0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
Assertive Community Treatment in Veterans Affairs Settings: Impact on Adherence to Antipsychotic Medication
Marcia Valenstein, M.D., M.S.; John F. McCarthy, Ph.D.; Dara Ganoczy, M.P.H.; Nicholas W. Bowersox, Ph.D.; Lisa B. Dixon, M.D., M.P.H.; Richard Miller, M.D.; Stephanie Visnic, B.A.; Eric P. Slade, Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201100543
View Author and Article Information

Dr. Valenstein, Dr. McCarthy, Ms. Ganoczy, Dr. Bowersox, and Ms. Visnic are affiliated with the U.S. Department of Veterans Affairs Health Services Research and Development Service and the Serious Mental Illness Treatment, Resource and Evaluation Center, University of Michigan North Campus Research Complex, Building 16, Ann Arbor, MI 48109 (e-mail: marciav@umich.edu). Dr. Valenstein, Dr. McCarthy, and Dr. Bowersox are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor, where Dr. Miller was formerly affiliated. Dr. Miller is currently with Our Lady of Fatima Hospital, North Providence, Rhode Island.
Dr. Dixon is with the Department of Psychiatry, Columbia University, and with the Center for Practice Innovations, New York State Psychiatric Institute, both in New York City. Dr. Slade is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objectives  Assertive community treatment (ACT) programs may improve patients’ outcomes, in part by increasing adherence to antipsychotic medication. This study assessed the association between ACT enrollment and subsequent antipsychotic adherence.

Methods  The authors identified a national sample of 763 Veterans Affairs (VA) patients with schizophrenia who were newly enrolled in ACT in fiscal years 2001 to 2004 and had valid antipsychotic medication possession ratios (MPRs) for five sequential six-month periods, the first occurring before ACT enrollment. Propensity scores were used to match ACT patients 1:1 with eligible veterans who did not initiate ACT. Logistic regression analyses and generalized estimating equations (GEE) were used to assess the association between ACT enrollment and subsequent antipsychotic adherence. Antipsychotic adherence was compared among ACT enrollees with high, partial, or no participation in ACT services.

Results  Before the index date, there was no significant difference in rates of good adherence (MPR ≥.8) among subsequent ACT enrollees (72%) and patients in the control group (70%). However, in each of the four periods after enrollment, ACT enrollees were more likely to have MPRs ≥.8. In GEE analyses, ACT enrollment was associated with 2.3 greater odds of MPRs ≥.8 (95% confidence interval=1.9–2.7). Among ACT enrollees, higher levels of participation were associated with MPRs ≥.8.

Conclusions  In this large, national study, ACT enrollment was associated with higher levels of antipsychotic adherence among VA patients with schizophrenia. This association persisted over time and was greatest among those with higher levels of ACT use.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Anchor for Jump
Table 1Characteristics of patients enrolled or not enrolled in assertive community treatment (ACT)
Table Footer Note

a A modified version of the Charlson Comorbidity Index (CCI) indicating the presence of 19 medical diagnoses in the year before study enrollment

Table Footer Note

b Medication possession ratios ≥.80 indicate good adherence.

Anchor for Jump
Table 2Patients enrolled or not enrolled in assertive community treatment (ACT) with good adherence to antipsychotic medication, by study perioda
Table Footer Note

a Medication possession ratios ≥.8 indicated good adherence.

Anchor for Jump
Table 3Association of good adherence with medication and enrollment in assertive community treatment (ACT), by patient characteristic and study perioda
Table Footer Note

a Good adherence was indicated by medication possession ratios (MPR) ≥.8.

Table Footer Note

b A modified version of the Charlson Comorbidity Index (CCI) indicating the presence of 19 medical diagnoses in the year before study enrollment

Anchor for Jump
Table 4Association of good adherence with medication and enrollment in ACT over time, by patient characteristica
Table Footer Note

a ACT, assertive community treatment. Medication possession ratios (MPRs) ≥.8 indicate good adherence.

Anchor for Jump
Table 5Engagement in ACT services among patients with good medication adherence, by study perioda
Table Footer Note

a A total of 763 patients were enrolled in assertive community treatment (ACT). Good adherence was indicated by medication possession ratios ≥.8.

Table Footer Note

b A total of 62 patients had no visits between 13 and 24 months.

Table Footer Note

c Partial engagement was defined as <42 visits over a 12-month period (N=126, 0–12 months; N=187, 13–24 months).

Table Footer Note

d Full engagement was defined as ≥42 visits over a 12-month period (N=637, 0–12 months; N=514, 13–24 months).

+

References

Lacro  JP;  Dunn  LB;  Dolder  CR  et al:  Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature.  Journal of Clinical Psychiatry 63:892–909, 2002
[CrossRef] | [PubMed]
 
Valenstein  M;  Copeland  LA;  Blow  FC  et al:  Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission.  Medical Care 40:630–639, 2002
[CrossRef] | [PubMed]
 
Valenstein  M;  Ganoczy  D;  McCarthy  JF  et al:  Antipsychotic adherence over time among patients receiving treatment for schizophrenia: a retrospective review.  Journal of Clinical Psychiatry 67:1542–1550, 2006
[CrossRef] | [PubMed]
 
Weiden  PJ;  Kozma  C;  Grogg  A  et al:  Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia.  Psychiatric Services 55:886–891, 2004
[CrossRef] | [PubMed]
 
Eaddy  M;  Grogg  A;  Locklear  J:  Assessment of compliance with antipsychotic treatment and resource utilization in a Medicaid population.  Clinical Therapeutics 27:263–272, 2005
[CrossRef] | [PubMed]
 
Gilmer  TP;  Dolder  CR;  Lacro  JP  et al:  Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia.  American Journal of Psychiatry 161:692–699, 2004
[CrossRef] | [PubMed]
 
Subotnik  KL;  Nuechterlein  KH;  Ventura  J  et al:  Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia.  American Journal of Psychiatry 168:286–292, 2011
[CrossRef] | [PubMed]
 
Blow  FC;  McCarthy  JF;  Valenstein  M  et al: Care in the VHA for Veterans With Psychoses 2002: National Psychoses Registry (Fourth Annual Report).  Ann Arbor, Mich,  Veterans Health Administration, Health Services Research and Development, 2003
 
Blow  FC;  McCarthy  JF;  Valenstein  M  et al: Care for Veterans With Psychosis in the Veterans Health Administration: FY09 (11th Annual Report on Veterans with Psychoses).  Ann Arbor, Mich,  Serious Mental Illness Treatment Resource and Evaluation Center, 2011
 
Zygmunt  A;  Olfson  M;  Boyer  CA  et al:  Interventions to improve medication adherence in schizophrenia.  American Journal of Psychiatry 159:1653–1664, 2002
[CrossRef] | [PubMed]
 
Valenstein  M;  Kavanagh  J;  Lee  T  et al:  Using a pharmacy-based intervention to improve antipsychotic adherence among patients with serious mental illness.  Schizophrenia Bulletin 37:727–736, 2009
[CrossRef] | [PubMed]
 
Velligan  DI;  Diamond  PM;  Maples  NJ  et al:  Comparing the efficacy of interventions that use environmental supports to improve outcomes in patients with schizophrenia.  Schizophrenia Research 102:312–319, 2008
[CrossRef] | [PubMed]
 
Allred  CA;  Burns  BJ;  Phillips  SD:  The assertive community treatment team as a complex dynamic system of care.  Administration and Policy in Mental Health and Mental Health Services Research 32:211–220, 2005
[CrossRef] | [PubMed]
 
Blow  FC;  Ullman  E;  Barry  KL  et al:  Effectiveness of specialized treatment programs for veterans with serious and persistent mental illness: a three-year follow-up.  American Journal of Orthopsychiatry 70:389–400, 2000
[CrossRef] | [PubMed]
 
Bond  GR;  McGrew  JH;  Fekete  DM:  Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis.  Journal of Mental Health Administration 22:4–16, 1995
[CrossRef] | [PubMed]
 
Rosenheck  R;  Neale  M;  Leaf  P  et al:  Multisite experimental cost study of intensive psychiatric community care.  Schizophrenia Bulletin 21:129–140, 1995
[CrossRef] | [PubMed]
 
Clarke  GN;  Herinckx  HA;  Kinney  RF  et al:  Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs usual care.  Mental Health Services Research 2:155–164, 2000
[CrossRef] | [PubMed]
 
Dixon  L;  Weiden  P;  Torres  M  et al:  Assertive community treatment and medication compliance in the homeless mentally ill.  American Journal of Psychiatry 154:1302–1304, 1997
[PubMed]
 
Manuel  JI;  Covell  NH;  Jackson  CT  et al:  Does assertive community treatment increase medication adherence for people with co-occurring psychotic and substance use disorders? Journal of the American Psychiatric Nurses Association 17:51–56, 2011
[CrossRef] | [PubMed]
 
VHA Mental Health Intensive Case Management (VHA Directive 2006-004). Washington, DC, Department of Veterans Affairs, Veterans Health Administration, Jan 30, 2006. Available at www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1375
 
Dehejia  RH;  Wahba  S:  Propensity score-matching methods for nonexperimental causal studies.  Review of Economics and Statistics 84:151–161, 2002
[CrossRef]
 
Steiner  JF;  Koepsell  TD;  Fihn  SD  et al:  A general method of compliance assessment using centralized pharmacy records: description and validation.  Medical Care 26:814–823, 1988
[CrossRef] | [PubMed]
 
McCarthy  JF;  Valenstein  M;  Blow  FC:  Residential mobility among patients in the VA health system: associations with psychiatric morbidity, geographic accessibility, and continuity of care.  Administration and Policy in Mental Health and Mental Health Services Research 34:448–455, 2007
[CrossRef] | [PubMed]
 
Deyo  RA;  Cherkin  DC;  Ciol  MA:  Adapting a Clinical Comorbidity Index for use with ICD-9-CM administrative databases.  Journal of Clinical Epidemiology 45:613–619, 1992
[CrossRef] | [PubMed]
 
Veterans Equitable Resource Allocation File. Washington, DC, Department of Veterans Affairs, Veterans Health Administration, 2010. Available at http://tinyurl.com/a66ah9p
 
Zeger  SL;  Liang  KY:  Longitudinal data analysis for discrete and continuous outcomes.  Biometrics 42:121–130, 1986
[CrossRef] | [PubMed]
 
Slade  EP;  McCarthy  JF;  Valenstein  M  et al:  Cost savings from assertive community treatment services in an era of declining psychiatric inpatient use.  Health Services Research 48:195–217, 2013
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Articles
Books
APA Practice Guidelines > Chapter 17.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 32.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 56.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 32.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 22.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles