristics associated with 5-year patterns of survival and with retention in VHA care. Most cohort members (63%) survived the period with no break in VHA healthcare lasting over 12 months. Inconsistent utilization was associated with younger age, no service-connected disability, and less physical comorbidity, regardless of diagnosis. The influence of gender and ethnicity on attrition varied by diagnosis and gap-duration. Variation in attrition by gender and ethnicity warrants additional attention.
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- "While some dropouts could be for positive reasons, disengagement from services removes or delays opportunities to effectively support recovery. Disengaging can result in deterioration and additional distress, increased hospital admissions, and higher risk of becoming homeless or committing suicide (Dixon et al., 2009;Fischer et al., 2008). In summary, treatment continuity and dropout are all challenges for those working therapeutically with individuals experiencing psychosis (Fenton, Blyler, & Heinssen, 1997;Tarrier & Bobes, 2000). "
ABSTRACT: Objectives This study investigated the therapeutic alliance (TA) between clients and therapists involved in a telephone-based cognitive behaviour therapy (CBT) oriented psychological intervention for individuals experiencing psychosis. DesignThe telephone intervention involved recovery-focused CBT with use of a self-help guide and group intervention co-facilitated by colleagues with personal experience of psychosis. It was delivered as part of a Participant Preference Trial. Methods Twenty-one client/therapist dyads were examined within this study. In addition to a measure of TA, clients completed measures of depression, social functioning, symptom severity, and strength of treatment preference, while therapists completed measures related to the level of shared formulation, therapist confidence, and therapeutic change estimates. ResultsTherapeutic alliance levels were comparable to previously reported face-to-face psychosis intervention studies. Clients consistently reported significantly higher TA ratings compared to therapists. Depression scores and the strength of preference for treatment were significantly associated with client TA. Greater therapist perceived change was associated with higher therapist rated TA, while higher numbers of missed therapy sessions associated with lower therapist ratings. Conclusions Telephone-based psychosis interventions may support the formation of positive relationships that are comparable to the quality of relationships developed between therapists and clients during face-to-face CBT therapy. Methodological limitations including low participant numbers and heightened risk of a Type I error necessitate caution when interpreting findings. Further research into therapist and client variables associated with TA is required. Practitioner points Telephone delivered interventions to support people with psychosis-related difficulties can result in the development of a good quality TA between therapists and clients. There is a significant difference between therapist and client ratings of TA. Clients tend to score the quality of the TA significantly more highly than therapists. Providing clients with choice when participating in therapeutic interventions could potentially contribute towards improved TA reporting by clients. 10.1111/(ISSN)2044-8341</doi
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- "These groups had different patterns of attrition, with the high attendance group leaving in a steady manner throughout the follow-up period while the low attendance group experienced initial extreme attrition followed by steady, moderate-level loss. Our study found that increased perceived family treatment support was associated with shorter time to attrition, a result that runs contrary to previous research on treatment engagement in psychiatric patients (e.g., Fischer et al. 2008a, b) and suggests the need for collaboration between families and caregivers of patients. The relationship between increased perceived cost of care and earlier attrition mirrors previous work that found increased attrition in patients who expected care to be more expensive or require increased time commitments (Rossi et al. 2002; Young et al. 2000). "
ABSTRACT: Disengagement from outpatient care following psychiatric hospitalization is common in high-utilizing psychiatric patients and contributes to intensive care utilization. To investigate variables related to treatment attrition, a range of demographic, diagnostic, cognitive, social, and behavioral variables were collected from 233 veterans receiving inpatient psychiatric services who were then monitored over the following 2 years. During the follow-up period, 88.0 % (n = 202) of patients disengaged from post-inpatient care. Attrition was associated with male gender, younger age, increased expectations of stigma, less short-term participation in group therapy, and poorer medication adherence. Of those who left care, earlier attrition was predicted by fewer prior-year inpatient psychiatric days, fewer lifetime psychiatric hospitalizations, increased perceived treatment support from family, and less short-term attendance at psychiatrist appointments. Survival analyses were used to analyze the rate of attrition of the entire sample as well as the sample split by short-term group therapy attendance. Implications are discussed.
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- " Moreover, patients with schizophrenia are less likely to remain engaged in appropriate health care, although when mentally ill patients are "well-engaged" in care, appropriate care is more likely. [13-15] Dixon's research group noted diminished quality of care for patients with both serious mental illness (schizophrenia or major mood disorder) and diabetes, relative to patients with diabetes alone, in their study of quality indicators.  This is a troubling finding in view of the high level of risk factors for diabetes among VA patients with serious mental illness. "
ABSTRACT: Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period. The Veterans Healthcare Administration (VA) is the largest integrated healthcare system in the United States. Administrative extracts of the VA's all-electronic medical records were studied. Patients over age 50 and diagnosed with schizophrenia in 2002 were age-matched 1:4 to diabetes patients. All patients were followed through 2005. Cluster analysis explored trajectories of primary care use. Proportional hazards regression modelled the impact of these primary care utilization trajectories on survival, controlling for demographic and clinical covariates. Patients comprised three diagnostic groups: diabetes only (n = 188,332), schizophrenia only (n = 40,109), and schizophrenia with diabetes (Scz-DM, n = 13,025). Cluster analysis revealed four distinct trajectories of primary care use: consistent over time, increasing over time, high and decreasing, low and decreasing. Patients with schizophrenia only were likely to have low-decreasing use (73% schizophrenia-only vs 54% Scz-DM vs 52% diabetes). Increasing use was least common among schizophrenia patients (4% vs 8% Scz-DM vs 7% diabetes) and was associated with improved survival. Low-decreasing primary care, compared to consistent use, was associated with shorter survival controlling for demographics and case-mix. The observational study was limited by reliance on administrative data. Regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For schizophrenia patients, with or without comorbid diabetes, primary care offers a survival benefit, suggesting that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
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