MANAGEMENT BRIEF

Number 10 Overviews of Health Care Topics for VA Senior Managers July 1999

Mental Illness –Treatment Challenges

Without appropriate treatment for mental illness, “the loss of human potential is staggering.” 1

William Jefferson Clinton

President of the United States

“HSR&D has committed significant resources to the study of mental illness, and we expect

our research efforts will continue to improve treatment methods and outcomes for our veteran

population who are afflicted by these disorders.”

John G. Demakis, MD

Director, Health Services Research and Development

What is mental illness?

Mental illness is any illness that affects the healthy or normal functioning of the mind. There are many different forms

of mental illness or disorders: depression, post-traumatic

stress disorder (PTSD), and schizophrenia, to name a few.

Everyone gets the “blues” on occasion, but for someone with

clinical depression the “blues” don’t disappear in a few hours

or days but are relentlessly chronic and can be debilitating.

Persons with PTSD, diagnosed before 1980 as “combat fatigue” or “shell shock,” often involuntarily, and repeatedly,

experience the trauma of a terrifying event (i.e., war, violent

assault, sexual abuse, or severe accident). It is estimated that

over 15% of Vietnam theater veterans (approximately

480,000 men) currently suffer from PTSD.2

 And schizophrenia, a prevalent illness among VA service users, is often a

chronic, debilitating condition with a pervasive influence on

all aspects of a person’s life, on family members, and on the

community. As with any type of illness, the severity and chronicity of the disorder varies based upon the individual. However, what is true for most people who suffer from mental

illness, and their loved ones, is the shame associated with this

type of disorder. Tipper Gore, a well known advocate for

mental health issues, stated at a recent White House Conference on Mental Health that, “It is time to bring mental health

care into the 21st Century and end the stigma...” 3

How does mental illness impact veterans’ health care?

Mental illness represents a substantial burden to national

health care. For example, the economic burden of schizophrenia in the US exceeds $30 billion per year, and depression

costs approximately $43 billion annually.4

 As the largest system of health care in the US, VA is greatly impacted by the

responsibilities and challenges associated with the treatment

and care of patients who suffer from mental illness. By the

very nature of the illness, persons with mental disorders are

often difficult to treat. Patients who have schizophrenia, for

instance, may not see the need for medication unless their

condition has already been stabilized by medication. Further

complications arise with comorbidity (coexistence of two or

more illnesses) which often affects treatment. For example,

40% of veterans with PTSD have concurrent clinically significant depression and are particularly difficult to treat.5

It is also estimated that up to 52% of seriously mentally ill

veterans have significant comorbid substance abuse that

complicates treatment and often results in poor outcomes.

Substance abuse is a particular problem for those who suffer

from depression and/or anxiety, and who try to alleviate

their symptoms by using alcohol or other drugs. In addition,

those who suffer from mental illness may be reluctant to seek

help due to the embarrassment often associated with this type

of illness.

All VA clinicians face many challenges in treating mental

illness, including identifying patients with this type of illness

and assuring patient compliance with treatment once an illness has been diagnosed. Despite the difficulties associated

with treating mental illness, new and rapidly expanding pharmacological and psychosocial treatments are available.

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How is health services research helping alleviate the

impact of mental illness on the VA health care system?

HSR&D focuses on advancing mental health care within

VA and nationwide, through the development, implementation and dissemination of health services research that will result in improved treatment and policies for the mentally ill.

The HSR&D Center for Mental Health Care and Outcomes

Research in Little Rock, Arkansas (CeMHOR) conducts

research on mental health care topics, such as depression,

schizophrenia, dementia, and comorbid psychiatric and substance abuse disorders. HSR&D’s Center for Health Care

Evaluation in Palo Alto, California focuses on improving

many aspects of heath care services including treatments for

substance abuse and psychiatric disorders. HSR&D investigates patients’ access to mental health care and patient outcomes. HSR&D also is leading the new Quality Enhancement

Research Initiative (QUERI) with the mission to translate research discoveries and innovations into better patient care and

systems improvement. QUERI is a comprehensive, datadriven, outcomes based, quality improvement program that

focuses on eight high volume and/or high-risk conditions

among veterans. Mental health and substance abuse are two

of the eight conditions of initial QUERI focus. The Mental

Health QUERI targets two disorders: major depressive disorder and schizophrenia. Both of these disorders have a devastating impact on affected veterans’ lives and impose a

substantial cost on the VA. The Substance Abuse QUERI is

working to establish an evidence-based program which identifies best practices for the treatment of substance use disorders, developing new research and disseminating information

in order to promote ongoing improvements in practice.

Below are promising studies and recent findings from

HSR&D research projects addressing the issues of mentally

ill veterans.

PTSD Seriously Impacts Health and Health Care Use

Post-traumatic stress disorder (PTSD) occurs in response

to an extreme traumatic stressor, and it is estimated that

approximately 1 million patients who were exposed to combat may suffer from this disorder. Despite the substantial impact on VA resources, the extent and means by which PTSD

affects health and health care use is unclear. This three-year

ongoing study of 2,425 VA ambulatory care patients will

establish the validity of a PTSD screening measure for VA

ambulatory care settings; estimate the prevalence of PTSD in

this treatment setting; and enhance understanding of the

effects of PTSD on health status and health care.

Thus far, findings suggest that PTSD has a direct effect on

health status that is independent of the effects of comorbid

medical conditions, depression, and alcohol use. Results also

show that PTSD has both a direct and an indirect effect on

health care utilization, after controlling for comorbid medical

conditions, depression, and alcohol use. In addition to demonstrating that traumatic events and the reaction to such

events (e.g., PTSD) can and do have long-term effects, this

study will provide VA administrators and policy makers

with a better understanding of the role PTSD plays in the

health status and health care use of ambulatory care patients so that VA can best plan resource utilization.

Spiro A III, Hankin CS, Mansell D, Kazis L. Post-traumatic stress disorder and health status: The Veterans

Health Study. Medical Care Monographs. (In press.)

HSR&D Study #IIR 96-030

Medication Management for Schizophrenia

Essential for Better Treatment

Antipsychotic medication is an essential component of

treatment for schizophrenia, which is the second most frequent discharge diagnosis in VA. Although the efficacy of

antipsychotic medications are well established, there is

little research data about their effectiveness in routine

clinical settings. A three-year study by HSR&D sought out

such data to investigate how patient outcomes are predicted by the management of their medication (e.g., dosage) and to identify unacceptable medication management

practices. Using an existing data set from a longitudinal

outcomes study, several patient screening components

were examined, such as daily antipsychotic dose range and

transition to outpatient care. Results of this study, so far,

have shown that nearly half of the 152 subjects were prescribed doses outside the range recommended by practice

guidelines for schizophrenia: 15% prescribed less than an

optimal dose and 34% greater than guidelines suggest.

Study findings also indicate that guideline dose category,

for oral antipsychotic medication only, significantly predicted follow-up symptom severity.

Results from this ongoing investigation will help VA

clinicians and managers determine which treatment variables are related to patient outcomes and also will help

them measure performance of important aspects of care

recommended by guidelines. This is especially important

in light of the recent publication of clinical practice guidelines for schizophrenia.

Owen, R.R. The Quality of Medication

Management for Schizophrenia.

HSR&D Study #IIR 95-020

Improved Treatment for Substance Abuse

Patients with Psychiatric Disorders

With the changing health care landscape, it is more important than ever to determine the best and most cost effective treatment available. In 1997, HSR&D began a study to

provide information on current efforts to transfer mental

health care away from hospitals and to match patients to

different types of community care, as it relates to patients

with comorbid substance abuse and psychiatric disorders.

This study compares hospital-based treatment programs to
References:

1. “Clinton pushes mental health protection.” Woodward, C.

Associated Press. Boston Globe June 8, 1999.

2. Friedman, M.J., Schnurr, P., Group Treatment of PTSD for

Vietnam Theater Veterans

CSP Study # 420

3. The White House Conference on Mental Health:

Working for a Healthier America

http://www.mentalhealth.gov/backgrdtext.asp

July 12, 1999.

4. Fischer E, Marder SR, Smith GR, et al., Mental Health

QUERI. Medical Care (In press).

5. Dunn, N.J., Denney, L., Blackburn, A., Garcia, J., Wurth,

M.; Baker, B., Stulb, V., & Perry, B.D. Stereotypes of the

Vietnam Vet: Experiences of the Houston VAMC PTSD

Specialty Clinic. Poster presented at the annual meeting of

the International Society for Traumatic Stress Studies. San

Antonio, TX., October 1993.

For more information or to send comments contact:

Gerry McGlynn, M.Ed., MDRC, Manager, Information

Dissemination Program, 150 S. Huntington Avenue, Boston,

MA 02130. Phone: FTS 700-839-4433 or 617-278-4433.

Fax: 617-278-4438. Visit the Research and Development web

page at http://www.va.gov/resdev/prt to see additional

MDRC publications and reports.

This is our tenth MANAGEMENT BRIEF. Please give us your

suggestions and comments:

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The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within the VA’s Office of Research &

Development, Health Services Research and Development Service.

The purpose of the MANAGEMENT BRIEF is to provide VA senior managers with a concise and timely overview of a specific health care topic

that includes topic definition, benefits, VA activities, and resources for

further information.

community-based programs, depending on the severity of

patient illness and intensity of the treatment program.

Investigators hypothesized that patients with severe clinical

and functional problems will have better outcomes when

matched to service- and structure-intensive programs, while

patients with moderate problems will have better outcomes

when matched to programs of a lower treatment intensity. Initial findings indicate that community residential facilities

were more likely to serve dual diagnosis patients in 1998 than

they were in 1995, and were also more likely to provide more

services (i.e., rehabilitation and medical services, etc.). Data

gathered from this study, which continues until September

2001, will help VA develop treatment programs that will best

match the individual patient’s needs thus resulting in the best

possible outcome.

Timko, C. Matching Outcomes and

Costs in Substance Abuse /Psychiatric Treatment.

HSR&D Study #IIR 95-011

Telepsychiatry and the Treatment of Depression

Telepsychiatry is a novel means of providing expert psychiatric treatment to patients who live in geographically

remote areas or in areas where psychiatric treatment is unavailable or expensive to maintain. HSR&D is conducting a

three-year study, Efficacy of Telepsychiatry in the Treatment

of Depression, to demonstrate whether or not treatment of depressive disorders via telepsychiatry is as effective as “live,”

in-person, treatment, and to determine if patients are as compliant and satisfied with this new method of care.

This randomized, controlled study examines 144 veterans

treated at three VA Maryland health care facilities. Psychiatrists from each of the three facilities conduct both “live” and

“remote” treatment, which involves eight sessions lasting 30

minutes each over a six-month study period. Treatment

consists of psychotropic medication and psycho-education

concerning the disease, medications, and side effects. Preliminary data suggest that treatment efficacy is similar for

patients treated “live” and “remotely.” Further, anecdotal

evidence suggests that even older veterans are comfortable

using telecommunications technology for treatment. With

the use of telepsychiatry, VA health care can be widely expanded at great convenience to veterans and without incurring high costs.

Ruskin PE, Reed S, Kumar R, et al. Reliability and

acceptability of psychiatric diagnosis via telecommunications

and audiovisual technology. Psychiatric Services,

49(8): 1086-1090, Aug 1998.

HSR&D Study #ACC 97-034

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