Comorbid Severe Mental Illness Research Articles

Patients with Schizophrenia Showed Worse Cognitive Performance than Bipolar and Major Depressive Disorder in a Sample with Comorbid Substance Use Disorders.

Comorbidity of substance use disorders (SUD) and severe mental illness (SMI) is highly frequent in patients, the most common diagnoses being schizophrenia (SZ), bipolar disorder (BD) and major depressive disorder (MDD). Since comorbidity has its own clinical features, and neurocognitive functioning is not always similar to psychiatric symptoms the present study explores the cognitive performance of patients with dual disorders. A neuropsychological battery of tests was used to assess 120 under treatment male patients, 40 for each group considered (SZ + SUD, BD + SUD and MDD + SUD) who were mainly polyconsumers. Significant differences (with premorbid IQ as a covariate) were found among the groups, with SZ + SUD having a worse performance in attention, verbal learning, short term memory and recognition. The consideration of a global Z score for performance evidenced an impaired neurocognitive pattern for SZ + SUD compared with BD + SUD and MDD + SUD. According to norms, all patients showed difficulties in verbal learning, short-term memory and recognition. Our research indicated that the neurocognitive functioning of dual disorder patients was influenced by the comorbid SMI, with SZ + SUD presenting major difficulties. Future studies should thoroughly explore the role of such difficulties as indicators or endophenotypes for dual schizophrenia disorders, and their usefulness for prevention and treatment.

The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis.

People with severe mental illness (SMI) are at higher risk of physical health conditions compared to the general population, however, the impact of specific underlying health conditions on the use of secondary care by people with SMI is unknown. We investigated hospital use in people managed in the community with SMI and five common physical long-term conditions: cardiovascular diseases, COPD, cancers, diabetes and liver disease. We performed a systematic review and meta-analysis (Prospero: CRD42020176251) using terms for SMI, physical health conditions and hospitalisation. We included observational studies in adults under the age of 75 with a diagnosis of SMI who were managed in the community and had one of the physical conditions of interest. The primary outcomes were hospital use for all causes, physical health causes and related to the physical condition under study. We performed random-effects meta-analyses, stratified by physical condition. We identified 5,129 studies, of which 50 were included: focusing on diabetes (n = 21), cardiovascular disease (n = 19), COPD (n = 4), cancer (n = 3), liver disease (n = 1), and multiple physical health conditions (n = 2). The pooled odds ratio (pOR) of any hospital use in patients with diabetes and SMI was 1.28 (95%CI:1.15-1.44) compared to patients with diabetes alone and pooled hazard ratio was 1.19 (95%CI:1.08-1.31). The risk of 30-day readmissions was raised in patients with SMI and diabetes (pOR: 1.18, 95%CI:1.08-1.29), SMI and cardiovascular disease (pOR: 1.27, 95%CI:1.06-1.53) and SMI and COPD (pOR:1.18, 95%CI: 1.14-1.22) compared to patients with those conditions but no SMI. People with SMI and five physical conditions are at higher risk of hospitalisation compared to people with that physical condition alone. Further research is warranted into the combined effects of SMI and physical conditions on longer-term hospital use to better target interventions aimed at reducing inappropriate hospital use and improving disease management and outcomes.

Diabetes Care in the Psychiatric Inpatient Setting: A National Survey of Mental Health Professionals Knowledge, Attitudes and Skills

AimsPeople with Severe Mental Illness (SMI) are at increased risk of developing diabetes. There is currently a lack of monitoring and standardisation of diabetes care in the NHS psychiatric inpatient setting. This presents as a missed opportunity, as inpatient admission could be used to improve diabetes care for this population. We surveyed the multi-disciplinary teams in psychiatric inpatient units across England to develop understanding of current diabetes care in this setting.MethodsA 13-item questionnaire was designed to assess the knowledge, attitudes and skills relating to diabetes care. This was piloted via think out loud interviews with 5 staff at a Forensic unit. Amendments were then made to the questionnaire to improve the validity prior to national roll-out.Site coordinators working within General Adult, Old Age, Rehabilitation and Forensic inpatient services were recruited via medical education and academic links. This included 19 inpatient sites within 11 NHS Mental Health Trusts across England. Site coordinators circulated the questionnaire, primarily via electronic survey. A small number of paper responses were also collected.Results156 responses were collected via the national survey (electronic = 136, paper = 20). 6 responses were excluded due to missing professional role information or roles not involving physical healthcare. Respondents included within the analysis comprised 43 Doctors, 55 Nurses and 52 Allied Healthcare Professionals.93% of respondents agreed that addressing physical health needs was an important part of the mental health team's role, although only 28% had received physical healthcare training within the last 12 months.68% agreed that they had adequate skills and knowledge to manage diabetes safely on the ward. 69% agreed that the diabetic care on the ward was of an acceptable standard according to National Institute for Health and Care Excellent (NICE) guidelines. This reflects a need for appropriate training and guidance to help improve this aspect of care.Additionally, only 51% agreed that they felt able to refer a patient with diabetes to the most appropriate diabetes service based on type of diabetes and medication prescribed. This highlights an important issue, as cohesive shared-care and clear referral pathways are key when considering effective diabetes management.ConclusionPsychiatric inpatient admission could be used opportunistically to improve the healthcare disparities for people with comorbid diabetes and SMI. This national survey highlights key areas that would need to be addressed to standardise and optimise diabetes care in this setting. This includes appropriate training, clear guidelines and cohesive shared-care pathways.

Primary care for people with severe mental illness and comorbid obstructive airways disease: a qualitative study of patient perspectives with integrated stakeholder feedback.

ObjectivesTo explore patient and stakeholder perspectives on primary respiratory care for people with severe mental illness (SMI) and comorbid obstructive airways disease (OAD).DesignQualitative, semistructured qualitative interviews were undertaken with a purposive sample of people with a diagnosis of SMI (bipolar illness, schizophrenia, affective disorder with psychosis) and comorbid asthma or chronic obstructive pulmonary disease. Transcribed data were analysed using an interpretive phenomenological approach. Study results were discussed with stakeholders.SettingEight UK general practices.Participants16 people aged 45–75 years, with SMI and comorbid asthma or chronic obstructive pulmonary disease, were interviewed. Twenty-one people, four with lived experience of SMI and seventeen health/social care/third sector practitioners, participated in discussion groups at a stakeholder event.ResultsParticipants described disability and isolation arising from the interplay of SMI and OAD symptoms. Social support determined ease of access to primary care. Self-management of respiratory health was not person-centred as practitioners failed to consider individual needs and health literacy. Participants perceived smoking cessation impossible without tailored support. Less than half of the practices facilitated personalised access to timely primary care and continuity. Overall, there was a reliance on urgent care if service adaptations and social support were lacking. The stakeholder group expressed concern about gaps in care, the short-term funding of community organisations and fear of loss of benefits. Potential solutions focused on supported navigation of care pathways, relational continuity, individual and community asset building and the evolving social prescriber role.ConclusionThis study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care that builds social capital and tailors support for self-management is needed, alongside service-level interventions to enhance access to healthcare for patients with comorbid SMI and OAD.

Risk of First General Hospital Admissions for Self-Harm Among People With Personality Disorder: A Retrospective Cohort Study

For individuals with a personality disorder (PD), it is unknown whether additional psychiatric conditions increase their risk of self-harm. The authors therefore conducted a retrospective cohort study, using data from secondary mental health care, to identify self-harm admissions. Adults with diagnosed PD, followed up over a 6-year period, were involved (N = 7,475). Cox regression was used to model the risk of self-harm admissions, with comorbid depression, substance use disorders (SUD), severe mental illness (SMI), anorexia nervosa (AN), and bulimia nervosa (BN) as primary exposures; sociodemographics were considered as confounders. In multivariable analyses, comorbid SUD (adjusted HR = 1.66; 95% CI [1.45, 1.90]), depressive disorder (1.25; [1.09, 1.44]), AN (1.63; [1.10, 2.39]), and BN (1.65; [1.09, 2.51]) were positively associated with increased risks of hospitalization due to self-harm. However, a negative association was found for comorbid SMI. The findings highlight the importance of assessing and treating comorbid psychiatric disorders in PD.

Healthcare resource use and costs for people with type 2 diabetes mellitus with and without severe mental illness in England: longitudinal matched-cohort study using the Clinical Practice Research Datalink.

Approximately 60 000 people in England have coexisting type 2 diabetes mellitus (T2DM) and severe mental illness (SMI). They are more likely to have poorer health outcomes and require more complex care pathways compared with those with T2DM alone. Despite increasing prevalence, little is known about the healthcare resource use and costs for people with both conditions. To assess the impact of SMI on healthcare resource use and service costs for adults with T2DM, and explore the predictors of healthcare costs and lifetime costs for people with both conditions. This was a matched-cohort study using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics for 1620 people with comorbid SMI and T2DM and 4763 people with T2DM alone. Generalised linear models and the Bang and Tsiatis method were used to explore cost predictors and mean lifetime costs respectively. There were higher average annual costs for people with T2DM and SMI (£1930 higher) than people with T2DM alone, driven primarily by mental health and non-mental health-related hospital admissions. Key predictors of higher total costs were older age, comorbid hypertension, use of antidepressants, use of first-generation antipsychotics, and increased duration of living with both conditions. Expected lifetime costs were approximately £35 000 per person with both SMI and T2DM. Extrapolating nationally, this would generate total annual costs to the National Health Service of around £250 m per year. Our estimates of resource use and costs for people with both T2DM and SMI will aid policymakers and commissioners in service planning and resource allocation.

Meta-Analysis of the Treatment of Posttraumatic Stress Disorder in Adults With Comorbid Severe Mental Illness.

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder). Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness. Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis. Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1–0 in R (3.6.0). Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = −1.009, P < .001, k = 34). Prolonged exposure (g = −1.464; P < .001; SE = 0.276; k = 5), eye movement desensitization and reprocessing (g = −1.351; P < .001; SE = 0.276; k = 5), and brief treatment program (g = −1.009; P < .001; SE = 0.284; k = 5) had the largest effects on PTSD symptoms. Conclusions: Although underrepresented in the PTSD literature, PTSD psychotherapies are effective for individuals with SMI. Treatments with an exposure-based component may have greater efficacy in this clinical population.

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

PurposeTo investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).MethodsAll residents admitted to Norwegian in- and outpatient specialist health care services during 2009–2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.ResultsMortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6–4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0–12.0), but increased also for natural causes of death (2.2, 95% CI 2.0–2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.ConclusionThe SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

Cognitive Trajectories in Comorbid Dementia With Schizophrenia or Bipolar Disorder: The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register

ObjectivesWe aimed to compare trajectories of cognitive performance in individuals diagnosed with dementia with and without severe mental illness (SMI). DesignRetrospective cohort study. SettingWe used data from a large longitudinal mental healthcare case register, the Clinical Record Interactive Search (CRIS), at the South London and Maudsley NHS Foundation Trust (SLaM) which provides mental health services to four south London boroughs. ParticipantsOur sample (N = 4718) consisted of any individual who had a primary or secondary diagnosis of dementia from 2007 to 2018, was 50 years old or over at first diagnosis of dementia and had at least 3 recorded Mini-Mental State Examination (MMSE) scores. MeasurementsCognitive performance was measured using MMSE. Linear mixed models were fitted to explore whether MMSE trajectories differed between individuals with or without prior/current SMI diagnoses. Models were adjusted by socio-demographics, cardiovascular risk, smoking, and medication. Results and conclusionsOur results showed differences in the rate of change, where individuals with comorbid SMI had a faster decline when compared with those that have dementia without comorbid SMI. However, this association was partially attenuated when adjusted by socio-demographics, smoking and cardiovascular risk factors; and more substantially attenuated when medication was included in models. Additional analyses showed that this accelerated decline might be more evident in individuals with bipolar disorders. Future research to detangle the potential biological underlying mechanisms of these associations is needed.

Risk of First General Hospital Admissions for Self-Harm Among People With Personality Disorder: A Retrospective Cohort Study.

For individuals with a personality disorder (PD), it is unknown whether additional psychiatric conditions increase their risk of self-harm. The authors therefore conducted a retrospective cohort study, using data from secondary mental health care, to identify self-harm admissions. Adults with diagnosed PD, followed up over a 6-year period, were involved (N = 7,475). Cox regression was used to model the risk of self-harm admissions, with comorbid depression, substance use disorders (SUD), severe mental illness (SMI), anorexia nervosa (AN), and bulimia nervosa (BN) as primary exposures; sociodemographics were considered as confounders. In multivariable analyses, comorbid SUD (adjusted HR = 1.66; 95% CI [1.45, 1.90]), depressive disorder (1.25; [1.09, 1.44]), AN (1.63; [1.10, 2.39]), and BN (1.65; [1.09, 2.51]) were positively associated with increased risks of hospitalization due to self-harm. However, a negative association was found for comorbid SMI. The findings highlight the importance of assessing and treating comorbid psychiatric disorders in PD.

Exploring healthcare professionals' perspectives of barriers and facilitators to supporting people with severe mental illness and Type 2 diabetes mellitus.

Individuals with comorbid severe mental illness (SMI) and diabetes experience an average mortality gap of 20years compared to individuals without these conditions. There has been some recognition by policies that there is a gap between mental healthcare and physical healthcare for SMI patients. Despite this, there are still no defined care pathways for individuals with SMI and diabetes. The aim of this study was to explore healthcare professionals' (HCPs) perspectives of barriersandsolutions to supporting people with SMIanddiabetes. HCPs in areas of South London were invited to attend a workshop event to discuss their views of SMI and diabetes pathways. Fifty participants were recruited using the Local Care Network. HCPs included GPs, mental health nurses, psychiatrists, diabetologists and care co-ordinators. The main themes were as follows: (a) poor coordination of care and care planning between services; (b) key techniques to improve integrated care; (c) perceived difficulties achieving better care and (d) supporting patient empowerment. The findings and recommendations from this workshop may provide some insight into key factors in providing and improving integrated SMI and diabetes care for patients in South East London and further afield.

Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System.

Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21-1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87-0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02-1.05, p < .001; aRR 1.02; 95% CI 1.00-1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02-1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71-0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control.

Addressing the Challenges of Recruitment and Retention in Sleep and Circadian Clinical Trials

ABSTRACTObjective/Background: Sleep and circadian disorders are prevalent worldwide and frequently comorbid with physical and mental illnesses. Thus, recruiting and retaining samples for sleep and circadian research are high priorities. The aims of this paper are to highlight barriers to recruitment and retention for participants with sleep or circadian dysfunction, and to share strategies used across two randomized controlled trials (RCTs) testing the efficacy of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) to address these challenges. Participants: The first RCT recruited 176 adolescents with an evening circadian chronotype, who were at risk in at least one of five health domains: behavioral, cognitive, emotional, physical, and social. The second RCT recruited 121 low-income, racial or ethnic minority adults diagnosed with severe mental illness (SMI) and comorbid sleep or circadian dysfunction. Methods: The current study examined participant, environment, and research factors that impacted recruitment and retention of participants with sleep or circadian dysfunction, and identified strategies to enhance recruitment and retention. Results: Strategies used to recruit participants included community-based recruiting, reducing stigma, and alleviating burdensome sleep data collection. Strategies used to retain participants in our studies included flexible scheduling, mitigating participant barriers, building rapport with participants through empathic and positive interactions, creative problem solving, consulting participant networks, and utilizing incentives and other positive engagement tools. Conclusion: Both at-risk adolescents and low-income, minority adults with comorbid SMI and sleep or circadian dysfunction experience significant barriers to research participation. Recruitment and retention strategies were creatively tailored to meet the unique barriers of these diverse populations.

The Impact of co-morbid severe mental illness and HIV upon mental and physical health and social outcomes: a systematic review

ABSTRACTOur aim was to review the evidence related to the impact of co-morbid severe mental illness SMI (schizophrenia, schizoaffective and bipolar disorder) and HIV upon mental health, physical health and social outcomes. We carried out a systematic review of scientific evidence, searching online databases (MEDLINE, PsychInfo, EMBASE, Global Health and Scopus) for studies between 1983 and 2017 using search terms for SMI and HIV. Studies were included if they compared health or social outcomes between people living with co-morbid SMI and HIV and people living with either: a) HIV only; or b) SMI only. Outcomes of interest were: mortality, health service use, HIV/SMI-related, co-morbidities, and social outcomes. We identified 20 studies which met our inclusion criteria. Although studies were generally high quality, there was heterogeneity in both selection of outcomes and choice of measure. It was therefore difficult to draw strong conclusions regarding the impact of co-morbid SMI and HIV across any outcome. We found little evidence that co-morbid SMI and HIV were associated with lower levels of treatment, care or poorer clinical outcomes compared to people living with SMI or HIV alone. However, mortality appeared to be higher among the co-morbid group in three out of four analyses identified. Physical and mental co-morbidities and social outcomes were rarely measured. Limited data mean that the impact of co-morbid SMI and HIV is uncertain. In order to develop evidence-based guidelines, there is an urgent need for further research. This may be realized by exploring opportunities for using data from existing cohort studies, routinely collected data and data linkage to investigate important questions relating to this neglected but potentially important area.

A core outcome set for evaluating self-management interventions in people with comorbid diabetes and severe mental illness: study protocol for a modified Delphi study and systematic review

BackgroundPeople with diabetes and comorbid severe mental illness (SMI) form a growing population at risk of increased mortality and morbidity compared to those with diabetes or SMI alone. There is increasing interest in interventions that target diabetes in SMI in order to help to improve physical health and reduce the associated health inequalities. However, there is a lack of consensus about which outcomes are important for this comorbid population, with trials differing in their focus on physical and mental health. A core outcome set, which includes outcomes across both conditions that are relevant to patients and other key stakeholders, is needed.MethodsThis study protocol describes methods to develop a core outcome set for use in effectiveness trials of self-management interventions for adults with comorbid type-2 diabetes and SMI. We will use a modified Delphi method to identify, rank, and agree core outcomes. This will comprise a two-round online survey and multistakeholder workshops involving patients and carers, health and social care professionals, health care commissioners, and other experts (e.g. academic researchers and third sector organisations). We will also select appropriate measurement tools for each outcome in the proposed core set and identify gaps in measures, where these exist.DiscussionThe proposed core outcome set will provide clear guidance about what outcomes should be measured, as a minimum, in trials of interventions for people with coexisting type-2 diabetes and SMI, and improve future synthesis of trial evidence in this area. We will also explore the challenges of using online Delphi methods for this hard-to-reach population, and examine differences in opinion about which outcomes matter to diverse stakeholder groups.Trial registrationCOMET registration: http://www.comet-initiative.org/studies/details/911. Registered on 1 July 2016

Double trouble: Psychiatric comorbidity and opioid addiction—All-cause and cause-specific mortality

BackgroundOpioid misusers have recognized high mortality but the influence of psychiatric comorbidity in excess cause-specific mortality is unclear. MethodsOpioid use disorder (OUD) patients were identified in the South London and Maudsley Case Register. Deaths were identified through database linkage to the national mortality dataset. Standard mortality ratios were calculated to compare mortality risk with the general population. Cox and competing risk regression models were used to investigate the effect of psychiatric comorbidity and psychological health on all-cause and cause-specific mortality (respectively) in OUD patients. ResultsOf 4837 OUD patients, 176 had died. Mortality rates were substantially higher than the general population (SMR 4.23; 95%CI 3.63–4.90). Among those with OUD, comorbid personality disorder (PD) and comorbid alcohol use disorder (AUD) was associated with increased all-cause mortality in all models, including the fully adjusted model, controlling for socio-demographic factors, severity of drug use, risk behaviours and physical health (HR2.15, 95%CI 1.17–3.95; HR2.28, 95%CI 1.54–3.36). AUD was associated with increased risk of fatal overdose (HR2.57, 95%CI 1.26–5.26) and hepatic-related deaths (HR7.26, 95%CI 2.79–18.86). Individuals with OUD and comorbid PD had almost four times greater risk of liver related deaths compared to those without PD (HR3.76, 95%CI 1.21–11.74). Comorbid severe mental illness and poor psychological health were not associated with increased mortality. ConclusionsThis study highlights the importance of assessment for PD and AUD in OUD patients in order to identify individuals at substantially elevated mortality risk to enable a more personalized approach to their medical care.

Use of Medical Homes by Patients With Comorbid Physical and Severe Mental Illness

Patients with comorbid severe mental illness (SMI) may use primary care medical homes differently than other patients with multiple chronic conditions (MCC). To compare medical home use among patients with comorbid SMI to use among those with only chronic physical comorbidities. We examined data on children and adults with MCC for fiscal years 2008-2010, using generalized estimating equations to assess associations between SMI (major depressive disorder or psychosis) and medical home use. Medicaid and medical home enrolled children (age, 6-17 y) and adults (age, 18-64 y) in North Carolina with ≥2 of the following chronic health conditions: major depressive disorder, psychosis, hypertension, diabetes, hyperlipidemia, seizure disorder, asthma, and chronic obstructive pulmonary disease. We examined annual medical home participation (≥1 visit to the medical home) among enrollees and utilization (number of medical home visits) among participants. Compared with patients without depression or psychosis, children and adults with psychosis had lower rates of medical home participation (-12.2 and -8.2 percentage points, respectively, P<0.01) and lower utilization (-0.92 and -1.02 visits, respectively, P<0.01). Children with depression had lower participation than children without depression or psychosis (-5.0 percentage points, P<0.05). Participation and utilization among adults with depression was comparable with use among adults without depression or psychosis (P>0.05). Overall, medical home use was relatively high for Medicaid enrollees with MCC, though it was somewhat lower among those with SMI. Targeted strategies may be required to increase medical home participation and utilization among SMI patients.

Severe Mental Illness and Retention in Anti-Retroviral Care: A Retrospective Study

Severe mental illness (SMI) in people living with HIV (PLWH) may impact on the initiation and adherence to combination antiretroviral treatment. We conducted a cross-sectional retrospective folder review of 100 PLWH suffering from an SMI, in Cape Town, South Africa. Information pertaining to whether these patients had attended a six-month visit at the referral HIV clinic after discharge from a psychiatric hospital was obtained. Of the 100 participants, 63 did not attend a first 6-month HIV clinic follow-up. There were no significant differences between 6-month attenders and non-attenders on demographic or clinical variables. After adjustment, respondents who had been re-admitted to a psychiatric hospital more than once were more likely not to attend their follow-up visit compared to those with no re-admissions (1 re-admission: PR = 1.52, 95 % CI 1.00-2.31; 2 or more re-admissions: PR = 1.60, 1.08-2.37). PLWH who have a co-morbid SMI are an especially vulnerable group of patients. Psychosocial support and interventions such as case management may be useful.

Dual Diagnosis Among Intensive Case Management Participants in the Veterans Health Administration: Correlates and Outcomes

Objective: Persons with comorbid severe mental illness and substance use disorder (dual diagnosis) are often referred to intensive case management. There has been little evaluation in real-world settings of the process and outcomes of intensive case management for such clients. Methods: This study used evaluation data on 3422 clients of the Veterans Health Administration treated in rural and urban intensive case management programs to compare veterans with and without dual diagnosis on characteristics at program entry, service delivery, and 6-month outcomes, adjusting for baseline differences. Results: At treatment entry, participants with dual diagnosis had more severe symptoms, more indicators of suicidality, poorer quality of life, more hospitalizations, and more arrests than those without dual diagnosis. They were also younger and more likely to be male. After 6 months of treatment, 2584 participants were still attending the treatment program. A higher proportion of those with dual diagnosis had received rehabilitation, housing, substance abuse, and supportive vocational services, but not other services. The rate of treatment dropout was higher for veterans with dual diagnosis and clinicians rated their alliance with these clients lower than their clients without dual diagnosis. With regard to outcomes, improvement was observed for both groups on almost all measures. The only significant difference in 6-month outcomes was that veterans with dual diagnosis had slightly higher violence index scores than veterans without dual diagnosis. Conclusions: These data suggest practical feasibility and potential effectiveness of intensive case management for veterans with, and those without, dual diagnosis.

Cannabis Abuse and Vulnerability to Psychosis: Targeting Preventive Services

Cannabis is the most widely used illicit substance in the world and due to the high levels of use observed among young people with psychosis, most research has focused on the causal relationship between cannabis use and mental health problems. Despite a large interest in developing intervention models to target this group, there are as yet no established and effective methods of prevention and intervention focusing on cannabis use. In this paper we present the available evidence for the effectiveness of substance use treatments in patients with co-morbid severe mental illness, as well as exploring the prevention and early intervention initiatives for substance use in the general population.