Reply to Schizophrenia-Related Outpatient Treatment of Medicaid-Financed Patients After Hospital Discharge

Dr Olfson and Colleagues Reply

To the Editor: We agree with Dr van den Noort and Ms Bosch that wide variation exists in the quality and effectiveness of outpatient care for schizophrenia. We view successful linkage to outpatient care as a necessary, though not sufficient, aspect of high-quality community care. Much needs to be learned about the factors that govern connections to different modalities of treatment. In this sense, we view our work, which focused on linkages to any outpatient treatment, as only a first step in understanding the processes that shape delivery of effective community care following hospital discharge.

We are also keenly aware that, as Dr van den Noort and Ms Bosch note, important differences exist in the clinical circumstances surrounding use of long-acting injectable and oral antipsychotic medications.1 For outpatients who receive long-acting injectable antipsychotics prior to inpatient admission, it may be especially important that their posthospital outpatient treatment setting be staffed to offer long-acting injectable medications. In our recent analysis, we considered only whether antipsychotic medication use prior to hospital admission serves as a marker to help predict subsequent treatment engagement. We found that those receiving long-acting injectable medications prior to admission were quite likely to remain engaged in treatment following hospital discharge, though we did not assess whether these patients continued to receive long-acting medications following hospital discharge. Further analysis of this issue might reveal the factors that influence continuity of antipsychotic treatment for this patient group.

As Dr van den Noort and Ms Bosch also indicate, the results of our analysis of a national sample of Medicaid patients do not generalize to uninsured patients. Understanding determinants of service use in this highly vulnerable population remains a key priority.

Reference

1. West JC, Marcus SC, Wilk J, et al. Use of depot antipsychotic medications for medication nonadherence in schizophrenia. Schizophr Bull. 2008;34(5):995-1001. PubMed doi:10.1093/schbul/sbm137

Mark Olfson, MD, MPH

[email protected]

Steven C. Marcus, PhD

Jalpa A. Doshi, PhD

Author affiliations: Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York (Dr Olfson); Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, and School of Social Policy & Practice, University of Pennsylvania, Philadelphia (Dr Marcus); and Leonard Davis Institute of Health Economics, University of Pennsylvania and Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia (Dr Doshi). Potential conflicts of interest: Dr Olfson has received grant/research support from Bristol-Myers Squibb and Eli Lilly. Dr Marcus is a consultant for Eli Lilly. Dr Doshi is a consultant for Eli Lilly and Bristol-Myers Squibb. Funding/support: The research discussed in this letter was funded by a grant to Columbia University from Eli Lilly; Dr Olfson, principal investigator.

doi:10.4088/JCP.10lr06511ayel

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