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2.  Opioid dose and risk of suicide 
Pain  2016;157(5):1079-1084.
doi:10.1097/j.pain.0000000000000484
PMCID: PMC4939394  PMID: 26761386
3.  Feasibility and challenges of inpatient psychotherapy for psychosis: lessons learned from a veterans health administration pilot randomized controlled trial 
BMC Research Notes  2016;9:376.
Background
In large health care systems, decision regarding broad implementation of psychotherapies for inpatients with psychosis require substantial evidence regarding effectiveness and feasibility for implementation. It is important to recognize challenges in conducting research to inform such decisions, including difficulties in obtaining consent from and engaging inpatients with psychosis in research. We set out to conduct a feasibility and effectiveness Hybrid Type I pilot randomized controlled trial of acceptance and commitment therapy (ACT) and a semi-formative evaluation of barriers and facilitators to implementation.
Findings
We developed a training protocol and refined an ACT treatment manual for inpatient treatment of psychosis for use at the Veterans Health Administration. While our findings on feasibility were mixed, we obtained supportive evidence of the acceptability and safety of ACT. Identified strengths of ACT included a focus on achievement of valued goals rather than symptoms. Weaknesses included that symptoms may limit patient’s understanding of ACT. Facilitators included building trust and multi-stage informed consent processes. Barriers included restrictive eligibility criteria, rigid use of a manualized protocol, and individual therapy format. Conclusions are limited by our randomization of only 18 patient participants (with nine completing all aspects of the study) out of 80 planned.
Conclusions
Future studies should include (1) multi-stage informed consent processes to build trust and alleviate patient fears, (2) relaxation of restrictions associated with obtaining efficacy/effectiveness data, and (3) use of Hybrid Type II and III designs.
doi:10.1186/s13104-016-2179-z
PMCID: PMC4967502  PMID: 27475904
Randomized controlled trial; Hybrid type I; Acceptance and commitment therapy; Feasibility; Psychosis
4.  Examining the Relationship between Clinical Monitoring and Suicide Risk among Patients with Depression: Matched Case–Control Study and Instrumental Variable Approaches 
Health Services Research  2010;45(5 Pt 1):1205-1226.
Objective
To assess the relationship between closer monitoring of depressed patients during high-risk treatment periods and death from suicide, using two analytic approaches.
Data Source
VA patients receiving depression treatment between 1999 and 2004.
Study Design
First, a case–control design was used, adjusting for age, gender, and high-risk days (1,032 cases and 2,058 controls). Second, an instrumental variable (IV) approach (N=714,106) was used, with IVs of (1) average monitoring rates in the VA facility of most use and (2) monitoring rates of VA facilities weighted inversely by distance from patients' residences.
Principal Findings
The case–control approach indicated a modest increase in suicide risk with each additional visit (odds ratio=1.02; 95 percent confidence interval=1.002, 1.04). The “facility used” IV estimate indicated near zero change in risk (0.0008 percent increase; p=.97) with each additional visit, while the distance-weighted IV estimate indicated a 0.032 percent decrease in risk (p=.29). An alternative analysis assuming a threshold effect of ≥4 visits during high-risk periods also showed a decrease (0.15 percent; p=.08) using the distance IV.
Conclusions
The IV approach appeared to address the selection bias more appropriately than the case–control analysis. Neither analysis clearly indicated that closer monitoring during high-risk periods was significantly associated with reduced suicide risks, but the distance-weighted IV estimate suggested a potentially protective effect.
doi:10.1111/j.1475-6773.2010.01132.x
PMCID: PMC2939263  PMID: 20609017
Suicide; HEDIS visit; depression treatment; case–control; instrumental variable
5.  Impact of Distance and Facility of Initial Diagnosis on Depression Treatment 
Health Services Research  2011;46(3):768-786.
Objective
To assess whether distance to services or diagnosis at a hospital-based medical center compared with a community clinic influences the receipt of psychotherapy versus pharmacotherapy for depression.
Data Source
Veterans Affairs (VA) administrative data for 132,329 depressed veterans between October 2003 and September 2004.
Study Design
Multivariable logistic and multinomial regression models were used to examine the relationship between distance to the nearest mental health facility and the facility of initial depression diagnosis on receipt of any and adequate psychotherapy and/or pharmacotherapy, adjusted for patient characteristics.
Principal Findings
Compared with those living within 30 miles of the nearest mental health treatment facility, depressed patients living between 30 and 60 miles away had a decreased likelihood of receiving psychotherapy (OR = 0.71; 95 percent CI: 0.66, 0.76) and a greater likelihood of receiving antidepressant treatment (OR = 1.27; 95 percent CI: 1.22, 1.33). Initial diagnosis at a small community clinic compared with a VA medical center was not associated with a difference in receipt of any psychotherapy (OR = 0.95; 95 percent CI: 0.83, 1.09), but it was associated with decreased likelihood of receiving eight or more psychotherapy visits (OR = 0.46; 95 percent CI: 0.35, 0.61) or any antidepressant treatment (OR = 0.69; 95 percent CI: 0.63, 0.75).
Conclusions
The VA and similar health systems should make efforts to insure adequate psychotherapy is provided to patients who initiate treatment at small community clinics and provide psychotherapy alternatives that may be less sensitive to travel barriers for patients living remote distances from mental health treatment. Extending services to small community clinics that support antidepressant treatment should also be considered.
doi:10.1111/j.1475-6773.2010.01228.x
PMCID: PMC3097401  PMID: 21210800
Access; geographic; psychotherapy; antidepressant; services
6.  Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study 
BMC Psychiatry  2014;14:357.
Background
Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate.
Methods
A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008.
Results
Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015).
Conclusions
In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-014-0357-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-014-0357-x
PMCID: PMC4343189  PMID: 25515091
Suicide; Lithium; Valproate; Veterans; Veterans Health Administration; Propensity score; Matching; Discontinuation; Intent-to-treat; Suicidal behavior
7.  Impact of Distance and Facility of Initial Diagnosis on Depression Treatment 
Health services research  2011;46(3):768-786.
Objective
To assess whether distance to services or diagnosis at a hospital-based medical center compared to a community clinic influences the receipt of psychotherapy vs. pharmacotherapy for depression.
Data Source
VA administrative data for 132,329 depressed veterans between October 2003 and September 2004.
Study Design
Multivariable logistic and multinomial regression models were used to examine the relationship between distance to the nearest mental health facility and the facility of initial depression diagnosis on receipt of any and adequate psychotherapy and/or pharmacotherapy, adjusted for patient characteristics.
Principal Findings
Compared to those living within 30 miles of the nearest mental health treatment facility, depressed patients living between 30 to 60 miles away had a decreased likelihood of receiving psychotherapy (OR 0.71; 95% CI: 0.66, 0.76) and a greater likelihood of receiving antidepressant treatment (OR 1.27; 95% CI: 1.22, 1.33). Initial diagnosis at a small community clinic compared to a VA medical center was not associated with a difference in receipt of any psychotherapy (OR 0.95; 95% CI: 0.83, 1.09), but was associated with decreased likelihood of receiving 8 or more psychotherapy visits (OR 0.46; 95% CI: 0.35, 0.61), or any antidepressant treatment (OR 0.69; 95% CI: 0.63, 0.75).
Conclusions
The VA and similar health systems should make efforts to insure adequate psychotherapy is provided to patients who initiate treatment at small community clinics and provide psychotherapy alternatives that may be less sensitive to travel barriers for patients living remote distances from mental health treatment. Extending services to small community clinics which support antidepressant treatment should also be considered.
doi:10.1111/j.1475-6773.2010.01228.x
PMCID: PMC3097401  PMID: 21210800
access; geographic; psychotherapy; antidepressant; services
8.  Examining the Relationship between Clinical Monitoring and Suicide Risk among Patients with Depression: Matched Case-Control Study and Instrumental Variable Approaches 
Health services research  2010;45(5 Pt 1):1205-1226.
Objective
To assess the relationship between closer monitoring of depressed patients during high-risk treatment periods and death from suicide, using two analytic approaches.
Data Source
VA patients receiving depression treatment between 1999 and 2004.
Study Design
First, a case-control (CC) design was used, adjusting for age, gender, and high-risk days (1,032 cases and 2,058 controls). Second, an instrumental variable (IV) approach (N=714,106) was used, with IVs of (1) average monitoring rates in the VA facility of most use and (2) monitoring rates of VA facilities weighted inversely by distance from patients' residences.
Principal Findings
The CC approach indicated a modest increase in suicide risk with each additional visit (OR=1.02; 95% CI=1.002, 1.04). The “facility used” IV estimate indicated near zero change in risk (0.0008% increase; p=0.97) with each additional visit, while the distance-weighted IV estimate indicated a 0.032% decrease in risk (p=0.29). An alternative analysis assuming a threshold effect of ≥4 visits during high-risk periods also showed a decrease (0.15%; p = 0.08) using the distance IV.
Conclusions
The IV approach appeared to address the selection bias more appropriately than the CC analysis. Neither analysis clearly indicated that closer monitoring during high-risk periods was significantly associated with reduced suicide risks, but the distance-weighted IV estimate suggested a potentially protective effect.
doi:10.1111/j.1475-6773.2010.01132.x
PMCID: PMC2939263  PMID: 20609017
Suicide; HEDIS visit; depression treatment; case-control; instrumental variable
9.  Quality of Care for Cardiometabolic Disease 
Medical care  2010;48(1):72-78.
Background
This study examines quality of cardiometabolic care among veterans receiving care in the Veterans Affairs (VA) health system. We assess whether quality of care disparities by mental disorder status are magnified for individuals living in rural areas.
Research Design
We identified all patients in a 2005 national Veterans Administration cardiometabolic quality of care chart review. The intersection of this cohort and VA registries, that include patients with and without mental disorder, permitted identification of chart review patients with and without mental disorder. Using residential ZIP code, patients were assigned to rural-urban commuting area codes. We used logistic regression adjusting for age, demographics, comorbidities, and income.
Measures
We assessed association between rural residence and 9 cardiometabolic care quality indicators including care processes and intermediate outcomes.
Results
Compared with those without mental disorder, patients with mental disorder were less likely to receive diabetes sensory foot exams (OR: 0.82; 95% CI: 0.72–0.94), retinal exams (OR: 0.82; 95% CI: 0.73–0.93), and renal tests (OR: 0.79; CI: 0.74–0.90). Rural residence was associated with no differences in quality measures. Primary care visit volume was associated with significantly greater likelihood of obtaining diabetic retinal examination and renal testing, but did not explain disparities among patients with mental disorder.
Conclusions
Mental disorder is associated with lesser attainment of quality cardiometabolic care. In this integrated VA care system, rurality and visit volume did not explain this disparity. Other explanations for disparities must be explored to improve the health and health care of this population.
doi:10.1097/MLR.0b013e3181bd49f7
PMCID: PMC4057647  PMID: 19927015
Mental Disorders; Cardiovascular Diseases; Rural Health Services; Health Care Disparities
10.  VA Primary Care–Mental Health Integration: Patient Characteristics and Receipt of Mental Health Services, 2008–2010 
Objective
In 2007, the U.S. Department of Veterans Affairs (VA) health system began nationwide implementation of primary care–mental health integration (PC-MHI) programs to enhance mental health access and promote treatment of common mental health conditions for patients in primary care settings. This report describes patients initiating PC-MHI services in fiscal years (FYs) 2008–2010, including those who received prior mental health services.
Methods
Using VA administrative records, the investigators examined characteristics and services utilization of individuals who initiated PC-MHI services in FY 2008 (N=76,985), FY 2009 (N=107,417), or FY 2010 (N=149,938).
Results
PC-MHI service initiation increased by 95%, from 76,985 to 149,938 veterans. Over time, new user cohorts were increasingly younger, newer to VA services, and less likely to have received VA mental health treatment in the prior year.
Conclusions
This study documents substantial expansion in VA PC-MHI program activity. PC-MHI program expansion may increase access to mental health services in primary care settings.
doi:10.1176/appi.ps.201100365
PMCID: PMC4049174  PMID: 23117512
11.  Excess heart-disease-related mortality in a national study of patients with mental disorders: identifying modifiable risk factors 
General hospital psychiatry  2009;31(6):555-563.
Objective
People with mental disorders are estimated to die 25 years younger than the general population, and heart disease (HD) is a major contributor to their mortality. We assessed whether Veterans Affairs (VA) health system patients with mental disorders were more likely to die from HD than patients without these disorders, and whether modifiable factors may explain differential mortality risks.
Methods
Subjects included VA patients who completed the 1999 Large Health Survey of Veteran Enrollees (LHSV) and were either diagnosed with schizophrenia, bipolar disorder, other psychotic disorders, major depressive disorder or other depression diagnosis or diagnosed with none of these disorders. LHSV data on patient sociodemographic, clinical and behavioral factors (e.g., physical activity, smoking) were linked to mortality data from the National Death Index of the Centers for Disease Control and Prevention. Hierarchical multivariable Cox proportional hazards models were used to assess 8-year HD-related mortality risk by diagnosis, adding patient sociodemographic, clinical and behavioral factors.
Results
Of 147,193 respondents, 11,809 (8%) died from HD. After controlling for sociodemographic and clinical factors, we found that those with schizophrenia [hazard ratio (HR)=1.25; 95% confidence interval (95% CI): 1.15–1.36; P<.001] or other psychotic disorders (HR=1.41; 95% CI: 1.27–1.55; P<.001) were more likely to die from HD than those without mental disorders. Controlling for behavioral factors diminished, but did not eliminate, the impact of psychosis on mortality. Smoking (HR=1.32; 95% CI: 1.26–1.39; P<.001) and inadequate physical activity (HR=1.66; 95% CI: 1.59–1.74; P<.001) were also associated with HD-related mortality.
Conclusions
Patients with psychosis were more likely to die from HD. For reduction of HD-related mortality, early interventions that promote smoking cessation and physical activity among veterans with psychotic disorders are warranted.
doi:10.1016/j.genhosppsych.2009.07.008
PMCID: PMC4033835  PMID: 19892214
Heart-disease-related mortality; Mental disorders; Modifiable risk factors; Mortality
12.  Integrated Care: Treatment Initiation Following Positive Depression Screens 
ABSTRACT
BACKGROUND
Primary Care-Mental Health Integration (PC-MHI) may improve mental health services access and continuity of care.
OBJECTIVE
To assess whether receipt of integrated PC-MHI services on the date of an initial positive depression screen influences receipt of depression treatment among primary care (PC) patients in the Veterans Health Administration.
DESIGN
Retrospective cohort study.
SUBJECTS
Thirty-six thousand, two hundred and sixty-three PC patients with positive depression screens between October 1, 2009 and September 30, 2010.
MAIN MEASURES
Subjects were assessed for depression diagnosis and initiation of antidepressants or psychotherapy on the screening day, within 12 weeks, and within 6 months. Among individuals with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Using multivariable generalized estimating equations (GEE) logistic regression, we assessed likelihood of treatment initiation, adjusting for demographic and clinical measures, including depression screening score.
KEY RESULTS
Patients who received same-day PC-MHI services were more likely to initiate psychotherapy (OR: 8.16; 95 % CI: 6.54–10.17) and antidepressant medications (OR: 2.33, 95 % CI: 2.10–2.58) within 12 weeks than were those who received only PC services on the screening day.
CONCLUSIONS
Receipt of same-day PC-MHI may facilitate timely receipt of depression treatment.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2218-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-012-2218-y
PMCID: PMC3579958  PMID: 23150068
depression screening; integrated care; veterans
13.  Service Implications of Providing Intensive Monitoring During High-Risk Periods for Suicide Among VA Patients With Depression 
Psychiatric services (Washington, D.C.)  2009;60(4):10.1176/appi.ps.60.4.439.
Objectives
Department of Veterans Affairs (VA) patients in depression treatment have high suicide rates after psychiatric hospitalization, antidepressant starts, and dosage changes. Policy makers have recommended closer monitoring during these periods to reduce suicide. This study assessed the frequency of high-risk periods in clinical settings, the levels of monitoring provided during these periods, and the estimated costs of providing monitoring consistent with the most stringent Food and Drug Administration recommendation for treatment periods after antidepressant change (seven visits in the first 12 weeks).
Methods
Monitoring visits were identified in the 12-week period after antidepressant starts and dosage changes and after discharge from psychiatric hospitalization for 100,000 randomly selected VA patients in depression treatment between April 1, 1999, and September 30, 2004. Incremental costs of providing intensive monitoring were estimated by using VA Health Economics Resource Center average cost data.
Results
Patients averaged less than one high-risk period each year. They completed an average of 2.4 monitoring visits during the 12-week period after antidepressant treatment events and 4.9 visits after psychiatric hospitalization. Providing intensive monitoring would cost an additional $408–$537 for each high-risk period after antidepressant treatment events and $313–$341 for each high-risk period after psychiatric hospitalization. During fiscal year 2004 providing intensive monitoring during all high-risk periods would have cost an additional $183–$270 million. Providing intensive monitoring only after psychiatric hospitalizations would have cost an additional $15–$17 million.
Conclusions
Providing intensive monitoring for VA patients in depression treatment during all high-risk periods for suicide would require substantial services reorganization and incremental expenditures. Modest expenditures would support intensive monitoring during the highest-risk period that follows psychiatric hospitalization.
doi:10.1176/appi.ps.60.4.439
PMCID: PMC3855267  PMID: 19339317
14.  Veterans Affairs Health System and Mental Health Treatment Retention among Patients with Serious Mental Illness: Evaluating Accessibility and Availability Barriers 
Health Services Research  2007;42(3 Pt 1):1042-1060.
Objective
We examine the impact of two dimensions of access—geographic accessibility and availability—on VA health system and mental health treatment retention among patients with serious mental illness (SMI).
Methods
Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using county-level VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored.
Results
There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant.
Conclusions
Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention.
doi:10.1111/j.1475-6773.2006.00642.x
PMCID: PMC1955257  PMID: 17489903
Access/demand/utilization of services; mental health; VA health system
15.  Understanding Associations between Serious Mental Illness and Hepatitis C Virus among Veterans: A National Multivariate Analysis 
Psychosomatics  2009;50(1):30-37.
Background
Although individuals with serious mental illness (SMI) have a high prevalence of Hepatitis C (HCV), the nature of this relationship is unclear.
Methods
To determine crude and adjusted recorded prevalence of HCV among a national sample of veterans with and without SMI.
Results
HCV was recorded in 8.1% of patients with bipolar disorder, 7.1% of patients with schizophrenia, and 2.5% of patients without SMI. Substance use increased HCV risk among SMI patients. Patients with bipolar disorder had greater risks than patients with schizophrenia.
Conclusions
Efforts to address HCV among patients with SMI and co-occurring substance abuse are warranted.
doi:10.1176/appi.psy.50.1.30
PMCID: PMC3774160  PMID: 19213970
16.  Eight-Year Trends of Cardiometabolic Morbidity and Mortality in Patients with Schizophrenia 
General Hospital Psychiatry  2012;34(4):368-379.
Objective
We examined cardiometabolic disease and mortality over eight years among individuals with and without schizophrenia.
Method
We compared 65,362 patients in the Veteran Affairs (VA) health system with schizophrenia to 65,362 VA patients without serious mental illness (non-SMI) matched on age, service access year, and location. The annual prevalence of diagnosed cardiovascular disease, diabetes, dyslipidemia, hypertension, obesity, and all-cause and cause-specific mortality were compared for fiscal years 2000–2007. Mean years of potential life lost (YPLL) was calculated annually.
Results
The cohort was mostly male (88%) with a mean age of 54 years. Cardiometabolic disease prevalence increased in both groups with non-SMI patients having higher disease prevalence in most years. Annual between-group differences ranged from < 1% to 6%. Annual mortality was stable over time for schizophrenia (3.1%) and non-SMI patients (2.6%). Annual mean YPLL increased from 12.8 to 15.4 in schizophrenia and from 11.8 to 14.0 for non-SMI groups.
Conclusions
VA patients with and without schizophrenia show increasing but similar prevalence rates of cardiometabolic diseases. YPLLs were high in both groups and only slightly higher among patients with schizophrenia. Findings highlight the complex population served by the VA while suggesting a smaller mortality impact from schizophrenia than previously reported.
doi:10.1016/j.genhosppsych.2012.02.009
PMCID: PMC3383866  PMID: 22516216
schizophrenia; cardiovascular disease; morbidity; mortality; cardiometabolic
17.  Long-Term Antipsychotic Polypharmacy in the VA Health System: Patient Characteristics and Treatment Patterns 
Objective
Although antipsychotic polypharmacy is being prescribed with increasing frequency, few studies have described patient characteristics and treatment patterns associated with long-term use of this treatment strategy.
Methods
By using data from the National Psychosis Registry of the Department of Veterans Affairs, 5,826 patients with schizophrenia or schizoaffective disorder who received long-term antipsychotic polypharmacy (simultaneous treatment with two or more antipsychotics for 90 or more days) during fiscal year 2000 and 39,745 patients who received long-term antipsychotic monotherapy were identified. By using multivariate regression models, patient demographic and clinical characteristics, antipsychotic dosages, and use of antiparkinson and adjunctive psychotropic medications were compared between the two groups.
Results
Patients were more likely to receive antipsychotic polypharmacy if they were younger, were unmarried, had a military service–connected disability, had schizophrenia rather than schizoaffective disorder, or had greater use of inpatient and outpatient mental health services. Patients were less likely to receive antipsychotic polypharmacy if they were African American, had concurrent diagnoses of depression or substance use disorder, or had greater medical comorbidity. For most antipsychotics, dosages prescribed for patients receiving polypharmacy were the same or modestly higher than those prescribed for patients receiving monotherapy. Patients given prescriptions for polypharmacy were more likely to receive antiparkinson medications, antianxiety agents, and mood stabilizers and equally likely to receive concurrent treatment with antidepressants.
Conclusions
Long-term antipsychotic polypharmacy appears to be reserved for more severely ill patients with psychotic symptoms rather than mood symptoms. These patients may experience increased adverse effects as a result of excess antipsychotic exposure.
doi:10.1176/appi.ps.58.4.489
PMCID: PMC3673552  PMID: 17412850
18.  Antidepressant Agents and Suicide Death Among US Department of Veterans Affairs Patients in Depression Treatment 
Background
Studies report mixed findings regarding antidepressant agents and suicide risks, and few examine suicide deaths. Studies using observational data can accrue the large sample sizes needed to examine suicide death but selection biases must be addressed. We assessed associations between suicide death and treatment with the seven most commonly used antidepressants in a national sample of VA patients in depression treatment. Multiple analytic strategies were used to address potential selection biases.
Methods
We identified VA patients with depression diagnoses and new antidepressant starts between April 1, 1999 and September 30, 2004 (N=502,179). Conventional Cox regression models, Cox models with inverse probability of treatment weighting, propensity stratified Cox models, marginal structural models (MSM), and instrumental variable (IV) analyses were used to examine relationships between suicide and exposure to: bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine.
Results
Crude suicide rates varied from 88 to 247/100,000 person-years across antidepressant agents. In multiple Cox and MSM models, sertraline and fluoxetine had lower risks for suicide death than paroxetine. Bupropion had lower risks than several antidepressants in Cox but not MSM models. IV analyses did not find significant differences across antidepressants.
Discussion
Most antidepressants did not differ in their risk for suicide death. However, across several analytic approaches, although not IV analyses, fluoxetine and sertraline had lower risks of suicide death than paroxetine. These findings are congruent with the FDA meta-analysis of RCTs reporting lower risks for “suicidality” for sertraline and a trend towards lower risks with fluoxetine than for other antidepressants. Nevertheless, divergence in findings by analytic approach suggests caution when interpreting results.
doi:10.1097/JCP.0b013e3182539f11
PMCID: PMC3517726  PMID: 22544011
19.  Mitigation of building-related polychlorinated biphenyls in indoor air of a school 
Environmental Health  2012;11:24.
Background
Sealants and other building materials sold in the U.S. from 1958 - 1971 were commonly manufactured with polychlorinated biphenyls (PCBs) at percent quantities by weight. Volatilization of PCBs from construction materials has been reported to produce PCB levels in indoor air that exceed health protective guideline values. The discovery of PCBs in indoor air of schools can produce numerous complications including disruption of normal operations and potential risks to health. Understanding the dynamics of building-related PCBs in indoor air is needed to identify effective strategies for managing potential exposures and risks. This paper reports on the efficacy of selected engineering controls implemented to mitigate concentrations of PCBs in indoor air.
Methods
Three interventions (ventilation, contact encapsulation, and physical barriers) were evaluated in an elementary school with PCB-containing caulk and elevated PCB concentrations in indoor air. Fluorescent light ballasts did not contain PCBs. Following implementation of the final intervention, measurements obtained over 14 months were used to assess the efficacy of the mitigation methods over time as well as temporal variability of PCBs in indoor air.
Results
Controlling for air exchange rates and temperature, the interventions produced statistically significant (p < 0.05) reductions in concentrations of PCBs in indoor air of the school. The mitigation measures remained effective over the course of the entire follow-up period. After all interventions were implemented, PCB levels in indoor air were associated with indoor temperature. In a "broken-stick" regression model with a node at 20°C, temperature explained 79% of the variability of indoor PCB concentrations over time (p < 0.001).
Conclusions
Increasing outdoor air ventilation, encapsulating caulk, and constructing a physical barrier over the encapsulated material were shown to be effective at reducing exposure concentrations of PCBs in indoor air of a school and also preventing direct contact with PCB caulk. In-place management methods such as these avoid the disruption and higher costs of demolition, disposal and reconstruction required when PCB-containing building materials are removed from a school. Because of the influence of temperature on indoor air PCB levels, risk assessment results based on short-term measurements, e.g., a single day or season, may be erroneous and could lead to sub-optimal allocation of resources.
doi:10.1186/1476-069X-11-24
PMCID: PMC3353159  PMID: 22490055
Remediation; Abatement; Flux; Risk management
20.  Predictors of Antidepressant Initiation Among U.S. Veterans Diagnosed with Depression 
Pharmacoepidemiology and drug safety  2010;19(10):1049-1056.
Objectives
Naturalistic studies comparing differences in risks across antidepressant agents must take into account factors which influence selection of specific agents and may be associated with outcomes. We examined predictors of antidepressant choice among VA patients treated for depression
Methods
Retrospective cohort study of VA patients with depression diagnoses and a new start of one of the seven most commonly prescribed antidepressant agents between April 1, 1999-September 30, 2004 (N=502,179). We examined the relationship between patient and facility characteristics and new starts of bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine. We also examined factors associated with new starts only among patients starting selective serotonin reuptake inhibitors (SSRIs).
Results
33% of patients starting mirtazapine had at least 3 outpatient mental health visits in the prior year, compared to ≤ 24% of patients prescribed other antidepressants. Patients starting mirtazapine were also most likely to have received at least 2 other psychotropic medications in the prior year. Of the four SSRIs, 40% of patients ≥65 years old received sertraline while only 31% received fluoxetine. A comorbid anxiety disorder (other than PTSD) was diagnosed in 21% of paroxetine patients compared with ≤ 15% of other SSRI patients.
Conclusion
Choice of antidepressant medication for depressed VA patients was associated with important differences in demographic and clinical variables, including psychiatric illness severity, older age and likelihood of a comorbid anxiety disorder. These findings emphasize the importance of controlling for selection bias when using observational data to compare risks from or effect of mental health treatments.
doi:10.1002/pds.1985
PMCID: PMC2948143  PMID: 20629192
Antidepressant selection; Predictors; Depression Diagnosis
21.  Does Adherence to Medications for Type 2 Diabetes Differ Between Individuals With Vs Without Schizophrenia? 
Schizophrenia Bulletin  2008;36(2):428-435.
Individuals with schizophrenia are at increased risk for poor health outcomes and mortality. This may be due to inadequate self-management of co-occurring conditions, such as type 2 diabetes. We compared adherence to oral hypoglycemic medications for diabetes patients with vs without comorbid schizophrenia. Using Veterans Affairs (VA) health system administrative data, we identified all patients with both schizophrenia and type 2 diabetes and with at least one oral hypoglycemic prescription fill in fiscal year 2002 (N = 11 454) and a comparison group of patients with diabetes who were not diagnosed with schizophrenia (N = 10 560). Nonadherence was operationalized as having a medication possession ratio indicating receipt of less than 80% of needed hypoglycemic medications. Poor adherence was less prevalent among diabetes patients with (43%) than without schizophrenia (52%, P < .001). In multivariable analyses, having schizophrenia was associated with a 25% lower likelihood of poor adherence compared with not having schizophrenia (adjusted odds ratio: 0.75, 95% confidence interval: 0.70–0.80). Poorer adherence was associated with black race, homelessness, depression, substance use disorder, and medical comorbidity. Having more outpatient visits, a higher proportion of prescriptions delivered by mail, lower prescription copayments, and more complex medication regimens were each associated with increased adherence. Among veterans with diabetes receiving ongoing VA care, overall hypoglycemic medication adherence was low, but individuals with comorbid schizophrenia were more likely to be adherent to these medications. Future studies should investigate whether factors such as comanagement of a chronic psychiatric illness or regular contact with mental health providers bestow benefits for diabetes self-management in persons with schizophrenia.
doi:10.1093/schbul/sbn106
PMCID: PMC2833120  PMID: 18718883
co-occurring medical conditions; administrative data
22.  Higher Risk Periods for Suicide Among VA Patients Receiving Depression Treatment 
Journal of affective disorders  2008;112(1-3):50-58.
Background
Health systems with limited resources may have the greatest impact on suicide if their prevention efforts target the highest-risk treatment groups during the highest-risk periods. To date, few health systems have carefully segmented their depression treatment populations by level of risk and prioritized prevention efforts on this basis.
Methods
We conducted a retrospective cohort study of 887,859 VA patients receiving depression treatment between 4/1/1999 and 9/30/2004. We calculated suicide rates for five sequential 12-week periods following treatment events that health systems could readily identify: psychiatric hospitalizations, new antidepressant starts (>6 months without fills), “other” antidepressant starts, and dose changes. Using piecewise exponential models, we examined whether rates differed across time-periods. We also examined whether suicide rates differed by age-group in these periods.
Results
Over all time periods, the suicide rate was 114/100,000 person-years (95% CI; 108,120). In the first 12-week periods, suicide rates were: 568/100,000 p-y (95% CI; 493,651) following psychiatric hospitalizations; 210/100,000 p-y (95% CI; 187, 236) following new antidepressant starts; 193/100,000 p-y (95% CI; 167, 222) following other starts; and 154/100,000 p-y (95% CI; 133, 177) following dose changes. Suicide rates remained above the base rate for 48 weeks following hospital discharge and 12 weeks following antidepressant events. Adults aged 61–80 years were at highest risk in the first 12-weeks periods
Conclusions
To have the greatest impact on suicide, health systems should prioritize prevention efforts following psychiatric hospitalizations. If resources allow, closer monitoring may also be warranted in the first 12 weeks following antidepressant starts, across all age-groups.
doi:10.1016/j.jad.2008.08.020
PMCID: PMC2909461  PMID: 18945495
23.  Quality of Care for Cardiovascular Disease-related Conditions in Patients with and without Mental Disorders 
Journal of General Internal Medicine  2008;23(10):1628-1633.
Objective
We compared the quality of care for cardiovascular disease (CVD)-related risk factors for patients diagnosed with and without mental disorders.
Methods
We identified all patients included in the fiscal year 2005 (FY05) VA External Peer Review Program’s (EPRP) national random sample of chart reviews for assessing quality of care for CVD-related conditions. Using the VA’s National Psychosis Registry and the National Registry for Depression, we assessed whether patients had received diagnoses of serious mental illness (schizophrenia, bipolar disorder, or other psychoses) or depression during FY05. Using multivariable logistic regression and generalized estimating equation analyses, we assessed patient and facility factors associated with receipt of guideline concordant care for hypertension (total N = 24,016), hyperlipidemia (N = 46,430), and diabetes (N = 10,943).
Results
Overall, 70% had good blood pressure control, 90% received a cholesterol (hyperlipidemia) screen, 77% received a retinal exam for diabetes, and 63% received recommended renal tests for diabetes. After adjustment, compared to patients without SMI or depression, patients with SMI were less likely to be assessed for CVD risk factors, notably hyperlipidemia (OR = 0.58; p < 0.001), and less likely to receive recommended follow-up assessments for diabetes: foot exam (OR = 0.68; p < 0.001), retinal exam (OR = 0.65; p < 0.001), or renal testing (OR = 0.64; p < 0.001). Patients with depression were also significantly less likely to receive adequate quality of care compared to non-psychiatric patients, although effects were smaller than those observed for patients with SMI.
Conclusions
Quality of care for major chronic conditions associated with premature CVD-related mortality is suboptimal for VA patients with SMI, especially for procedures requiring care by a specialist.
doi:10.1007/s11606-008-0720-z
PMCID: PMC2533391  PMID: 18626722
quality of care; cardiovascular disease; mental disorders
24.  Reducing patients’ exposures to asthma and allergy triggers in their homes: an evaluation of effectiveness of grades of forced air ventilation filters 
The Journal of Asthma  2014;51(6):585-594.
Objective
Many interventions to reduce allergen levels in the home are recommended to asthma and allergy patients. One that is readily available and can be highly effective is the use of high performing filters in forced air ventilation systems.
Methods
We conducted a modeling analysis of the effectiveness of filter-based interventions in the home to reduce airborne asthma and allergy triggers. This work used “each pass removal efficiency” applied to health-relevant size fractions of particles to assess filter performance. We assessed effectiveness for key allergy and asthma triggers based on applicable particle sizes for cat allergen, indoor and outdoor sources of particles <2.5 µm in diameter (PM2.5), and airborne influenza and rhinovirus.
Results
Our analysis finds that higher performing filters can have significant impacts on indoor particle pollutant levels. Filters with removal efficiencies of >70% for cat dander particles, fine particulate matter (PM2.5) and respiratory virus can lower concentrations of those asthma triggers and allergens in indoor air of the home by >50%. Very high removal efficiency filters, such as those rated a 16 on the nationally recognized Minimum Efficiency Removal Value (MERV) rating system, tend to be only marginally more effective than MERV12 or 13 rated filters.
Conclusions
The results of this analysis indicate that use of a MERV12 or higher performing air filter in home ventilation systems can effectively reduce indoor levels of these common asthma and allergy triggers. These reductions in airborne allergens in turn may help reduce allergy and asthma symptoms, especially if employed in conjunction with other environmental management measures recommended for allergy and asthma patients.
doi:10.3109/02770903.2014.895011
PMCID: PMC4133967  PMID: 24555523
Asthma and allergy triggers; filtration; indoor air; particulate; PM2.5

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