Wisdom is a unique psychological trait noted since antiquity, long discussed in humanities disciplines, recently operationalized by psychology and sociology researchers, but largely unexamined in psychiatry or biology.
We discuss recent neurobiological studies related to subcomponents of wisdom identified from several published definitions/descriptions of wisdom by clinical investigators in the field – i.e., prosocial attitudes/behaviors, social decision-making/pragmatic knowledge of life, emotional homeostasis, reflection/self-understanding, value relativism/tolerance, and acknowledgement of and dealing effectively with uncertainty.
Literature overview focusing primarily on neuroimaging/brain localization and secondarily on neurotransmitters, including their genetic determinants.
Functional neuroimaging permits exploration of neural correlates of complex psychological attributes such as those proposed to comprise wisdom. The prefrontal cortex figures prominently in several wisdom subcomponents (e.g., emotional regulation, decision-making, value relativism), primarily via top-down regulation of limbic and striatal regions. The lateral prefrontal cortex facilitates calculated, reason-based decision-making, whereas the medial prefrontal cortex is implicated in emotional valence and prosocial attitudes/behaviors. Reward neurocircuitry (ventral striatum, nucleus accumbens) also appears important for promoting prosocial attitudes/behaviors. Monoaminergic activity (especially dopaminergic and serotonergic), influenced by several genetic polymorphisms, is critical to certain subcomponents of wisdom such as emotional regulation (including impulse control), decision-making, and prosocial behaviors.
We have proposed a speculative model of the neurobiology of wisdom involving fronto-striatal and fronto-limbic circuits and monoaminergic pathways. Wisdom may involve optimal balance between functions of phylogenetically more primitive brain regions (limbic system) and newer ones (prefrontal cortex). Limitations of the putative model are stressed. It is hoped that this review will stimulate further research in characterization, assessment, neurobiology, and interventions related to wisdom.
Wisdom; Neurobiology; Cognition; Emotional regulation; Resilience; Imaging; Decision making
Psychosis is common in late life and exacts enormous costs to society, affected individuals, and their caregivers. A multitude of etiologies for late-life psychosis exist, the two most prototypical being schizophrenia and psychosis of Alzheimer’s Disease (AD). As such, this review will focus on the non-affective, neuropsychiatric causes of chronic psychosis in the elderly, specifically schizophrenia, delusional disorder, and the psychosis of AD and other dementias. As evidenced in this review, the current research regarding the onset and course of late-life schizophrenia reflects a more favorable prognosis than that painted by the Kraepelinian notion of schizoprenia as “dementia praecox.” Antipsychotics are useful in controlling the symptoms of late-life schizophrenia, but their use among older adults warrants increased vigilance because of older adults’ increased proclivity to side effects. Psychosocial interventions can be effective, usually in conjunction with medication. Meanwhile, psychosis of AD occurs in nearly half of people with AD and is associated with increased hospitalizations, institutionalization, caregiver distress, and mortality. Despite the profound consequences of psychotic symptoms associated with dementias, the extant literature does not afford clinicians clear, consistent guidance on how to provide optimal treatment to specific patients. Second generation antipsychotics are usually the choice treatment for psychosis, but the black box warning regarding their associated 1–2% increased absolute risk in stroke and overall mortality in patients with dementia complicates their use. Using second generation antipsychotics in low doses for brief periods and discontinuing them when possible is the best clinical practice for dementia-related psychosis. Psychosocial interventions for the treatment of psychosis with AD appear promising in empirical research, but more rigorous study is needed.
schizophrenia; psychosis; late-life; dementia; age
There is a widening disparity between the proportion of ethnic minority Americans in the population and the number of researchers from these minority groups. One major obstacle in this arena relates to a dearth of mentors for such trainees. The present academic settings are not optimal for development and sustenance of research mentors, especially for mentees from underrepresented minority ethnic groups.
Mentoring skills can and should be evaluated and enhanced. Universities, medical schools, and funding agencies need to join hands and implement national- and local-level programs to help develop and reward mentors of junior scientists from ethnic minority groups.
The study of wisdom has recently become a subject of growing scientific interest, although the concept of wisdom is ancient. This article focuses on conceptualization of wisdom in the Bhagavad Gita, arguably the most influential of all ancient Hindu philosophical/religious texts. Our review, using mixed qualitative/quantitative methodology with the help of Textalyser and NVivo software, found the following components to be associated with the concept of wisdom in the Gita: Knowledge of life, Emotional Regulation, Control over Desires, Decisiveness, Love of God, Duty and Work, Self-Contentedness, Compassion/Sacrifice, Insight/Humility, and Yoga (Integration of personality). A comparison of the conceptualization of wisdom in the Gita with that in modern scientific literature shows several similarities, such as rich knowledge about life, emotional regulation, insight, and a focus on common good (compassion). Apparent differences include an emphasis in the Gita on control over desires and renunciation of materialistic pleasures. Importantly, the Gita suggests that at least certain components of wisdom can be taught and learned. We believe that the concepts of wisdom in the Gita are relevant to modern psychiatry in helping develop psychotherapeutic interventions that could be more individualistic and more holistic than those commonly practiced today, and aimed at improving personal well-being rather than just psychiatric symptoms.
Purpose of review
Although the basic standards of adjudicative competence were specified by the U.S. Supreme Court in 1960, there remain a number of complex conceptual and practical issues in interpreting and applying these standards. In this report we provide a brief overview regarding the general concept of adjudicative competence and its assessment, as well as some highlights of recent empirical studies on this topic.
Most adjudicative competence assessments are conducted by psychiatrists or psychologists. There are no universal certification requirements, but some states are moving toward required certification of forensic expertise for those conducting such assessments. Recent data indicate inconsistencies in application of the existing standards even among forensic experts, but the recent publication of consensus guidelines may foster improvements in this arena. There are also ongoing efforts to develop and validate structured instruments to aid competency evaluations. Telemedicine-based competency interviews may facilitate evaluation by those with specific expertise for evaluation of complex cases. There is also interest in empirical development of educational methods to enhance adjudicative competence.
Adjudicative competence may be difficult to measure accurately, but the assessments and tools available are advancing. More research is needed on methods of enhancing decisional capacity among those with impaired competence.
Competence; ethics; informed consent
A review of literature on the neurodevelopmental origins of schizophemia is presented, with particular attention to neurodevelopmental processes in late-onset schizophemia. Definitions of the term “neurodevelopmental” as used in schizophernia literature are first provided. Next, evidence for the developmental origins of the neuropathology in schizophemia is reviewed. This evidence includes studies of the associations between schizophemia and neurodevelopmental brain aberrations, minor physical anomalies, obstetric complications, prenatal viral exposure, childhood neuromotor abnormalities, and pandysmaturation. A brief discussion of the predominant theories about the neurodevelopmental origins of schizophemia is then provided. The concept and nature of “late-onset schizophenia ”is next defined and discussed. Finally, the neurodevelopmental literature is discussed in relation to the phenomenon of late-onset schizophemia. Based on this review, we conclude that there exists a strong likelihood that late-onset schizophrenia involves neurodevelopmental processes.
Psychosis; neurodegeneration; dementia; congnition; aging; developmental disabilities
To determine whether cognitive behavioral social skills training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST.
An 18-month, single-blind, randomized controlled trial.
Outpatient clinic at a university-affiliated Veterans Affairs hospital.
Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N=79) age 45–78.
CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals.
Blind raters assessed functioning (primary outcome: Independent Living Skills Survey) CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction.
Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem and life satisfaction.
CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning.
Context: The nature of executive dysfunction in schizophrenia is nebulous, due to inconsistencies in conceptualizing and operationalizing the construct, and the broader question of whether schizophrenia is best characterized in terms of specific vs generalized cognitive deficits. The current study aimed to determine whether executive functions represent unitary vs diverse constructs in schizophrenia.
Methods: Participants included 145 community-dwelling individuals with schizophrenia. Executive functions were measured with the Delis-Kaplan Executive Functioning System (D-KEFS). We conducted an exploratory factor analysis (EFA) with principal axis factoring, as well as parallel analyses to examine the latent constructs underlying the D-KEFS tasks, a second EFA on weighted residuals of the D-KEFS tasks (after accounting for processing speed measured with the Digit Symbol task), and bivariate correlations to examine relationships between the D-KEFS components and relevant demographic and clinical variables, crystallized verbal knowledge, and functional capacity.
Results: EFA of the D-KEFS tasks yielded 2 factors (cognitive flexibility/timed tests and abstraction). EFA of the processing speed-weighted D-KEFS residuals also yielded 2 factors (cognitive flexibility and abstraction). Cognitive flexibility was negatively correlated with psychopathology. Better abstraction was associated with higher education, shorter illness duration, and better functional capacity. Both factors were positively correlated with crystallized verbal knowledge.
Conclusions: Executive functions in schizophrenia could be parsed into 2 partially related but separable subconstructs. Future efforts to elucidate functional outcomes as well as neurobiological underpinnings of schizophrenia may be facilitated by attending to the distinction between cognitive flexibility and abstraction.
cognitive flexibility; abstraction; D-KEFS; factor analysis
This study is a retrospective chart review comparing rural-dwelling Caucasian and Hispanic outpatients' attribution of depressive symptoms. Based on the data gathered at intake, Hispanics were more likely to attribute depression to curse/spell and supernatural causes, while Caucasians were more likely to attribute symptoms to hereditary factors or job stress. Among both groups, higher CESD score was associated with problems with significant others or how they got along with others. Among Hispanics, depression severity was additionally associated with problems related to job or finances. Our findings point to a consequential role for clinical inquiry into attributed causes of depressive symptoms.
Schizophrenia is associated with executive dysfunction. Yet, the degree to which executive functions are impaired differentially, or above and beyond underlying basic cognitive processes is less clear. Participants included 145 matched pairs of individuals with schizophrenia (SCs) and normal comparison subjects (NCs). Executive functions were assessed with 10 tasks of the Delis-Kaplan Executive Function System (D-KEFS), in terms of “achievement scores” reflecting overall performance on the task. Five of these tasks (all measuring executive control) were further examined in terms of their basic component (e.g., processing speed) scores and contrast scores (reflecting residual higher order skills adjusted for basic component skills). Group differences were examined via multivariate analysis of variance. SCs had worse performance than NCs on all achievement scores, but the greatest SC-NC difference was that for the Trails Switching task. SCs also had worse performance than NCs on all basic component skills. Of the executive control tasks, only Trails Switching continued to be impaired after accounting for impairments in underlying basic component skills. Much of the impairment in executive functions in schizophrenia may reflect the underlying component skills rather than higher-order functions. However, the results from one task suggest that there might be additional impairment in some aspects of executive control.
Cognition; Executive function; Schizoaffective disorder; Psychotic disorders; Trail Making Test; D-KEFS
Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end of life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness).
110 participants receiving hospice services completed a one-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews.
In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43–2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity.
Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision-making may lead to effective interventions to improve decision-making and honor the wishes of patients and families.
dementia; delirium; hospice; neuropsychology; cognitive impairment; decision-making; palliative care
The reasons for the reportedly high use of TV watching among older adults despite its potential negative health consequences are not known.
To investigate age differences in time use and affective experience in TV use in a nationally representative sample
Using an innovative assessment of affective experience in a nationally representative sample, several putative reasons were examined for age-related increases in TV use. A sample of 3982 Americans aged 15–98 years who were assessed using a variant of the Day Reconstruction Method, a survey method for measuring how people experience their lives, was analyzed. To understand age increases in TV use, analyses examined whether older people (1) enjoy TV more, (2) watch TV because it is less stressful than alternatives, or whether (3) TV use related to age differences in demographics, being alone, or life satisfaction. Data were collected in 2006 and analyzed in 2008–2009.
Adults aged >65 years spent threefold more waking time watching TV than young adults. Despite this trend, older people enjoyed TV less, in contrast to stable enjoyment with other leisure activities. Older adults did not seem to experience the same stress buffering effects of watching TV as did young and middle-aged adults. This negative age-associated trend in how TV was experienced was not accounted for by demographic factors or in time spent alone. Greater TV use, but not time spent in other leisure activities, was related to lower life satisfaction.
Older adults watch more TV but enjoy it less than younger people. Awareness of this discrepancy could be useful for those developing interventions to promote reduced sedentary behaviors in older adults.
Lay perceptions of “successful aging” are important for understanding this multifaceted construct and developing ways to assist older adults to age well. The purpose of this qualitative study was to obtain older adults’ individual perspectives on what constitutes successful aging, along with their views regarding activities and interventions to enhance its likelihood.
Qualitative interviews were conducted with 22 community-dwelling adults over age 60. Participants were recruited from retirement communities, a low-income senior housing complex, and a continued learning center in San Diego County. Interview transcripts were analyzed using a “Coding Consensus, Co-occurrence, and Comparison” grounded theory framework.
The mean age of participants was 80 years (range: 64 to 96), with 59% being women. Two primary themes were identified as key to successful aging - i.e., self-acceptance/self-contentment (with sub-themes of realistic self-appraisal, a review of one’s life, and focusing on the present) and engagement with life/self-growth (with sub-themes of novel pursuits, giving to others, social interactions, and positive attitude). A balance between these two constructs appeared critical. A need for interventions that address support systems and personally tailored information to make informed decisions and enhance coping strategies were also emphasized.
Older adults viewed successful aging as a balance between self-acceptance and self-contentedness on one hand and engagement with life and self-growth in later life on the other. This perspective supports the concept of wisdom as a major contributor to successful aging. Interventions to enhance successful aging may include those that promote productive and social engagement along with effective coping strategies.
Successful aging; Adaptation; Resilience; Qualitative methods; Wisdom
Treatments for the cognitive impairments of schizophrenia are urgently needed. We developed and tested a 12-week, group-based, manualized, Compensatory Cognitive Training (CCT) intervention targeting prospective memory, attention, learning/memory, and executive functioning. The intervention focused on compensatory strategies such as calendar use, self-talk, note-taking, and a six-step problem-solving method, and did not require computers.
In a randomized controlled trial, 69 outpatients with DSM-IV primary psychotic disorders were assigned to receive standard pharmacotherapy (SP) alone or CCT + SP for 12 weeks. Assessments of neuropsychological performance and functional capacity (primary outcomes) and psychiatric symptom severity, quality of life, social skills performance, cognitive insight, and self-reported everyday functioning (secondary outcomes) were administered at baseline, post-treatment, and 3-month follow-up. Data were collected between September 2003 and August 2009.
Hierarchical linear modeling analyses demonstrated significant CCT-associated effects on attention at follow-up (p=0.049), verbal memory at post-treatment and follow-up (ps≤0.039), and functional capacity (UCSD Performance-based Skills Assessment) at follow-up (p=0.004). The CCT group also differentially improved in negative symptom severity at post-treatment and follow-up (ps≤0.025) and subjective quality of life at follow-up (p=0.002).
Compensatory Cognitive Training, a low-tech, brief intervention, has the potential to improve not only cognitive performance, but also functional skills, negative symptoms, and self-rated quality of life in people with psychosis.
schizophrenia; rehabilitation; cognitive remediation; memory
Longitudinal data suggest heterogeneity in the long-term course of schizophrenia. It is unclear how older adults with schizophrenia perceive changes in their experience of schizophrenia over the lifespan. We interviewed 32 adults aged 50 years and older diagnosed with schizophrenia (mean duration 35 years) about their perceived changes in the symptoms of schizophrenia and functioning over the lifespan. Interview transcripts were analyzed using grounded theory techniques of coding, consensus, co-occurrence, and comparison. The study was conducted by a research partnership involving a multidisciplinary team of academic researchers, community members, and mental health clients engaged in all aspects of study design, interviewing, and analysis and interpretation of data. Results revealed that, in regard to early course of illness, participants experienced confusion about diagnosis, active psychotic symptoms, and withdrawal/losses in social networks. Thereafter, nearly all participants believed that their symptoms had improved, which they attributed to increased skills in self-management of positive symptoms. In contrast to consistency among participants in describing illness course, there was marked heterogeneity in perceptions about functioning. Some participants were in despair about the discrepancy between their current situations and life goals, others were resigned to remain in supported environments, and others working toward functional attainments and optimistic about the future. In conclusion, middle-aged and older adults with schizophrenia believed that their symptoms had improved over their lifespan, yet there was substantial variability among participants in how they perceived their functioning. Functional rehabilitation may need to be tailored to differences in perceptions of capacity for functional improvement.
aging; psychosis; disability; qualitative research; quality of life
The objective of this study was to examine the influence of military veteran status within a data set of older patients with schizophrenia or schizoaffective disorder.
The data set was examined to determine whether veteran status influenced psychopathology, quality of life, cognitive performance, and everyday functioning among 746 male participants.
There were no significant differences between the groups on measures of premorbid functioning or psychopathology. Veterans in the sample were older, had a higher likelihood of being married (or previously married), had a lower likelihood of living in a board-and-care facility, and had a later age of onset of schizophrenia compared with nonveterans. Though veterans reported worse physical health, they also had better everyday functioning and better performance on some cognitive tasks than nonveterans. Fewer veterans endorsed current use of substances than nonveterans.
There were several differences based on veteran status, including everyday functioning, health-related quality of life, cognitive performance, and current substance use.
aging; cognitive functioning; quality of life; schizophrenia; substance use; veterans
Supported employment is the evidence-based treatment of choice for assisting individuals with severe mental illness to achieve competitive employment, but few supported employment programs specifically target older clients with psychiatric illness. The purpose of this study was to evaluate the efficacy of supported employment for middle-aged or older people with schizophrenia.
Participants included 58 outpatients with schizophrenia or schizoaffective disorder aged 45 or older who were recruited from a community mental health clinic. Participants were randomly assigned to receive Individual Placement and Support (IPS; the manualized version of supported employment) or conventional vocational rehabilitation (CVR) for one year, and completed assessments at baseline, six months, and twelve months.
IPS was superior to CVR on nearly all work outcome measures, including attainment of competitive employment, weeks worked, and wages earned. Fifty-seven percent of IPS participants worked competitively, compared with 29% of CVR participants; 70% of IPS participants obtained any paid work, compared with 36% of CVR participants. Within the IPS group, better baseline functional capacity (as measured by the UCSD Performance Based Skills Assessment) and more recent employment were modestly associated with better work outcomes.
Middle-aged and older adults with schizophrenia are good candidates for supported employment services.
psychosis; rehabilitation; geriatric psychiatry
Many neuroimaging studies interpret the commonly reported findings of age-related increases in frontal response and/or increased bilateral activation as suggestive of compensatory neural recruitment. However, it is often unclear whether differences are due to compensation or reflective of other cognitive or physiological processes. This study aimed to determine whether there are compensatory age-related changes in brain systems supporting successful associative encoding while taking into account potentially confounding factors including age-related differences in task performance, atrophy, and resting perfusion. Brain response during encoding of face-name pairs was measured using functional magnetic resonance imaging in 10 older and nine young adults and was correlated with memory performance. During successful encoding, older adults demonstrated increased frontal and decreased occipital activity as well as greater bilateral involvement relative to the young. Findings remained significant after controlling for age-related cortical atrophy and hypoperfusion. Among the older adults, greater response was associated with better memory performance. Cognitive aging may involve recruitment of compensatory mechanisms to improve performance or prevent impairment. Results extend previous findings by suggesting that age-related alterations in activation cannot be attributed to the commonly observed findings of poorer task performance, reduced resting perfusion, or cortical atrophy among older adults.
Magnetic resonance imaging; Aging; Cognition; Frontal lobe; Neuropsychology; Paired associate learning
This study examined differences in the frequency of leisure activity participation and relationships to depressive symptom burden and cognition in Latino and Caucasian women. Cross-sectional data were obtained from a demographically matched subsample of Latino and Caucasian (n = 113 each) post-menopausal women (age ≥60), interviewed in 2004–06 for a multi-ethnic cohort study of successful aging in San Diego County. Frequencies of engagement in 16 leisure activities and associations between objective cognitive performance and depressive symptom burden by ethnicity were identified using bivariate and linear regression, adjusted for physical functioning and demographic covariates. Compared to Caucasian women, Latinas were significantly more likely to be caregivers and used computers less often. Engaging in organized social activity was associated with fewer depressive symptoms in both groups. Listening to the radio was positively correlated with lower depressive symptom burden for Latinas, and better cognitive functioning in Caucasians. Cognitive functioning was better in Latinas who read and did puzzles. Housework was negatively associated with Latinas’ emotional health and Caucasians’ cognitive functioning. Latino and Caucasian women participate in different patterns of leisure activities. Additionally, ethnicity significantly affects the relationship between leisure activities and both emotional and cognitive health.
Unimpaired cognition is an important feature of successful aging. Differences in cognitive performance among healthy older adults may be related to differences in brain structure. We reviewed the literature to examine the relationship between brain structure size and cognitive performance in older adults. Eighty-three percent of studies found at least one positive relationship between these factors; however, findings were variable. Positive relationships emerged most consistently between the hippocampal formation and global cognition and memory and between frontal measures and executive function. Additional longitudinal study is needed to further evaluate structure-cognition relationships in older adulthood and across the adult lifespan.
Brain structure; successful aging; healthy aging; cognition; magnetic resonance imaging
Aging is not a uniform process. In the general population, there is a paradox of aging: age-associated decline in physical and some cognitive functions stands in contrast to an enhancement of subjective quality of life and psychosocial functioning. This paradox is even more striking in people with schizophrenia. Compared with the overall population, individuals with schizophrenia have accelerated physical aging (with increased and premature medical comorbidity and mortality) but a normal rate of cognitive aging, although with mild cognitive impairment starting from premorbid period and persisting throughout life. Remarkably, psychosocial function improves with age, with diminished psychotic symptoms, reduced psychiatric relapses requiring hospitalization and better self-management. Many older adults with schizophrenia successfully adapt to the illness, with increased use of positive coping techniques, enhanced self-esteem and increased social support. Although complete remission is uncommon, most individuals with schizophrenia experience significant improvement in their quality of well-being. Cohort effect and survivor bias may provide a partial explanation for this phenomenon. However, the improvement also may reflect some brain changes that are beneficial for the course of schizophrenia along with neuroplasticity of aging. The proposed hypothesis has several implications. As significant medical morbidity in schizophrenia takes years to develop, studies of changes in sensitive biomarkers of aging during the course of illness may point to new treatments aimed at normalizing the rate of biological aging in schizophrenia. At the same time, effective psychotherapeutic interventions can affect brain structure and function and produce lasting positive behavioral changes in aging adults with schizophrenia.
psychosis; geriatric; quality of life; psychotherapy; neuropsychological; biomarkers
The purpose of this study was twofold: 1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use—Andersen’s Behavioral Model of Health Service Use —in individuals enrolled in a large, public-funded mental health system; and 2) To document service utilization by high use consumers prior to a transformation of the service delivery system.
We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000–2004. Subjects with information in the database for the index year (fiscal year 2000–2001) and all of the following three years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than one year).
Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU.
Characteristics with the strongest association with heavy use of a public mental health system were mutable enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.
Cognitive heterogeneity has been a key barrier to clarifying the neuropathologic underpinnings of schizophrenia. We used an idiographic method for cluster analysis of neuropsychological data from 144 middle-aged and older people with schizophrenia to characterize and group the patterns of relative (within-person) profiles of cognitive strength and weakness. Results indicated a 5-cluster solution as most appropriate, with relatively even distribution across the five clusters in terms of the proportion of patients in each cluster. Cognitive subtyping may be useful in imaging and genetic research on schizophrenia, as well as having practical utility in treatment planning and cognitive rehabilitation.