Schizophrenia-Related Outpatient Treatment of Medicaid-Financed Patients After Hospital Discharge
To the Editor: With great interest, we read the study by Olfson et al1 of schizophrenia-related outpatient treatment of Medicaid-financed patients after hospitalization. Unfortunately, the authors give no further information on what kind of follow-up treatment (eg, various antipsychotics, psychoeducation) the outpatients received. With respect to the risk of relapse and mental health outcomes,1 not only is the absolute percentage of outpatients who received follow-up treatment of importance, but the quality of the intervention(s) is also of particular importance.2 From previous research on outpatients with schizophrenia, for instance, it is known that the success rates of the different treatments3 and combinations of treatments4 differ significantly, as do the percentages of compliance to the different treatments5 and combinations of treatment.6
In addition, even after controlling for prior outpatient mental health care, Olfson et al1 found that patients who received long-acting injectable antipsychotic medication prior to hospital admission were more likely to follow through with outpatient care than were patients who received only oral antipsychotic medication during this period. Moreover, it was found that patients who received no antipsychotic medication before hospital admission for the treatment of schizophrenia had the lowest rate of outpatient follow-up. However, unfortunately, the authors fail to mention what exactly happened after hospital discharge. Did all patients receive oral antipsychotic medication, or did some of the patients still receive long-acting injectable antipsychotic medication? It should be noted that injectable antipsychotic medication is, even after hospital discharge, injected by another person (mostly by nursing staff),7 whereas oral antipsychotic medication is taken by the patient, with no caretaker present. As a result, the social control7 and external pressure to comply are different between the treatment methods, and it seems that this might play a substantial role in the explanation of why the results are different between the 3 groups of outpatients, ie, those who received injectable antipsychotics before hospitalization, those who received oral antipsychotics before hospitalization, and those who received no antipsychotics before hospitalization, and why the results are in favor of injectable antipsychotics.
Finally, the focus of the study was on Medicaid-financed patients; however, it is important to keep in mind Yanos and colleagues’ 8 finding that about 20% of patients with schizophrenia in a statewide health care system had no health insurance at all. Uninsured patients often receive no, or inadequate, inpatient or outpatient health care.9 As a result, they are at higher risk of conducting violence and criminal behavior,10 further increase the already extremely high schizophrenia-related costs for society,11 and have even worse mental health outcomes compared to Medicaid-financed patients.
The results of Olfson and colleagues’ retrospective longitudinal cohort analysis1 support the view that, with respect to risk of relapse and poor mental health outcome, it is important to further increase access to public health insurance,12 thereby reducing gaps in the provision of services to patients with schizophrenia.
References
1. Olfson M, Marcus SC, Doshi JA. Continuity of care after inpatient discharge of patients with schizophrenia in the Medicaid program: a retrospective longitudinal cohort analysis. J Clin Psychiatry. 2010;71(7):831-838. PubMed doi:10.4088/JCP.10m05969yel
2. Schmidt-Kraepelin C, Janssen B, Gaebel W. Prevention of rehospitalization in schizophrenia: results of an integrated care project in Germany. Eur Arch Psychiatry Clin Neurosci. 2009;259(suppl 2):S205-S212. PubMed doi:10.1007/s00406-009-0056-7
3. Obradovic M, Mrhar A, Kos M. Cost-effectiveness of antipsychotics for outpatients with chronic schizophrenia. Int J Clin Pract. 2007;61(12):1979-1988. PubMed doi:10.1111/j.1742-1241.2007.01431.x
4. Clark RE, Bartels SJ, Mellman TA, et al. Recent trends in antipsychotic combination therapy of schizophrenia and schizoaffective disorder: implications for state mental health policy. Schizophr Bull. 2002;28(1):75-84. PubMed
5. Garc×a-Cabeza I, Gómez JC, Sacristán JA, et al. Subjective response to antipsychotic treatment and compliance in schizophrenia: a naturalistic study comparing olanzapine, risperidone and haloperidol (EFESO Study). BMC Psychiatry. 2001;1(1):7. PubMed doi:10.1186/1471-244X-1-7
6. Lee SH, Choi TK, Suh S, et al. Effectiveness of a psychosocial intervention for relapse prevention in patients with schizophrenia receiving risperidone via long-acting injection. Psychiatry Res. 2010;175(3):195-199. PubMed doi:10.1016/j.psychres.2008.06.043
7. Haddad PM, Taylor M, Niaz OS. First-generation antipsychotic long-acting injections v. oral antipsychotics in schizophrenia: systematic review of randomised controlled trials and observational studies. Br J Psychiatry suppl. 2009;195(52):S20-S28. PubMed doi:10.1192/bjp.195.52.s20
8. Yanos PT, Lu W, Minsky S, et al. Correlates of health insurance among persons with schizophrenia in a statewide behavioral health care system. Psychiatr Serv. 2004;55(1):79-82. PubMed doi:10.1176/appi.ps.55.1.79
9. Rabinowitz J, Bromet EJ, Lavelle J, et al. Relationship between type of insurance and care during the early course of psychosis. Am J Psychiatry. 1998;155(10):1392-1397. PubMed
10. Soyka M, Graz C, Bottlender R, et al. Clinical correlates of later violence and criminal offences in schizophrenia. Schizophr Res. 2007;94(1-3):89-98. PubMed doi:10.1016/j.schres.2007.03.027
11. Andlin-Sobocki P, Jönsson B, Wittchen HU, et al. Cost of disorders of the brain in Europe. Eur J Neurol. 2005;12(suppl 1):1-27. PubMed doi:10.1111/j.1468-1331.2005.01202.x
12. Goldman HH. Will health insurance reform in the United States help people with schizophrenia? Schizophr Bull. 2010;36(5):893-894. PubMed doi:10.1093/schbul/sbq082
Author affiliations: Research Group of Pain and Neuroscience, Kyung Hee University, Seoul, Republic of Korea, and Free University of Brussels, Belgium (Dr van den Noort); and Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands, and LVR-Klinik Bedburg-Hau, Bedburg-Hau, Germany (Ms Bosch). Potential conflicts of interest: None reported. Funding/support: None reported.
doi:10.4088/JCP.10lr06511yel
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