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Background and Hypothesis: In the United States, women with schizophrenia face challenges in receiving gynecologic care, but little is known about how cervical cancer screening rates vary across time or states in a publicly insured population. We hypothesized that women Medicaid beneficiaries with schizophrenia would be less likely to receive cervical cancer screening across the United States compared with a control population, and that women with schizophrenia and other markers of vulnerability would be least likely to receive screening., Study Design: This retrospective cohort study used US Medicaid administrative data from across 44 states between 2002 and 2012 and examined differences in cervical cancer screening test rates among 283 950 female Medicaid beneficiaries with schizophrenia and a frequency-matched control group without serious mental illness, matched on age and race/ethnicity. Among women with schizophrenia, multivariable logistic regression estimated the odds of receiving cervical cancer screening using individual sociodemographics, comorbid conditions, and health care service utilization., Study Results: Compared to the control group, women with schizophrenia were less likely to receive cervical cancer screening (OR = 0.76; 95% CI 0.75-0.77). Among women with schizophrenia, nonwhite populations, younger women, urban dwellers, those with substance use disorders, anxiety, and depression and those connected to primary care were more likely to complete screening., Conclusions: Cervical cancer screening rates among US women Medicaid beneficiaries with schizophrenia were suboptimal. To address cervical cancer care disparities for this population, interventions are needed to prioritize women with schizophrenia who are less engaged with the health care system or who reside in rural areas., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: To describe patterns of antipsychotic switching among patients hospitalized for schizophrenia and to correlate antipsychotic switching with hospital readmission risk., Methods: We identified 3295 patients with index hospitalizations for schizophrenia or schizoaffective disorder from New York State Medicaid claims 2017-2018 who had filled at least one prescription for an antipsychotic in both the 44 days (one month +14 day grace period) prior to and after their admission. We identified patients who had kept or switched any of their antipsychotic medication between the pre- and post-periods surrounding their index hospitalization. We compared the kept and switched any groups, adjusting for patient characteristics., Results: Of patients who had filled antipsychotic prescriptions in both the 44 days prior to and after their hospitalization, 1599 (48.6 %) had switched at least one antipsychotic and 1215 (36.8 %) had switched their primary antipsychotic. Switching any antipsychotic was associated with increased hazards of readmission, HR = 1.21, 95%CI 1.09-1.35, which was slightly concentrated during the first 90 days after hospital discharge., Conclusions: Switching antipsychotic medications during hospitalization occurs commonly and is associated with higher rehospitalization risk following hospital discharge., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Importance: Dose-related effects of antipsychotic medications may increase mortality in children and young adults., Objective: To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications., Design, Setting, and Participants: This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023., Exposures: Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers)., Main Outcome and Measures: Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights., Results: The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29)., Conclusions and Relevance: In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.

Background: People with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia., Setting: Nationally representative sample of Medicaid enrollees with and without schizophrenia., Methods: Using retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts., Results: Higher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia., Conclusion: Overall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: People with schizophrenia have more HIV risk factors and higher rates of HIV infection than the general U.S. population. The authors aimed to examine HIV testing patterns in this population nationally and by demographic characteristics and presence of high-risk comorbid conditions., Methods: This retrospective longitudinal study compared HIV testing between Medicaid-only enrollees with schizophrenia and without schizophrenia during 2002-2012 (N=6,849,351). Interrupted time series were used to analyze the impacts of the 2006 federal policy change recommending expanded HIV testing. Among enrollees with schizophrenia, multivariable logistic regression was used to estimate associations between testing and both demographic characteristics and comorbid conditions. Sensitivity analyses were also conducted., Results: Enrollees diagnosed as having schizophrenia had consistently higher HIV testing rates than those without schizophrenia. When those with comorbid substance use disorders or sexually transmitted infections were excluded, testing was higher for individuals without schizophrenia (p<0.001). The federal policy change likely increased testing for both groups (p<0.001), but the net change was greater for those without schizophrenia (3.1 vs. 2.2 percentage points). Among enrollees with schizophrenia, testing rates doubled during 2002-2012 (3.9% to 7.2%), varied across states (range 17 percentage points), and tripled for those with at least one annual nonpsychiatric medical visit (vs. no visit; adjusted OR=3.10, 95% CI=2.99-3.22)., Conclusions: Nationally, <10% of enrollees with schizophrenia had annual HIV testing. Increases appear to be driven by high-risk comorbid conditions and nonpsychiatric encounters, rather than by efforts to target people with schizophrenia. Psychiatric guidelines for schizophrenia care should consider HIV testing alongside annual metabolic screening., Competing Interests: Dr. Walkup provides training at the Northeast/Caribbean AIDS Education and Training Center. Ms. Dawson receives support from the Elton John AIDS Foundation. Dr. Mangurian receives support from the Genentech Charitable Foundation, the Doris Duke Charitable Foundation, Weston Havens Foundation, the United Health Group, and the California Health Care Foundation. The other authors report no financial relationships with commercial interests.

Objective: Women with serious mental illness are more likely to be diagnosed as having late-stage breast cancer than women without serious mental illness, suggesting a disparity in screening mammography. This study aimed to compare screening mammography rates in a nationally representative sample of Medicaid beneficiaries with and without schizophrenia., Methods: Medicaid Analytic eXtract files, 2007-2012, were used to identify a cohort of women ages 40-64 with schizophrenia who were eligible for Medicaid but not Medicare (N=87,572 in 2007 and N=114,341 in 2012) and a cohort without schizophrenia, frequency-matched by age, race-ethnicity, and state (N=97,003 in 2007 and N=126,461 in 2012). Annual screening mammography rates were calculated and adjusted for demographic characteristics and comorbid conditions. Multivariable logistic regression was used to estimate the association between beneficiary characteristics and screening mammography rates., Results: In 2012, 27.2% of women with schizophrenia completed screening mammography, compared with 26.8% of the control cohort. In the schizophrenia cohort, American Indian/Alaskan Native women had significantly lower odds of receiving mammography (OR=0.82, p=0.02) than White women, whereas Hispanic/Latina women had higher odds (OR=1.16, p<0.001). Women with schizophrenia and a nonalcohol-related substance use disorder had lower odds of receiving mammography (OR=0.74, p<0.001) than women without a substance use disorder. Having at least one medical visit in the past year (vs. no visits) increased the odds of receiving screening mammography (OR=5.08, p<0.001)., Conclusions: Screening mammography rates were similar between Medicaid-insured women with and those without schizophrenia. Interventions to increase uptake may need to focus on improving socioeconomic conditions and primary care engagement for vulnerable populations, regardless of psychiatric condition.

Background and Hypotheses: Adults with schizophrenia have increased risk of suicide with highest risk among younger adults. We investigated whether means of suicide among these adults were different from the general population., Study Design: This retrospective longitudinal analysis used the National Death Index to characterize means of suicide among 4 cohorts of Medicare patients with schizophrenia (2007-2016) by age: 18 to 34, 35 to 44, 45 to 54, and aged 55+ years. Means of suicide were categorized by age at death and sex. Adjusted hazard ratios were calculated for common means. Mortality rates per 100,000 person-years were estimated by age group stratified by sex, and standardized to the general population by age, sex, and race-ethnicity using standardized mortality ratios., Study Results: 668,836 adults were included with 2218 suicide decedents: 1444 men and 774 women. The most common means of suicide was poisoning (36.8 %), with a significant sex difference by means: 55.9 % of women died by poisoning, 13.8 % by firearms, 11.0 % by hanging and 9.4 % by jumping, while among men suicide by poisoning (26.6 %), firearms (25.5 %), and hanging (24.2 %) were similar, followed by jumping (12.0 %). Suicide by poisoning among the schizophrenia cohort was 10 times that of the general population, while suicide by firearm was twice that of the general population., Conclusions: Means of suicide differed for patients with schizophrenia compared to the general population: poisoning was the most common means among men and women with schizophrenia, while firearms accounted for over half of all suicides in the general U.S., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Although the cardiometabolic effects of atypical antipsychotics have been well-described in clinical samples, less is known about the longer-term impacts of these treatments. We report rates of metabolic syndrome in a nationally representative sample of U.S. adult inpatients 1993-2018 admitted for schizophrenia-spectrum disorders (n = 1,785,314), any mental health disorder (n = 8,378,773), or neither (n = 14,458,616) during a period of widespread atypical antipsychotic use. Metabolic syndrome, derived from additional diagnoses, was defined as three or more of hypertension, dyslipidemia, type II diabetes, hyperglycemia, and overweight or obese. Using an ecological age and period design, a 4-level period variable was constructed to proxy for atypical antipsychotic exposure as the minimum of age minus 20 years or the calendar year minus 1997 in accord with the disease course for schizophrenia-spectrum illness and the market share of atypical antipsychotics in the U.S. Logistic regression models, adjusted for age, year, and exposure main effects, estimated odds ratios (ORs) of metabolic syndrome. Relative to other mental health or other discharges, schizophrenia-spectrum discharges had an elevated risk for metabolic syndrome regardless of potential atypical antipsychotic exposure (OR = 1.46; 95 % CI, 1.30-1.64). For schizophrenia-spectrum discharges, periods of potential atypical antipsychotic exposure conferred additional metabolic syndrome risk OR = 1.21; 95 % CI, 1.04-1.41 for exposures of 1-2 years, OR = 1.29; 95 % CI, 1.13-1.46 for 3-7 years, OR = 1.27; 95 % CI, 1.12-1.44 for 8-12 years, and OR = 1.10; 95 % CI 0.98-1.24 for &gt;12 years. In summary, cardiometabolic disease and related risks were elevated among a nationally representative sample of adult inpatients with schizophrenia-spectrum disorders during a period of pervasive atypical antipsychotic use., Competing Interests: Conflict of interest None of the authors have COI to report., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Variation in prescription of psychotropic medications to patients with schizophrenia spectrum disorders may underlie health inequities. Using a national U.S. Medicaid sample, the authors examined prescription patterns of psychotropic medications commonly used for managing schizophrenia., Methods: Data from the 2011-2012 Medicaid Analytic eXtract were examined for demographic predictors of and variation across states in psychotropic medication prescription among adult patients diagnosed as having schizophrenia spectrum disorders (N=357,914). Percentages of patients in each state who filled prescriptions of at least 15 days of any antipsychotic, clozapine, antidepressant, benzodiazepine, mood stabilizer, or long-acting injectable (LAI) antipsychotic medication were determined after adjustment for demographic and clinical covariates. Multivariate regressions of clinical and demographic factors predicting prescription patterns were conducted., Results: Prescribing patterns for all types of psychotropic medications varied across states. Clozapine and LAI prescriptions showed the most dramatic differences across states and among patients with different demographic characteristics. Across states, adjusted proportions of prescriptions ranged from 4% to 22% for LAIs and from 1% to 11% for clozapine. Non-Hispanic Blacks and people of other race-ethnicities were more likely than non-Hispanic Whites to fill prescriptions for LAIs, and non-Hispanic Whites were more likely than individuals from other racial-ethnic groups to fill prescriptions for clozapine and all other medications., Conclusions: Considerable variation in prescribing patterns of LAIs and clozapine by race-ethnicity and across states suggests uneven quality of care for individuals with schizophrenia spectrum disorders in the United States. A better understanding of what causes this variation could inform policy makers to improve treatment for this vulnerable population.

Importance: Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span., Objective: To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population., Design, Setting, and Participants: Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021., Main Outcomes and Measures: For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity., Results: The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up., Conclusions and Relevance: In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

Importance: People with schizophrenia are at high risk of receiving a diagnosis of dementia. Understanding the magnitude and timing of this increased risk has important implications for practice and policy., Objective: To estimate the age-specific incidence and prevalence of dementia diagnoses among older US adults with schizophrenia and in a comparison group without serious mental illness (SMI)., Design, Setting, and Participants: This retrospective cohort study used a 50% random national sample of Medicare beneficiaries 66 years or older with fee-for-service plans and Part D prescription drug coverage from January 1, 2007, to December 31, 2017. The cohort with schizophrenia included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and at least 2 outpatient claims or at least 1 inpatient claim for schizophrenia during the qualifying years. The comparison group included adults with at least 12 months of continuous enrollment in fee-for-service Medicare and Part D and without a diagnosis of schizophrenia, bipolar disorder, or recurrent major depressive disorder during the qualifying year. Data were analyzed from January 1 to July 31, 2020., Main Outcomes and Measures: Dementia was defined using the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse diagnosis codes for Alzheimer disease and related disorders or senile dementia. Incident diagnoses were defined by at least 12 consecutive eligible months without a qualifying code before meeting dementia criteria., Results: The study population of 8 011 773 adults 66 years or older (63.4% women; mean [SD] age, 74.0 [8.2] years) included 74 170 individuals with a diagnosis of schizophrenia (56.6% women) and 7 937 603 without an SMI diagnosis (63.5% women) who contributed 336 814 and 55 499 543 person-years of follow-up, respectively. At 66 years of age, the prevalence of diagnosed dementia was 27.9% (17 640 of 63 287) among individuals with schizophrenia compared with 1.3% (31 295 of 2 389 512) in the group without SMI. By 80 years of age, the prevalence of dementia diagnoses was 70.2% (2011 of 2866) in the group with schizophrenia and 11.3% (242 094 of 2 134 602) in the group without SMI. The annual incidence of dementia diagnoses per 1000 person-years at 66 years of age was 52.5 (95% CI, 50.1-54.9) among individuals with schizophrenia and 4.5 (95% CI, 4.4-4.6) among individuals without SMI and increased to 216.2 (95% CI, 179.9-252.6) and 32.3 (95% CI, 32.0-32.6), respectively, by 80 years of age., Conclusions and Relevance: In this cohort study, compared with older adults without SMI, those with schizophrenia had increased risk of receiving a diagnosis of dementia across a wide age range, possibly because of cognitive and functional deterioration related to schizophrenia or factors contributing to other types of dementia. High rates of dementia among adults with schizophrenia have implications for the course of illness, treatment, and service use.

Importance: To date, the association of psychiatric diagnoses with mortality in patients infected with coronavirus disease 2019 (COVID-19) has not been evaluated., Objective: To assess whether a diagnosis of a schizophrenia spectrum disorder, mood disorder, or anxiety disorder is associated with mortality in patients with COVID-19., Design, Setting, and Participants: This retrospective cohort study assessed 7348 consecutive adult patients for 45 days following laboratory-confirmed COVID-19 between March 3 and May 31, 2020, in a large academic medical system in New York. The final date of follow-up was July 15, 2020. Patients without available medical records before testing were excluded., Exposures: Patients were categorized based on the following International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnoses before their testing date: (1) schizophrenia spectrum disorders, (2) mood disorders, and (3) anxiety disorders. Patients with these diagnoses were compared with a reference group without psychiatric disorders., Main Outcomes and Measures: Mortality, defined as death or discharge to hospice within 45 days following a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test result., Results: Of the 26 540 patients tested, 7348 tested positive for SARS-CoV-2 (mean [SD] age, 54 [18.6] years; 3891 [53.0%] women). Of eligible patients with positive test results, 75 patients (1.0%) had a history of a schizophrenia spectrum illness, 564 (7.7%) had a history of a mood disorder, and 360 (4.9%) had a history of an anxiety disorder. After adjusting for demographic and medical risk factors, a premorbid diagnosis of a schizophrenia spectrum disorder was significantly associated with mortality (odds ratio [OR], 2.67; 95% CI, 1.48-4.80). Diagnoses of mood disorders (OR, 1.14; 95% CI, 0.87-1.49) and anxiety disorders (OR, 0.96; 95% CI, 0.65-1.41) were not associated with mortality after adjustment. In comparison with other risk factors, a diagnosis of schizophrenia ranked behind only age in strength of an association with mortality., Conclusions and Relevance: In this cohort study of adults with SARS-CoV-2-positive test results in a large New York medical system, adults with a schizophrenia spectrum disorder diagnosis were associated with an increased risk for mortality, but those with mood and anxiety disorders were not associated with a risk of mortality. These results suggest that schizophrenia spectrum disorders may be a risk factor for mortality in patients with COVID-19.

Background: Suicide is a major cause of mortality for individuals with schizophrenia spectrum disorders (SSD). Understanding the risk factors for suicide at time of diagnosis can aid clinicians in identifying people at risk., Methods: Records from linked administrative health databases in Ontario, Canada were used to identify individuals aged 16 through 45 years who received a first lifetime diagnosis of SSD (schizophrenia, schizoaffective disorder, psychotic disorder not otherwise specified (NOS)) using a validated algorithm between 01/01/1993 and 12/31/2010. The main outcome was death by suicide following cohort entry until 12/31/2012., Outcomes: 75,989 individuals with a first SSD diagnosis (60.1% male, 39.9% female) were followed for an average of 9.56 years. During this period, 1.71% of the total sample (72.1% male, 27.9% female) died by suicide, after an average of 4.32 years. Predictors of suicide death included male sex (HR 2.00, 95% CI 1.76-2.27), age at diagnosis between 26 and 35 (HR 1.27, 95% CI 1.10-1.45) or 36-45 (HR 1.34, 95% CI 1.16-1.54), relative to 16-25, and suicide attempt (HR 2.23, 95% CI 1.86-2.66), drug use disorder (HR 1.21, 95% CI 1.04-1.41), mood disorder diagnosis (HR 1.32, 95% CI 1.17-1.50), or mental health hospitalization (HR 1.30 95% CI 1.13-1.49) in the 2 years prior to SSD diagnosis., Interpretation: Death by suicide occurs in 1 out of every 58 individuals and occurred early following first diagnosis of SSD. Psychiatric hospitalizations, mood disorder diagnoses, suicide attempts prior to SSD diagnosis, as well as a later age at first diagnosis, are all predictors of suicide and should be integrated into clinical assessment of suicide risk in this population., Competing Interests: Declaration of competing interest The authors do not have any conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed., Method: Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis., Results: In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit., Conclusions: Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Importance: People with schizophrenia are commonly treated with psychotropic medications in addition to antipsychotics, but there is little evidence about the comparative effectiveness of these adjunctive treatment strategies., Objective: To study the comparative real-world effectiveness of adjunctive psychotropic treatments for patients with schizophrenia., Design, Setting, and Participants: This comparative effectiveness study used US national Medicaid data from January 1, 2001, to December 31, 2010, to examine the outcomes of initiating treatment with an antidepressant, a benzodiazepine, a mood stabilizer, or another antipsychotic among adult outpatients (aged 18-64 years) diagnosed with schizophrenia who were stably treated with a single antipsychotic. Data analysis was performed from January 1, 2017, to June 30, 2018. Multinomial logistic regression models were used to estimate propensity scores to balance covariates across the 4 medication groups. Weighted Cox proportional hazards regression models were used to compare treatment outcomes during 365 days on an intention-to-treat basis., Main Outcomes and Measures: Risk of hospitalization for a mental disorder (primary), emergency department (ED) visits for a mental disorder, and all-cause mortality., Results: The study cohort included 81 921 adult outpatients diagnosed with schizophrenia (mean [SD] age, 40.7 [12.4] years; 37 515 women [45.8%]) who were stably treated with a single antipsychotic and then initiated use of an antidepressant (n = 31 117), a benzodiazepine (n = 11 941), a mood stabilizer (n = 12 849), or another antipsychotic (n = 26 014) (reference treatment). Compared with initiating use of another antipsychotic, initiating use of an antidepressant was associated with a lower risk (hazard ratio [HR], 0.84; 95% CI, 0.80-0.88) of psychiatric hospitalization, whereas initiating use of a benzodiazepine was associated with a higher risk (HR, 1.08; 95% CI, 1.02-1.15); the risk associated with initiating use of a mood stabilizer (HR, 0.98; 95% CI, 0.94-1.03) was not significantly different from initiating use of another antipsychotic. A similar pattern of associations was observed in psychiatric ED visits for initiating use of an antidepressant (HR, 0.92; 95% CI, 0.88-0.96), a benzodiazepine (HR, 1.12; 95% CI, 1.07-1.19), and a mood stabilizer (HR, 0.99; 95% CI, 0.94-1.04). Initiating use of a mood stabilizer was associated with an increased risk of mortality (HR, 1.31; 95% CI, 1.04-1.66)., Conclusions and Relevance: In the treatment of schizophrenia, initiating adjunctive treatment with an antidepressant was associated with reduced risk of psychiatric hospitalization and ED visits compared with initiating use of alternative psychotropic medications. Associations of benzodiazepines and mood stabilizers with poorer outcomes warrant clinical caution and further investigation.

Treatment-resistant schizophrenia (TRS) occurs in approximately 30% of individuals diagnosed with schizophrenia. The identification and management of TRS in clinical practice are inconsistent and not evidence based. No established clinically relevant criteria for defining and treating TRS exist, although guidelines have been promulgated for clozapine use among TRS patients. This report summarizes the consensus from a roundtable that focused on defining and identifying TRS, pathways to treatment resistance, current treatments, unmet needs, and disease burden. Nine clinical experts in schizophrenia and TRS participated in a closed meeting on June 23, 2017, sponsored by Lundbeck, at which published literature in key areas of TRS research was reviewed. The findings from published studies were synthesized by experts in each area and presented to the group for review and discussion. It was agreed that inadequate response to 2 different antipsychotics, each taken with adequate dose and duration, is required to establish TRS. This recommendation is consistent with guidelines for clozapine use. For each trial, objective symptom measures should be used to assess treatment response, with medication adherence ensured. Once nonresponse is established (after ≥ 12 weeks for positive symptoms [2 trials of ≥ 6 weeks]), the treatment plan should be reevaluated and alternative pharmacologic or nonpharmacologic treatments considered. With increased awareness, those involved in the care of patients with schizophrenia will be able to identify TRS earlier in its course, thus supporting more informed treatment decisions by clinicians, patients, and caregivers to reduce the overall disease burden., (© Copyright 2019 Physicians Postgraduate Press, Inc.)

Objective: The authors examined the use of different classes of psychotropic medication in outpatient treatment of schizophrenia and schizoaffective disorder., Methods: Data from the United States Medicaid program were used to examine psychotropic medication use in a cohort of patients who had a diagnosis of schizophrenia or schizoaffective disorder in the calendar year 2010., Results: The cohort of Medicaid recipients who filled one or more prescriptions for a psychotropic medication in 2010 included 116,249 patients classified as having schizophrenia and 84,537 classified as having schizoaffective disorder. During 2010, 86.1% of patients with schizoaffective disorder and 70.1% with schizophrenia were treated with two or more different classes of psychotropic., Conclusions: Psychotropic medications other than antipsychotics were commonly prescribed for individuals with a diagnosis of schizophrenia or schizoaffective disorder. Their widespread use and uncertainty about their net benefits signal a need for research on their efficacy, safety, and appropriate use in these conditions.

Compared with oral antipsychotics (OAPs), long-acting injectable antipsychotics (LAIs) should improve medication adherence and reduce relapses in schizophrenia. However, meta-analyses of randomized trials and mirror-image studies yielded inconsistent results. Nonrandomized cohort studies with parallel comparisons of LAIs and OAPs offer a third design to examine this issue. We meta-analyzed cohort studies with ≥24 weeks duration and hospitalization data. Primary outcome was hospitalization rate, ie, number of hospitalizations per person-year. Secondary outcomes included hospitalization risk, ie, proportion of patients experiencing ≥1 hospitalizations, all-cause discontinuation, and total hospitalization days. Patient severity and/or chronicity at baseline was also meta-analyzed and explored as a potential effect size moderator. Altogether, 42 studies (n = 101 624; follow-up = 18.6 ± 10.0 mo) were meta-analyzed. LAIs were superior to OAPs regarding hospitalization rate (studies = 15, person-years = 68 009, rate ratio = 0.85, 95% CI = 0.78-0.93, P < .001) and all-cause discontinuations (studies = 10, n = 37 293, risk ratio = 0.78, 95% CI = 0.67-0.91, P = .001), but not regarding hospitalization risk (studies = 33, n = 51 733, risk ratio = 0.92, 95% CI = 0.84-1.00, P = .06), and hospitalization days (studies = 11, n = 21 328, Hedges' g = -0.05, 95% CI = -0.16 to 0.06, P = .39). Illness severity/chronicity was significantly greater in patients prescribed LAIs vs OAPs when all available information was pooled together (studies = 23, n = 61 806, Hedges' g = 0.15, 95% CI = 0.03-0.26, P = .01), but not when examined separately. In summary, this meta-analysis of cohort studies, which included patients that are broadly representative of clinical practice, indicates that LAIs are superior to OAPs. The lack of significant superiority of LAIs for hospitalization risk and hospital days needs to be interpreted in the context of naturalistic treatment selection with subsequently greater illness severity/chronicity in LAI-treated patients.

Objective: Although outpatient care within 30 days of mental health hospital discharge is an established quality indicator, little is known about the clinical implications of not receiving such care. This study evaluated whether receipt of outpatient care within 30 days of discharge was associated with a reduced risk of readmission during days 31-120 postdischarge among adult inpatients with schizophrenia or bipolar disorder., Methods: Retrospective longitudinal cohort analyses were performed with Truven MarketScan Commercial (2010-2014) and Medicaid (2010-2013) databases. Among inpatients with schizophrenia (N=25,401) or bipolar disorder (N=46,375), overall and stratified associations were examined between receipt of an outpatient follow-up visit in the 30 days postdischarge and hospital readmission during days 31-120 postdischarge., Results: Receipt of a follow-up visit within 30 days of discharge was associated with a slightly lower adjusted odds ratio (AOR) of hospital readmission during days 31-120 postdischarge (schizophrenia, AOR=.88, 95% confidence interval [CI]=.81-.96; bipolar disorder, AOR=.91, CI=.85-.98). For patients with schizophrenia, the strongest observed inverse association of follow-up care with readmission risk was among inpatients whose index admissions were 13 to 30 days long (AOR=.73, CI=.61-.89). For patients with bipolar disorder, the strongest corresponding inverse association was among those in the manic phase of illness at the index discharge (AOR=.73, CI=.63-.86)., Conclusions: Outpatient visits during the 30 days after discharge were associated with a lower hospital readmission risk during the following 90 days. Assertive hospital discharge planning to secure outpatient visits after hospital discharge is needed for these patient populations.

Background: Concerns exist that clozapine is underutilized in the management of treatment-resistant schizophrenia. Although a 2015 change in the US Food and Drug Administration (FDA) monitoring recommendations lowered the threshold of the absolute neutrophil count for treatment interruption from 1,500/μL to 1,000/μL and removed white blood cell count thresholds from the monitoring algorithm, the implications of this policy change on clozapine interruptions remain unknown., Methods: We analyzed outpatient prescribing records for antipsychotic medications in the Veterans Integrated Service Network 7 (VISN 7) database between 1999 and 2012 to assess the potential impact of the recent changes in FDA neutropenia monitoring recommendations on clozapine treatment discontinuation. We evaluated results of complete blood count monitoring to compare percentages of patients who developed or would have developed ≥ 1 hematologic event under the previous and current FDA guidelines in the first year following initiation of clozapine., Results: From a cohort of 14,620 patients with schizophrenia (ICD-9-295.x), 246 patients received clozapine treatment (1.7%). No agranulocytosis was observed during the study period. Under the former recommendations, 5 patients in the clozapine initiation cohort (n = 160, 3.1%; 95% CI, 0.43-5.83) qualified for treatment interruption during the first year of clozapine treatment, while only 1 patient (0.6%) qualified under the current recommendations. Under the former recommendations, hematologic events occurred at a similar rate for individuals taking and not taking clozapine., Conclusions: While clozapine remains an underused medication, the new FDA monitoring guidelines are likely to substantially reduce the percentage of patients who meet criteria for clozapine-associated hematologic events requiring treatment interruption. This decrease may reduce the clinical burden of managing patients on clozapine and therefore increase the number of individuals treated with this uniquely effective medication. However, prospective studies of individuals treated under the new guidelines are needed to fully assess safety of the FDA's change., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

Clozapine remains the only medication approved for treatment-resistant schizophrenia. But underuse is the norm. In 2010, the New York State Office of Mental Health began a multifaceted initiative to promote the evidence-based use of clozapine. From 2009 to 2013, in the absence of a well-funded pharmaceutical marketing campaign, the proportion of new clozapine trials among all new outpatient antipsychotic trials increased 40% among adult New York Medicaid recipients with a diagnosis of schizophrenia. The largest gains occurred in state-operated clinics. New York's experience demonstrates the feasibility of making clozapine more accessible to patients who stand to benefit most.

Objective: The authors compared the effectiveness of initiating treatment with either clozapine or a standard antipsychotic among adults with evidence of treatment-resistant schizophrenia in routine clinical practice., Method: U.S. national Medicaid data from 2001 to 2009 were used to examine treatment outcomes in a cohort of patients with schizophrenia and evidence of treatment resistance that initiated clozapine (N=3,123) and in a propensity score-matched cohort that initiated a standard antipsychotic (N=3,123). Interventions were new initiation of clozapine or a standard antipsychotic medication, defined as no exposure to the new medication in the prior 365 days. The primary outcome was hospital admission for a mental disorder. Secondary outcomes included discontinuation of the index antipsychotic, use of an additional antipsychotic, incidence of serious medical conditions, and mortality., Results: Initiation of clozapine was associated with a significantly decreased rate of psychiatric hospital admission (hazard ratio=0.78, 95% CI=0.69-0.88), index antipsychotic discontinuation (hazard ratio=0.60, 95% CI=0.55-0.65), and use of an additional antipsychotic (hazard ratio=0.76, 95% CI=0.70-0.82). Clozapine was associated with significantly increased incidence of diabetes mellitus (2.8% for clozapine vs. 1.4% for standard antipsychotic; hazard ratio=1.63, 95% CI=0.98-2.70), hyperlipidemia (12.9% for clozapine vs. 8.5% for standard antipsychotic; hazard ratio=1.40, 95%CI=1.09-1.78), and intestinal obstruction (0.9% for clozapine vs. 0.3% for standard antipsychotic; hazard ratio=2.50, 95% CI=0.97-6.44)., Conclusions: In adults with schizophrenia and evidence of treatment resistance, initiating clozapine compared with initiating a standard antipsychotic was associated with greater effectiveness on several important outcomes. Increasing the judicious use of clozapine is warranted together with vigilance to prevent and detect serious medical adverse effects.

Long-acting injectable antipsychotics (LAIs) are among the most effective treatments in psychiatry, yet they remain underutilized in clinical practice. Although LAIs are typically used to maintain treatment adherence in patients with chronic schizophrenia, recent research has suggested that they may also provide an effective treatment strategy for patients with early-phase or first-episode disease. In October 2015, a group of 8 experts on the management of schizophrenia and LAIs met to evaluate the evidence surrounding the efficacy, safety, and cost-effectiveness of LAIs and to develop practical recommendations regarding the clinical use, education, and unmet needs related to LAIs. Participants were also asked to rate the importance of several patient characteristics when choosing an LAI versus an oral antipsychotic, from the perspectives of 4 different stakeholder groups: patients, health care professionals, families, and payers. The evidence review demonstrated that LAIs are superior to placebo for acute and maintenance treatment of schizophrenia and, in general, appear to be similar to one another in terms of schizophrenia relapse prevention. Study design impacts the demonstrated efficacy of LAIs versus oral antipsychotics, but recent database and randomized controlled studies favor the use of LAIs in early-phase schizophrenia patients. LAIs vary considerably in their propensity to cause certain adverse effects, including weight gain, metabolic effects, extrapyramidal symptoms, and prolactin elevation, and these differences can be used to help guide LAI selection. Some studies, but not all, have demonstrated significant reductions in health care utilization or overall costs with LAIs. The expert panel identified several barriers to LAI use in current practice, including clinician lack of knowledge, negative attitudes about LAIs, and resource and cost issues. The participants also identified a number of additional factors that should be considered when weighing the use of LAI therapy, including medication adherence, relapse risk and severity, cognitive impairment, ease of use, substance misuse, access and cost, stigma, social support, patient autonomy, control over medication dosing, fear of needles, and the potential for patient harm due to relapses and associated loss of functioning. This evidence review, discussion, and summary recommendations may help clinicians, patients, families, payers, and other stakeholders to better characterize the role of LAIs in the treatment of schizophrenia., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Importance: Although adults with schizophrenia have a significantly increased risk of premature mortality, sample size limitations of previous research have hindered the identification of the underlying causes., Objective: To describe overall and cause-specific mortality rates and standardized mortality ratios (SMRs) for adults with schizophrenia compared with the US general population., Design, Setting, and Participants: We identified a national retrospective longitudinal cohort of patients with schizophrenia 20 to 64 years old in the Medicaid program (January 1, 2001, to December 31, 2007). The cohort included 1,138,853 individuals, 4,807,121 years of follow-up, and 74,003 deaths, of which 65,553 had a known cause., Main Outcomes and Measures: Mortality ratios for the schizophrenia cohort standardized to the general population with respect to age, sex, race/ethnicity, and geographic region were estimated for all-cause and cause-specific mortality. Mortality rates per 100,000 person-years and the mean years of potential life lost per death were also determined. Death record information was obtained from the National Death Index., Results: Adults with schizophrenia were more than 3.5 times (all-cause SMR, 3.7; 95% CI, 3.7-3.7) as likely to die in the follow-up period as were adults in the general population. Cardiovascular disease had the highest mortality rate (403.2 per 100,000 person-years) and an SMR of 3.6 (95% CI, 3.5-3.6). Among 6 selected cancers, lung cancer had the highest mortality rate (74.8 per 100,000 person-years) and an SMR of 2.4 (95% CI, 2.4-2.5). Particularly elevated SMRs were observed for chronic obstructive pulmonary disease (9.9; 95% CI, 9.6-10.2) and influenza and pneumonia (7.0; 95% CI, 6.7-7.4). Accidental deaths (119.7 per 100,000 person-years) accounted for more than twice as many deaths as suicide (52.0 per 100,000 person-years). Nonsuicidal substance-induced death, mostly from alcohol or other drugs, was also a leading cause of death (95.2 per 100,000 person-years)., Conclusions and Relevance: In a US national cohort of adults with schizophrenia, excess deaths from cardiovascular and respiratory diseases implicate modifiable cardiovascular risk factors, including especially tobacco use. Excess deaths directly attributable to alcohol or other drugs highlight threats posed by substance abuse. More aggressive identification and management of cardiovascular risk factors, as well as reducing tobacco use and substance abuse, should be leading priorities in the medical care of adults with schizophrenia.

Objective: Antipsychotic medications are largely ineffective for approximately 30% of patients with schizophrenia that is considered "treatment resistant." Clozapine is the only antipsychotic approved for treatment-resistant schizophrenia, but it is rarely used. This nationwide study examined predictors of clozapine use to help identify ways to optimize its use., Methods: A retrospective study using U.S. Medicaid claims data from 45 states was conducted among 326,119 individuals with a schizophrenia spectrum disorder (ICD-9-CM code 295.X) who initiated one or more antipsychotic treatment episodes between January 2002 and December 2005. Multivariable logistic regression models were used to calculate odds ratios of baseline patient and county factors associated with clozapine initiation., Results: Among 629,809 unique antipsychotic treatment episodes, 79,934 showed service use patterns consistent with treatment resistance. Clozapine accounted for 2.5% of starts of antipsychotic medication among patients in the overall sample and for 5.5% of starts among patients with treatment resistance. Clozapine initiation was significantly associated with male sex, younger age, white race, more frequent outpatient service use for schizophrenia, and greater prior-year hospital use for mental health. Treatment resistance and living in a county with historically high rates of clozapine use were among the strongest predictors of clozapine use., Conclusions: The clozapine initiation rate was low compared with the expected proportion of patients who warrant a clozapine trial and was strongly affected by local treatment practices. Efforts to address irregular access to clozapine are needed to improve recovery opportunities for people with schizophrenia in the United States.

Scant information exists to guide pharmacological treatment of early-onset schizophrenia. We examine variation across commonly prescribed second-generation antipsychotic medications in medication discontinuation and psychiatric hospital admission among children and adolescents clinically diagnosed with schizophrenia. A 45-state Medicaid claims file (2001-2005) was analyzed focusing on outpatients, aged 6-17 years, diagnosed with schizophrenia or a related disorder prior to starting a new episode of antipsychotic monotherapy with risperidone (n = 805), olanzapine (n = 382), quetiapine (n = 260), aripiprazole (n = 173), or ziprasidone (n = 125). Cox proportional hazard regressions estimated adjusted hazard ratios of 180-day antipsychotic medication discontinuation and 180-day psychiatric hospitalization for patients treated with each medication. During the first 180 days following antipsychotic initiation, most youth treated with quetiapine (70.7%), ziprasidone (73.3%), olanzapine (73.7%), risperidone (74.7%), and aripirazole (76.5%) discontinued their medication (χ(2) = 1.69, df = 4, P = .79). Compared with risperidone, the adjusted hazards of antipsychotic discontinuation did not significantly differ for any of the 4-comparator medications. The percentages of youth receiving inpatient psychiatric treatment while receiving their initial antipsychotic medication ranged from 7.19% (aripiprazole) to 9.89% (quetiapine) (χ(2) = 0.79, df = 4, P = .94). As compared with risperidone, the adjusted hazard ratio of psychiatric hospital admission was 0.96 (95% CI: 0.57-1.61) for olanzapine, 1.03 (95% CI: 0.59-1.81) for quetiapine, 0.85 (95% CI: 0.43-1.70) for aripiprazole, and 1.22 (95% CI: 0.60-2.51) for ziprasidone. The results suggest that rapid antipsychotic medication discontinuation and psychiatric hospital admission are common in the community treatment of early-onset schizophrenia. No significant differences were detected in risk of either adverse outcome across 5 commonly prescribed second-generation antipsychotic medications.

This study assessed the relationship between pharmacological regimens at hospital discharge and hospital readmission among schizophrenia patients. The records reviewed were all consecutive admissions (N=720) from a specific catchment area during the period 1991-2005. Two main groups were selected for analysis: the first group (N=537) included patients discharged with first-generation antipsychotics (FGA), and the second group (N=183) included patients with second-generation antipsychotics (SGA). Data on clinical and demographic characteristics at discharge, including a brief psychiatric rating scale and pharmacological treatment, were collected. The rate of readmission within 12 months was analyzed in relation to the specific pharmacological treatment at discharge. There was no significant difference in the risk of readmission in patients treated with SGA compared with FGA. Adjuvant psychotropic medications to either FGA or SGA did not attenuate the risk of readmission. The readmission rate in patients treated with clozapine (N=74) was significantly lower in comparison with depot FGA (N=293) medications (P=0.016). There was no advantage of SGA over FGA, with or without adjuvant psychotropic treatment, with regard to rehospitalization risk during the 12-month follow-up. Clozapine was found to reduce the risk for readmission in comparison with depot FGA.

Objective: The authors identified patient characteristics that increased risk of hospital admission among adults with schizophrenia., Methods: A total of 1,460 participants in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) clinical trial were followed from the time they began a randomized trial of medication to first schizophrenia-related hospital admission., Results: In 869 person-years of follow-up, 203 patients were hospitalized. Increased risk of hospital admission was associated with early age (≤ 17 years) of first antipsychotic treatment (adjusted hazard ratio [AHR]=2.16, 95% confidence interval [CI]=1.49-3.11), psychiatric hospitalization in past year (AHR=2.99, CI=2.23-4.00), having had DSM-IV alcohol (AHR=1.56, CI=1.16-2.10) or drug (AHR=1.50, CI=1.13-2.00) use disorders in the past five years, and baseline severe symptoms according to the Clinical Global Impressions Scale (AHR=1.54, CI=1.04-2.27), presence of tardive dyskinesia (AHR=1.55, CI=1.07-2.23), a high score on the positive symptoms subscale of the Positive and Negative Syndrome Scale (AHR=1.52, CI=1.07-2.15), and low social function (AHR=1.45, CI=1.03-2.04). As compared with olanzapine, the drugs quetiapine (AHR=2.14, CI=1.39-3.31), perphenazine (AHR=1.80, CI=1.11-2.94), and ziprasidone (AHR=2.70, CI=1.64-4.44) were associated with increased hospitalization risk. Risperidone was associated with a lower hospitalization risk than quetiapine (AHR=1.50, CI=1.01-2.22) and ziprasidone (AHR=1.89, CI=1.19-3.01)., Conclusions: Efforts to lower hospital admission risk among individuals with schizophrenia should focus on history of early onset, recent inpatient admission, severe positive symptoms, poor social function, high global illness severity, and comorbid substance use disorders and on selection of an appropriate antipsychotic medication.

Objective: This study seeks to identify patient, facility, county, and state policy factors associated with timely schizophrenia-related outpatient treatment following hospital discharge., Method: A retrospective longitudinal cohort analysis was performed of 2003 national Medicaid claims data supplemented with the American Hospital Association facility survey, the Area Resource File, and a Substance Abuse and Mental Health Services Administration Medicaid policy report. The analysis focuses on treatment episodes of adults, aged 20 to 63 years, who received inpatient care for ICD-9-CM-diagnosed schizophrenia (59,567 total treatment episodes). Rate and adjusted odds ratio (AOR) of schizophrenia-related outpatient visits within 7 days and 30 days following hospital discharge are assessed., Results: Of the 59,567 hospital discharges, 41.7% received schizophrenia-related outpatient visits in 7 days and 59.3% in 30 days following hospital discharge. The adjusted odds of 30-day follow-up outpatient visits were significantly related to preadmission outpatient mental health visits (AOR = 3.72; 99% CI, 3.44-4.03), depot (AOR = 2.83; 99% CI, 2.53-3.18) or oral (AOR = 1.73; 99% CI, 1.62-1.84) antipsychotics as compared with no antipsychotics, and absence of a substance use disorder diagnosis (AOR = 1.35; 99% CI, 1.25-1.45). General hospital as compared with a psychiatric hospital treatment (AOR = 1.32; 99% CI, 1.14-1.54) and patient residence in a county with a larger number of psychiatrists per capita (AOR = 1.27; 99% CI, 1.08-1.50) were related to receiving follow-up outpatient visits. By contrast, residence in a county with a high poverty rate (AOR = 0.60; 99% CI, 0.54-0.67) and treatment in a state with prior authorization requirements for < 12 annual outpatient visits (AOR = 0.69; 99% CI, 0.63-0.75) reduced the odds of follow-up care., Conclusions: Patient characteristics, clinical management, geographical resource availability, and the mental health policy environment all appear to shape access to care following hospital discharge in the community treatment of adult schizophrenia., ((c) Copyright 2010 Physicians Postgraduate Press, Inc.)

We compare psychiatric management of antipsychotic non-adherence among schizophrenia outpatients with high and low levels of family contact. A national survey was conducted among a random sample of psychiatrists treating schizophrenia, providing data on 310 patients. Patients were stratified by level of family contact. Psychiatrists were more likely to use family interventions to manage non-adherence among patients with high family contact. Psychiatrists were significantly more likely to change antipsychotic dosing in patients with high family contact, though less likely to start depot antipsychotic medications. Family interventions appear to be commonly used in the psychiatric management of medication non-adherence in schizophrenia.

Objectives: To describe factors associated with initiation of depot antipsychotic medications in psychiatric outpatients with schizophrenia and recent medication nonadherence., Methods: A national sample of psychiatrists reported on adult outpatients with schizophrenia who were nonadherent with oral antipsychotic medications in the last year., Results: In total, 17.6% of psychiatrists initiated depot antipsychotic injections. Initiation was significantly and positively associated with public insurance, prior inpatient admission, proportion of time nonadherent, average or above average intellectual functioning, and living in a mental health residence. Use was inversely associated with using second-generation antipsychotics and other oral psychotropic medications prior to medication nonadherence. Psychiatrists who were male, nonwhite, and more optimistic about managing nonadherence were more likely to initiate depot injections., Conclusions: Initiation of depot injections is a joint function of patient, physician, treatment, and setting factors. Use of long-acting preparations in this population is uncommon despite clinical recommendations urging their use.

Objectives: This study examined psychiatrists' opinions regarding the use of second-generation antipsychotics for treatment-resistant schizophrenia. It then sought to identify factors associated with these opinions., Methods: A national survey was conducted (September 2003-January 2004) of psychiatrists engaged in the management of patients with schizophrenia., Results: Among survey respondents (N=431), most psychiatrists (88%) believed that one or more of the five currently available second-generation antipsychotics could improve treatment-resistant positive symptoms after a failed trial of optimal oral haloperidol treatment. Psychiatrists who reported familiarity with schizophrenia practice guidelines were more likely to have high levels of optimism that these medications improve positive symptoms (odds ratio [OR]=3.6, 95% confidence interval [CI]=1.4-9.3, p=.009). Psychiatrists who met with a pharmaceutical representative at least once a week were also more likely to have high levels of optimism toward second-generation antipsychotics (OR=2.3, CI=1.4-3.9, p=.001)., Conclusions: Reported familiarity with treatment guidelines and frequent contact with pharmaceutical representatives appear to be associated with optimism toward second-generation antipsychotics.

Objective: To estimate the proportions of acute care inpatient admissions and hospital days for schizophrenia patients in the Medicaid program that are attributable to gaps in outpatient antipsychotic treatment and to calculate the corresponding total health care costs of this care., Methods: A series of multivariate regressions were performed with statewide 2001-2003 California Medicaid data to estimate the fraction of acute care hospital admissions and hospital days for schizophrenia attributable to gaps in antipsychotic medication treatment. This fraction was then applied to national estimates of the number and costs of inpatient treatment episodes for patients with schizophrenia in the national Medicaid program., Results: In the United States, there are roughly 87 000 annual acute care inpatient admissions of Medicaid patients for the treatment of schizophrenia. These admissions include a total of approximately 930 000 hospital days at a total cost of $806 million. Improving adherence to eliminate gaps in antipsychotic medication treatment could lower the number of acute care admissions by approximately 12.3% (95% confidence interval [CI]: 11.7%-12.6%) and reduce the number of inpatient treatment days by approximately 13.1% (CI: 9.8%-16.5%) resulting in a savings of approximately $106 million (95% CI: $79.0 million-$133.0 million) in inpatient care costs for the national Medicaid system., Conclusions: Nonadherence to antipsychotic medication treatment accounts for a considerable proportion of inpatient treatment costs of Medicaid patients with schizophrenia. Improving continuity of antipsychotic medications could lead to savings by reducing the frequency and duration of inpatient treatment.

Objective: This study compares 3 cohorts of patients with schizophrenia before, during, and after initiating treatment with fluphenazine decanoate (FD), haloperidol decanoate (HD), or long-acting injectable risperidone (LAR)., Methods: Administrative data are analyzed from California Medicaid (Medi-Cal) beneficiaries with schizophrenia who initiated FD, HD, or LAR treatment. Patients were required to have been continuously enrolled in Medi-Cal for 180 days before and 180 days after the start of the new episode of long-acting antipsychotic therapy., Results: There were few demographic and clinical differences among patients initiating FD, HD, and LAR. During the 180 days before starting long-acting injections, most patients initiating FD (53.5%), HD (58.5%), and LAR (61.2%) received oral antipsychotic medications for <80% of the days in this period (medication possession ratio: <0.80). The mean duration of depot treatment episodes was 58.3 days (SD = 53.6) for FD, 71.7 days (SD = 56.4) for HD, and 60.6 days (SD = 48.8) for LAR (F = 18.3, df = 2, 2694, P < .0001, HD > FD). Few patients who started on FD (5.4%), HD (9.7%), or LAR (2.6%) continued for at least 180 days. Most patients in each group (FD [77.4%], HD [78.9%], and LAR [75.5%]) received oral antipsychotic medications during the 45 days after discontinuing long-acting injections. Coprescription with antidepressants, mood stabilizers, and benzodiazepines was common., Conclusions: Patients treated with long-acting antipsychotic injections tend to have complex pharmacological regimens and recent medication nonadherence. A great majority of patients initiating long-acting antipsychotic medications discontinue use within the first few months of treatment.

Objective: This study compared patients with schizophrenia whose antipsychotic medications were switched to manage treatment-resistant positive psychotic symptoms with those for whom another antipsychotic was added. Psychiatrists' characteristics and perceptions of effectiveness of the medication change on clinical outcomes were also reported., Methods: Psychiatrists participating in a nationally representative mailed survey (N=209) reported on the clinical features, management, and response to the change in antipsychotic medication (added versus switched) of one adult patient with treatment-refractory schizophrenia under their care for at least one year., Results: Thirty-three percent of patients were treated with an added antipsychotic medication. Compared with patients whose antipsychotic medications were switched, those with an added antipsychotic medication were more likely to be female, to have received care from the same psychiatrist for more than two years, and to have been recently prescribed an antidepressant. Compared with psychiatrists who switched antipsychotic prescriptions, those who added an antipsychotic reported that the change was less likely to reduce positive symptoms, improve functioning, and prevent hospitalization. Psychiatrists who added rather than switched antipsychotics reported more frequent attendance at educational programs sponsored by a pharmaceutical company., Conclusions: Consistent with other lines of research and practice guideline recommendations, psychiatrists perceive antipsychotic polypharmacy to be a generally ineffective strategy for treatment-resistant positive psychotic symptoms. In light of these findings, efforts to identify and implement more effective evidence-based pharmacologic approaches should be undertaken.

To compare the clinical characteristics and psychiatric management of antipsychotic nonadherence among outpatients with schizophrenia who either do or do not have current or past comorbid substance use disorders, a national survey was conducted of psychiatrists engaged in the management of schizophrenia. Respondents reported on the presentation and management of one adult patient who had been under their care for at least 1 year and who had been nonadherent with oral antipsychotic medications at some point in the last year. The response rate was 69.3%. Patients with schizophrenia only (N = 190) were compared with patients with schizophrenia and a history of a co-occurring substance use disorder (N = 105). Approximately one third (35.6%) of antipsychotic nonadherent schizophrenia patients had a comorbid substance use disorder. Denial of illness was the most commonly cited primary reason for antipsychotic nonadherence. Psychiatrists were significantly less likely to discuss with comorbid patients than patients without comorbid substance use linkages between antipsychotic adherence and progress toward personal goals (64.5% vs. 78.9%), and significantly less likely to explore the meaning of taking medication to the patient's identity (59.2% vs. 73.3%). However, psychiatrists were approximately two times more likely to add another antipsychotic for patients with substance use disorders (22.8% vs. 11.0%). There were no perceived differences between the two groups in effectiveness of interventions to manage medication nonadherence. Comorbid substance use disorders are common among psychiatric outpatients with schizophrenia who are nonadherent with antipsychotic medications. Some psychological approaches tend to be used less often with patients with comorbid substance use disorders, although when they are used, psychiatrists report they are no less effective than they are for schizophrenia patients without comorbid substance use disorders. These findings suggest that some psychological interventions may tend to be underutilized in the management of medication nonadherence among patients with comorbid schizophrenia and substance use disorders.

Objective: The purpose of this study was to assess the effects of patients' awareness of their illness on the clinical presentation, management, and course of nonadherence to antipsychotic medications among patients with schizophrenia., Methods: A national survey was conducted of psychiatrists who were treating patients with schizophrenia. The survey was sent to 771 psychiatrists, of whom 534 responded, for a response rate of 69 percent. The psychiatrists were asked to report on presentation, management, and course for one adult patient with schizophrenia who had been under their care for at least one year and who had been nonadherent to oral antipsychotics at some point in the past year. Patients who were aware that they had a mental illness were compared with those who were not aware., Results: Of the 534 respondent psychiatrists, 310 reported on an eligible patient, and 300 of these patients were classified by illness awareness. Ninety-seven patients, or 32 percent, were not aware that they had a mental illness. These patients who lacked awareness had significantly longer episodes of antipsychotic nonadherence, were more likely to completely cease taking the antipsychotic medication, were more likely to have severe positive symptoms, and were more likely to be psychiatrically hospitalized after nonadherence than those who were aware of their illness. Psychological interventions and several types of family interventions were significantly less effective among patients who lacked awareness., Conclusions: A lack of awareness of mental illness is common among patients with schizophrenia who are nonadherent to antipsychotics. Such nonadherence tends to be especially disruptive and unresponsive to simple commonly used psychological interventions.

Objectives: This study provided generalizable national data on the treatment of adult patients with schizophrenia in the United States and assessed conformance with the practice guideline treatment recommendations of the Schizophrenia Patient Outcomes Research Team and the American Psychiatric Association., Methods: National data from the American Psychiatric Institute for Research and Education's 1999 Practice Research Network study of psychiatric patients and treatments were used to examine treatment patterns for 151 adult patients with schizophrenia. Analyses were performed and adjusted for the weights and sample design to generate nationally representative estimates., Results: Findings indicated that patients with schizophrenia who were treated by psychiatrists had complex clinical problems and were markedly disabled. Forty-one percent of patients had a comorbid axis I disorder, and 75 percent were currently unemployed. Thirty-five percent were currently experiencing medication side effects, and 37 percent were currently experiencing problems with treatment adherence. Although most patients received guideline-consistent psychopharmacologic treatment, treatment was characterized by significant polypharmacy. Rates of conformance with the guideline recommendations were significantly lower for psychosocial recommendations than for psychopharmacologic recommendations. Although 69 percent of patients received at least some psychosocial treatment, none of the unemployed patients received vocational rehabilitation services in the past 30 days., Conclusions: These data suggest unmet need for psychosocial treatment services among individuals with schizophrenia. These findings raise questions about whether currently available antipsychotic medications are being used optimally or whether they offer limited effectiveness for patients with complex clinical problems who are treated in routine psychiatric practice.

Objective: To describe the prevalence and clinical correlates of sexual dysfunction in a sample of adult male outpatients with schizophrenia treated with olanzapine, risperidone, quetiapine, or haloperidol, focusing on associations between sexual dysfunction and patient-perceived quality of life., Method: Sexual dysfunction was assessed in 139 outpatients with DSM-IV schizophrenia who were receiving olanzapine, risperidone, quetiapine, or haloperidol, but no other medications associated with sexual side effects. Structured assessments were made of psychiatric symptoms, quality of life, and relationships., Results: Sexual dysfunction occurred in 45.3% of patients. Patients with and without sexual dysfunction did not significantly differ with respect to severity of psychiatric symptoms. However, as compared with patients without sexual dysfunction, patients with sexual dysfunction reported significantly lower ratings on global quality of life (t = 2.4, df = 136, p = .02) and the level of enjoyment in their life (t = 2.5, df = 136, p = .01). Patients with sexual dysfunction were significantly less likely than those without sexual dysfunction to report having a romantic partner (17.5% vs. 43.4%; chi(2) = 10.7, df = 1, p = .001), though they were not significantly less likely to report difficulty making friends (27.0% vs. 32.9%; chi(2) = 0.57, df = 1, p = .45). Among patients with romantic partners, those with sexual dysfunction reported significantly poorer quality of their relationships (t = 2.3, df = 42, p = .02) and were less likely to talk to their partner about their illness (t = 2.0, df = 42, p = .047)., Conclusions: Sexual dysfunction is common in men with schizophrenia who are treated with olanzapine, risperidone, quetiapine, or haloperidol and is associated with diminished quality of life, decreased occurrence of romantic relationships, and reduced intimacy when relationships are established. High prevalence and substantial interference with quality of life combine to make sexual dysfunction an important area for clinical assessment and appropriate intervention in the community management of schizophrenia.

Objective: Applying the schizophrenia treatment guidelines established by the Patient Outcomes Research Team (PORT) project, this study evaluated whether antipsychotic medication dosage influenced patient outcomes in routine clinical settings., Methods: The associations between discharge antipsychotic medication dosage and short-term clinical, social, and service use outcomes were observed in a sample of 246 patients with schizophrenia or schizoaffective disorder., Results: Patients who were given high dosages of antipsychotic medication at hospital discharge (more than 1,000 chlorpromazine milligram equivalents) had greater severity of symptoms three months after discharge than patients who were given guideline-recommended dosages (300 to 1,000 chlorpromazine milligram equivalents) (adjusted mean Brief Psychiatric Rating Scale scores of 45 and 39, respectively). Patients who were given low dosages of antipsychotic medication at hospital discharge (less than 300 chlorpromazine milligram equivalents) were less likely to report side effects (adjusted OR=.24) and slightly more likely to be nonadherent (21 percent of those within the recommended dose range compared with 39 percent of the those with low doses, not statistically significant after Bonferroni correction). No other differences related to medication dosage were observed in patient outcomes., Conclusions: Treatment that falls within antipsychotic medication dosage guidelines is associated with improvement in a limited, but critical, range of short-term patient outcomes in routine clinical settings.

Objective: Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice., Method: Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized., Results: Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services., Conclusions: Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

Administrative and pharmacy data bases represent a largely untapped resource for clinical decision support and quality improvement. In this study, we examined the feasibility of using New York State Office of Mental Health (NYSOMH) data bases to develop an automated clinical report to support implementation of schizophrenia guidelines. First we reviewed the structure of existing data bases for capacity and limitations in supporting guideline implementation. Second, we identified schizophrenia guideline recommendations and adherence measures that would be the focus of our implementation. Third, a preliminary report was programmed, based on operational definitions of the guideline recommendations. Finally, we developed user groups to define content and format of new reports, through an iterative process of field testing, feedback, and revision. Our experience suggests that administrative and pharmacy data bases, despite their limitations, can be used to develop guideline-based clinical decision support tools for schizophrenia with high physician acceptability.

Background and hypothesisIn the United States, women with schizophrenia face challenges in receiving gynecologic care, but little is known about how cervical cancer screening rates vary across time or states in a publicly insured population. We hypothesized that women Medicaid beneficiaries with schizophrenia would be less likely to receive cervical cancer screening across the United States compared with a control population, and that women with schizophrenia and other markers of vulnerability would be least likely to receive screening.Study designThis retrospective cohort study used US Medicaid administrative data from across 44 states between 2002 and 2012 and examined differences in cervical cancer screening test rates among 283 950 female Medicaid beneficiaries with schizophrenia and a frequency-matched control group without serious mental illness, matched on age and race/ethnicity. Among women with schizophrenia, multivariable logistic regression estimated the odds of receiving cervical cancer screening using individual sociodemographics, comorbid conditions, and health care service utilization.Study resultsCompared to the control group, women with schizophrenia were less likely to receive cervical cancer screening (OR = 0.76; 95% CI 0.75-0.77). Among women with schizophrenia, nonwhite populations, younger women, urban dwellers, those with substance use disorders, anxiety, and depression and those connected to primary care were more likely to complete screening.ConclusionsCervical cancer screening rates among US women Medicaid beneficiaries with schizophrenia were suboptimal. To address cervical cancer care disparities for this population, interventions are needed to prioritize women with schizophrenia who are less engaged with the health care system or who reside in rural areas.

BackgroundPeople with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia.SettingNationally representative sample of Medicaid enrollees with and without schizophrenia.MethodsUsing retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts.ResultsHigher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia.ConclusionOverall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.

ObjectiveAlthough people with schizophrenia are disproportionately affected by Hepatitis C virus (HCV) compared to the general population, HCV screening among US Medicaid recipients with schizophrenia has not been characterized. Following 1998 CDC recommendations for screening in high-risk populations, we estimated the proportion of Medicaid recipients with and without schizophrenia screened for HCV across states and over time. Examining patterns of screening will inform the current public health imperative to test all adults for HCV now that safer and more effective treatments are available.MethodsData are drawn from 1 353 424 Medicaid recipients aged 15-64 years with schizophrenia and frequency-matched controls from 2002 to 2012. Participants with known HCV infection one year prior and those dual-eligible for Medicare were excluded. Multivariable logistic regression estimated associations between predictor variables and HCV screening.ResultsHCV screening was low (

Treatment-resistant schizophrenia (TRS), the persistence of positive symptoms despite ≥2 trials of adequate dose and duration of antipsychotic medication with documented adherence, is a serious clinical problem with heterogeneous presentations. TRS can vary in its onset (at the first episode of psychosis or upon relapse), in its severity, and in the response to subsequent therapeutic interventions (i.e., clozapine, electroconvulsive therapy). The heterogeneity of TRS indicates that the underlying neurobiology of TRS may differ not only from treatment-responsive schizophrenia but also among patients with TRS. Several hypotheses have been proposed for the neurobiological mechanisms underlying TRS, including dopamine supersensitivity, hyperdopaminergic and normodopaminergic subtypes, glutamate dysregulation, inflammation and oxidative stress, and serotonin dysregulation. Research supporting these hypotheses is limited in part by variations in the criteria used to define TRS, as well as by the biological and clinical heterogeneity of TRS. Clinical trial designs for new treatments should be informed by this heterogeneity, and further clinical research is needed to more clearly understand the underlying neurobiology of TRS and to optimize treatment for patients with TRS.

Key Points: Question: What is the association between social vulnerability and mental health and substance use disorders and related treatment in the US noninstitutionalized population of adults aged 18 years and older? Findings: In this survey study of 4674 participants from US households, large increases in several mental health and substance use disorders and corresponding decreases in treatment were found in the most socially vulnerable communities. Meaning: The findings suggest that routine measurement of social vulnerability might assist in developing more comprehensive care models that integrate medical and social care for mental health and substance use disorders. This survey study evaluates associations of social vulnerability with mental health disorders and substance use disorders in a noninstitutionalized setting. Importance: Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study. Objective: To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older. Design, Setting, and Participants: A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews. Main Outcomes and Measures: Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level. Results: The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80). Conclusions and Relevance: In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, stimulant use disorder, and OUD with corresponding decreases in treatment. These results suggest that the SVM might assist in developing more comprehensive care models that integrate medical and social care for MH disorders and SUDs. [ABSTRACT FROM AUTHOR]