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Substance abuse and the need for money management assistance among psychiatric inpatients
Drug and Alcohol Dependence 67 (2002) 331 /334 www.elsevier.com/locate/drugalcdep
Short communication
Substance abuse and the need for money management assistance among psychiatric inpatients Marc I. Rosen a,*, Robert A. Rosenheck a, Andrew L. Shaner b, Thad A. Eckman b, Gail R. Gamache c, Christopher W. Krebs d a
Department of Psychiatry-116A, VA Connecticut Healthcare System, Bldg 1, Rm. 953-M, 950 Campbell Avenue, West Haven, CT 06516, USA b Department of Mental Health, VA Medical Center West Los Angles, Los Angles, CA 90073, USA c Mental Illness Research Education and Clinical Care Center, Northampton VA Medical Center, Leeds, MA 01053, USA d Mental Illness Research Education and Clinical Care Center, VA Bedford Medical Center, Bedford, MA 01730, USA Received 25 January 2002; received in revised form 5 April 2002; accepted 15 April 2002
Abstract Patients who mismanage their funds may benefit from financial advice, case management or the involuntary assignment of a payee who restricts direct access to funds. Data from a survey of psychiatric inpatients at four VA hospitals (N /236) was used to evaluate the relationship between substance abuse and clinician-rated need for money management assistance. Multivariate analytic techniques were used to control for sociodemographic factors and psychopathology. Alcohol and drug use severity both were modestly associated with need for assistance. The effect of substance use severity was greater in patients who were also diagnosed with a major mental illness. Clinicians indicated that 27 patients (11% of the sample) required an involuntary payee and 21 of the 27 (78%) had a Substance Abuse diagnosis. Only drug use severity was significantly associated with need for a payee. These data describe a substantial unmet need for money management assistance in psychiatric inpatients, particularly among those with substance abuse disorders. There is a need to examine the process by which the Social Security and Veterans Benefits Administrations assign payees to determine whether patients with co-morbid substance abuse are not being assigned a payee in spite of their discernible need for one. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Payee; Case management; Dual diagnosis; Substance abuse; Social services
1. Introduction There has been considerable concern that public support payments are often used to purchase alcohol and drugs and may exacerbate substance abuse disorders (Shaner et al., 1995; Satel, 1995). However, involuntary assignment of a payee based on substance use has been controversial because substance abuse is often episodic, and patients may be able to manage their funds independently when abstinent (Rosen and Rosenheck, 1999). Traditionally, payee assignment has been stipulated for patients who were incapable of managing their funds because of psychiatric disorders. Nevertheless, almost half the patients in one payeeship
* Corresponding author. Tel.: /1-203-932-5711x2112; fax: /1-203815-346-2208 E-mail address: [email protected] (M.I. Rosen).
program were assigned payees because of comorbid substance use (Luchins et al., 1998), and high rates of dual diagnosis have been reported in broader surveys of patients with payees (Ries and Dyck, 1997). There is little empirical information describing which patients from a more general clinical sample need a payee and have not been assigned one. More specifically, the importance of substance abuse in determining need for a payee has not been determined. In a prior paper (Rosen et al., in press), we reported results from a survey concerning money management habits among 78 veterans hospitalized on psychiatric units who received public support payments, had a substance abuse diagnosis and did not already have a payee. Altogether, 35 patients (13% of those surveyed) met more stringent criteria we had developed for needing a payee. This current study considers the larger sample of all 236 hospitalized patients without payees who participated in
03765-8716/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 0 2 ) 0 0 0 8 0 - 7
332
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
that survey in order to examine the relationship between substance use, psychopathology and clinician-rated need for money management assistance. Two questions were addressed: 1) Are patients with more severe substance abuse problems more likely to need money management assistance, after controlling for sociodemographic factors and psychopathology? 2) Is there an interaction between substance abuse and psychopathology such that dual-problem patients have a greater need for money management assistance than if the effects of the two problems were additive?
The independent variables for substance use were alcohol and drug composite scores calculated from patient responses to the drug and alcohol modules of the Addiction Severity Index (ASI), Version 5 (McClellan et al., 1992), using standard formulas (Alterman et al., 1984). To create a measure of overall substance abuse, alcohol and drug subscale scores were standardized (z -score transformation) and added together. Two independent variables reflecting psychopathology were used. One was whether or not the inpatient clinician diagnosed the patient with a severe mental illness (Schizophrenia, Bipolar, or Psychosis-NOS). The second was the number of psychiatric symptoms (from the checklist in the ASI mental health module) that the patient reported having experienced during the 30 days prior to admission.
2. Methods
3. Data analysis
The sampling procedure, survey methods and measures have been previously described (Rosen et al., in press) and are briefly summarized here. A sequential sample of 570 veterans hospitalized on inpatient psychiatry services at four VA Medical Centers was invited to answer a questionnaire focusing on how they managed their money. VA hospitals serve veterans of US military service. Participating patients provided written informed consent and all study procedures were approved at each institution’s Institutional Review Board. The patient questionnaires solicited information about the patients’ sociodemographic characteristics, substance abuse and psychiatric status. The treating inpatient clinicians were also asked to complete a brief questionnaire. Altogether, 55 different clinicians answered questions about the 236 patients in the sample. The surveyed clinician for each patient was the one identified by the treatment team as best able to answer questions about the patients’ ability to manage his or her funds. Clinicians rated statements about patients’ money management using a 4-point Likerttype scale (anchored by 1-strongly disagree to 4-strongly agree). Using four items we created a composite measure of the need for money management assistance. Crohnbach’s Alpha for the composite measure was 0.86 reflecting the high inter-correlation of the four items from which the scale was derived. The items reflected the mean of clinicians’ ratings of whether (a) the patient’s funds were already managed appropriately, (b) a money manager would have prevented this hospitalization, (c) someone to advise the patient about spending would be helpful and (d) someone who would receive and control the patients’ funds would be helpful. A second measure of need for assistance was dichotomous: whether or not the treating clinician strongly believed that an involuntary payee should be assigned.
The relationship between substance use and need for money management assistance was evaluated through three multiple regression analyses that adjusted for psychopathology and sociodemographic variables. The first analysis included the four independent variables listed above. The second included an interaction term computed by multiplying the summed alcohol and drug composite scores by variables representing the presence of severe mental illness. The third model included an interaction term computed by multiplying the summed composite substance abuse scores and the number of psychiatric symptoms endorsed. A separate logistic regression analysis was conducted to determine variables associated with needing a payee.
4. Results 4.1. The sample Of the 570 sequential psychiatric inpatients identified, 290 had completed patient and clinician questionnaires. Of these patients, 54 already had an assigned payee and were, therefore, not relevant to the analysis of need for a payee. Thus, the remaining 236 were included in this analysis. In order to detect selection biases, patients completing the surveys were compared with those who did not and for whom only clinician surveys were available. The vast majority of sociodemographic and clinical measures were not significantly different. Patients completing the survey differed from non-completers only in being older by a mean of 1.8 years, more likely to have been diagnosed with a personality disorder (19 vs. 12%) and more likely to have received public support payments (57 vs. 48%). As expected in VA medical centers, 95%
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
were male, mean age was 49 and 55% received either social security or veterans benefits. Most patients, 71%, were diagnosed by their clinicians with a DSM substance abuse diagnosis (61% alcohol, 22% cocaine, 13% opioids, 10% cannabis), and many patients had a severe mental illness (19% schizophrenia, 12% bipolar, 3% psychosis-NOS). 4.2. Relationship of predictors to need for money management assistance The ordinary least squares regression indicated that the full model accounted for a significant proportion of the variance in need for money management assistance (r2 /0.22; F(12, 212) /4.9; P B/001). The significant positive, albeit modest, relationships between need for assistance and both drug and alcohol problem severity are shown in Table 1. There was no relationship between need for assistance and either measure of psychiatric severity. Being married was associated with less need for money management assistance, and there were significant differences by site of hospitalization. The same set of covariates was used in two regression analyses examining the relationship between need for money management assistance and the interaction between substance use and psychopathology. In the first analysis, substance use severity significantly increased the risk of needing money management assistance among patients with severe mental illness. In the second analysis, which considered psychiatric symptoms instead of presence of severe mental illness in the interaction term, the interaction between number of psychiatric symptoms and substance use severity was not significantly associated with need for money management assistance. Table 1 Multivariate analysis of inpatients’ need for money management assistance showing effects of sociodemographic, substance use and psychiatric characteristics (N 236) Characteristic
Age (10 year increments) Caucasian Male Married Public support recipient Alcohol problem severity (ASI Composite Score) Drug problem severity (ASI Composite Score) Number of psychiatric symptoms Axis 1 Schiz, Bipolar or Psychosis NOS Interaction of ASI substance abuse measures and major axis I diagnosis Interaction of ASI substance abuse measures and number of psychiatric symptoms *P B 0.05. **P B 0.01. ***P B 0.001.
Standard b
333
4.3. Relationship of predictors to whether clinician would assign a payee Table 2 presents the logistic regression analysis of clinician-judged need for involuntary payee assignment. Only drug use severity was significantly associated with need for a payee. The 27 patients to whom clinicians would assign a payee were 11% of the total sample. Of the 27, 21 (78%) had a substance abuse diagnosis.
5. Discussion These data describe a notable unmet need for money management assistance among psychiatric inpatients, particularly among those with substance use disorders. These findings have two important implications. First, there is a need to examine the payee assignment process to determine whether patients with comorbid substance abuse are not being assigned a payee in spite of their discernible need for one. Second, interventions designed to improve quality of life through money management, including payee assignment, need to be developed and tested and must specifically address the substance abuse comorbidities occurring among psychiatric patients. Several limitations require comment. The generalizability of these findings is limited because the sample was primarily male veterans. It is also possible that a sample that included outpatients and a procedure that used more sensitive measures of psychopathology would have demonstrated a significant relationship between psychopathology and the need for money management assistance. Another limitation is that the response rate Table 2 Logistic regression analysis of whether clinican would assign a payee showing effects of sociodemographic, substance use and psychiatric characteristics (N 236) Characteristic
Exp (B)
95% Confidence interval
Age (10 year increments) Caucasian Male Married Public support recipient Alcohol problem severity (ASI Composite Score) Drug problem severity (ASI Composite Score) Number of psychiatric symptoms Axis 1 Schiz, bipolar or psychosis NOS Interaction of ASI substance abuse measures and major axis I diagnosis Interaction of ASI substance abuse measures and number of psychiatric symptoms
0.91 2 2 1.2 1.3 1.6
0.94 /1.04 0.8 /9.4 0.2 /21 0.3 /5.0 0.4 /3.7 0.9 /2.8
1.7*
1.0 /2.9
0.6 2.8 5.7
0.4 /1.1 1.0 /8.3 0.3 /1.2
0.8
0.2 /2.6
t -test
0.09 0.05 0.02 0.21 0.13 0.21
1.2 0.7 0.3 3.3*** 1.8 2.9**
0.17 0.02 0.05 0.28
2.4* 0.32 0.7 3.5***
0.10
1
*P B 0.05.
334
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
was low, although our analyses revealed only minor differences between patients who completed the surveys and those who did not. These findings support the assertion that substance abuse contributes to funds being misspent; that this effect is especially pronounced in patients with severe psychopathology; and that a substantial population of patients need money management interventions that specifically address problems related to substance use.
Acknowledgements This project was a multi-site collaboration among the following: VA Connecticut Healthcare System, Susan Harman; Bedford VA Medical Center, Charles Drebing and Alice Van Ormer; Northampton VA Medical Center, Christopher Cryan and Lynn Gordon; Veterans Affairs Medical Center, West Los Angeles. This project was supported in part by the Department of Veterans Affairs VISN 1 and VISN 22 Mental Illness Research Education and Clinical Care Center, Northeast Program Evaluation Center, R01-DA12952 (MIR) and P50DA09241.
References Alterman, A.I., Brown, L., Zabahero, L. 1984. The interviewer severity ratings of the ASI: a further look. Drug Alcohol Depend. 34, 201 / 209. Luchins, D.J., Hanrahan, P., Conrad, K.J., Savage, C., Matters, M.D., Shinderman, M. 1998. An agency-based representative payee program and improved community tenure of persons with mental illness. Psychiatr. Serv. 49 (9), 1218 /1222. McClellan, A.T., Kushner, H., Metzger, D., Peters, R., Smith, L., Grissom, G., Pettinati, H., Argerious, M. 1992. The fifth edition of the addiction severity index. J. Subst. Abuse Treat. 9, 199 / 213. Ries, R.K., Dyck, D.G. 1997. Representative payee practices of community mental health centers in Washington State. Psychiatr. Serv. 48, 811 /814. Rosen, M.I., Rosenheck, R.A. 1999. Substance abuse and the assignment of representative payees. Psychiatr. Serv. 50, 95 /98. Rosen, M.I., Rosenheck, R.A., Shaner, A., Eckman, T., Gamache, G., Krebs, C., 2002. Veterans potentially in need of a payee to prevent misuse of funds for drugs, Psychiatr. Serv., in press. Satel, S. 1995. When disability benefits make patients sicker. New Engl. J. Med. 33 (9), 794 /796. Shaner, A., Eckman, T.A., Roberts, L.J., Wilkins, J.N., Tucker, D.E., Tsuang, J., Mintz, J. 1995. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers: A government sponsored revolving door? New Engl. J. Med. 333, 777 /783.
Short communication
Substance abuse and the need for money management assistance among psychiatric inpatients Marc I. Rosen a,*, Robert A. Rosenheck a, Andrew L. Shaner b, Thad A. Eckman b, Gail R. Gamache c, Christopher W. Krebs d a
Department of Psychiatry-116A, VA Connecticut Healthcare System, Bldg 1, Rm. 953-M, 950 Campbell Avenue, West Haven, CT 06516, USA b Department of Mental Health, VA Medical Center West Los Angles, Los Angles, CA 90073, USA c Mental Illness Research Education and Clinical Care Center, Northampton VA Medical Center, Leeds, MA 01053, USA d Mental Illness Research Education and Clinical Care Center, VA Bedford Medical Center, Bedford, MA 01730, USA Received 25 January 2002; received in revised form 5 April 2002; accepted 15 April 2002
Abstract Patients who mismanage their funds may benefit from financial advice, case management or the involuntary assignment of a payee who restricts direct access to funds. Data from a survey of psychiatric inpatients at four VA hospitals (N /236) was used to evaluate the relationship between substance abuse and clinician-rated need for money management assistance. Multivariate analytic techniques were used to control for sociodemographic factors and psychopathology. Alcohol and drug use severity both were modestly associated with need for assistance. The effect of substance use severity was greater in patients who were also diagnosed with a major mental illness. Clinicians indicated that 27 patients (11% of the sample) required an involuntary payee and 21 of the 27 (78%) had a Substance Abuse diagnosis. Only drug use severity was significantly associated with need for a payee. These data describe a substantial unmet need for money management assistance in psychiatric inpatients, particularly among those with substance abuse disorders. There is a need to examine the process by which the Social Security and Veterans Benefits Administrations assign payees to determine whether patients with co-morbid substance abuse are not being assigned a payee in spite of their discernible need for one. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Payee; Case management; Dual diagnosis; Substance abuse; Social services
1. Introduction There has been considerable concern that public support payments are often used to purchase alcohol and drugs and may exacerbate substance abuse disorders (Shaner et al., 1995; Satel, 1995). However, involuntary assignment of a payee based on substance use has been controversial because substance abuse is often episodic, and patients may be able to manage their funds independently when abstinent (Rosen and Rosenheck, 1999). Traditionally, payee assignment has been stipulated for patients who were incapable of managing their funds because of psychiatric disorders. Nevertheless, almost half the patients in one payeeship
* Corresponding author. Tel.: /1-203-932-5711x2112; fax: /1-203815-346-2208 E-mail address: [email protected] (M.I. Rosen).
program were assigned payees because of comorbid substance use (Luchins et al., 1998), and high rates of dual diagnosis have been reported in broader surveys of patients with payees (Ries and Dyck, 1997). There is little empirical information describing which patients from a more general clinical sample need a payee and have not been assigned one. More specifically, the importance of substance abuse in determining need for a payee has not been determined. In a prior paper (Rosen et al., in press), we reported results from a survey concerning money management habits among 78 veterans hospitalized on psychiatric units who received public support payments, had a substance abuse diagnosis and did not already have a payee. Altogether, 35 patients (13% of those surveyed) met more stringent criteria we had developed for needing a payee. This current study considers the larger sample of all 236 hospitalized patients without payees who participated in
03765-8716/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 0 2 ) 0 0 0 8 0 - 7
332
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
that survey in order to examine the relationship between substance use, psychopathology and clinician-rated need for money management assistance. Two questions were addressed: 1) Are patients with more severe substance abuse problems more likely to need money management assistance, after controlling for sociodemographic factors and psychopathology? 2) Is there an interaction between substance abuse and psychopathology such that dual-problem patients have a greater need for money management assistance than if the effects of the two problems were additive?
The independent variables for substance use were alcohol and drug composite scores calculated from patient responses to the drug and alcohol modules of the Addiction Severity Index (ASI), Version 5 (McClellan et al., 1992), using standard formulas (Alterman et al., 1984). To create a measure of overall substance abuse, alcohol and drug subscale scores were standardized (z -score transformation) and added together. Two independent variables reflecting psychopathology were used. One was whether or not the inpatient clinician diagnosed the patient with a severe mental illness (Schizophrenia, Bipolar, or Psychosis-NOS). The second was the number of psychiatric symptoms (from the checklist in the ASI mental health module) that the patient reported having experienced during the 30 days prior to admission.
2. Methods
3. Data analysis
The sampling procedure, survey methods and measures have been previously described (Rosen et al., in press) and are briefly summarized here. A sequential sample of 570 veterans hospitalized on inpatient psychiatry services at four VA Medical Centers was invited to answer a questionnaire focusing on how they managed their money. VA hospitals serve veterans of US military service. Participating patients provided written informed consent and all study procedures were approved at each institution’s Institutional Review Board. The patient questionnaires solicited information about the patients’ sociodemographic characteristics, substance abuse and psychiatric status. The treating inpatient clinicians were also asked to complete a brief questionnaire. Altogether, 55 different clinicians answered questions about the 236 patients in the sample. The surveyed clinician for each patient was the one identified by the treatment team as best able to answer questions about the patients’ ability to manage his or her funds. Clinicians rated statements about patients’ money management using a 4-point Likerttype scale (anchored by 1-strongly disagree to 4-strongly agree). Using four items we created a composite measure of the need for money management assistance. Crohnbach’s Alpha for the composite measure was 0.86 reflecting the high inter-correlation of the four items from which the scale was derived. The items reflected the mean of clinicians’ ratings of whether (a) the patient’s funds were already managed appropriately, (b) a money manager would have prevented this hospitalization, (c) someone to advise the patient about spending would be helpful and (d) someone who would receive and control the patients’ funds would be helpful. A second measure of need for assistance was dichotomous: whether or not the treating clinician strongly believed that an involuntary payee should be assigned.
The relationship between substance use and need for money management assistance was evaluated through three multiple regression analyses that adjusted for psychopathology and sociodemographic variables. The first analysis included the four independent variables listed above. The second included an interaction term computed by multiplying the summed alcohol and drug composite scores by variables representing the presence of severe mental illness. The third model included an interaction term computed by multiplying the summed composite substance abuse scores and the number of psychiatric symptoms endorsed. A separate logistic regression analysis was conducted to determine variables associated with needing a payee.
4. Results 4.1. The sample Of the 570 sequential psychiatric inpatients identified, 290 had completed patient and clinician questionnaires. Of these patients, 54 already had an assigned payee and were, therefore, not relevant to the analysis of need for a payee. Thus, the remaining 236 were included in this analysis. In order to detect selection biases, patients completing the surveys were compared with those who did not and for whom only clinician surveys were available. The vast majority of sociodemographic and clinical measures were not significantly different. Patients completing the survey differed from non-completers only in being older by a mean of 1.8 years, more likely to have been diagnosed with a personality disorder (19 vs. 12%) and more likely to have received public support payments (57 vs. 48%). As expected in VA medical centers, 95%
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
were male, mean age was 49 and 55% received either social security or veterans benefits. Most patients, 71%, were diagnosed by their clinicians with a DSM substance abuse diagnosis (61% alcohol, 22% cocaine, 13% opioids, 10% cannabis), and many patients had a severe mental illness (19% schizophrenia, 12% bipolar, 3% psychosis-NOS). 4.2. Relationship of predictors to need for money management assistance The ordinary least squares regression indicated that the full model accounted for a significant proportion of the variance in need for money management assistance (r2 /0.22; F(12, 212) /4.9; P B/001). The significant positive, albeit modest, relationships between need for assistance and both drug and alcohol problem severity are shown in Table 1. There was no relationship between need for assistance and either measure of psychiatric severity. Being married was associated with less need for money management assistance, and there were significant differences by site of hospitalization. The same set of covariates was used in two regression analyses examining the relationship between need for money management assistance and the interaction between substance use and psychopathology. In the first analysis, substance use severity significantly increased the risk of needing money management assistance among patients with severe mental illness. In the second analysis, which considered psychiatric symptoms instead of presence of severe mental illness in the interaction term, the interaction between number of psychiatric symptoms and substance use severity was not significantly associated with need for money management assistance. Table 1 Multivariate analysis of inpatients’ need for money management assistance showing effects of sociodemographic, substance use and psychiatric characteristics (N 236) Characteristic
Age (10 year increments) Caucasian Male Married Public support recipient Alcohol problem severity (ASI Composite Score) Drug problem severity (ASI Composite Score) Number of psychiatric symptoms Axis 1 Schiz, Bipolar or Psychosis NOS Interaction of ASI substance abuse measures and major axis I diagnosis Interaction of ASI substance abuse measures and number of psychiatric symptoms *P B 0.05. **P B 0.01. ***P B 0.001.
Standard b
333
4.3. Relationship of predictors to whether clinician would assign a payee Table 2 presents the logistic regression analysis of clinician-judged need for involuntary payee assignment. Only drug use severity was significantly associated with need for a payee. The 27 patients to whom clinicians would assign a payee were 11% of the total sample. Of the 27, 21 (78%) had a substance abuse diagnosis.
5. Discussion These data describe a notable unmet need for money management assistance among psychiatric inpatients, particularly among those with substance use disorders. These findings have two important implications. First, there is a need to examine the payee assignment process to determine whether patients with comorbid substance abuse are not being assigned a payee in spite of their discernible need for one. Second, interventions designed to improve quality of life through money management, including payee assignment, need to be developed and tested and must specifically address the substance abuse comorbidities occurring among psychiatric patients. Several limitations require comment. The generalizability of these findings is limited because the sample was primarily male veterans. It is also possible that a sample that included outpatients and a procedure that used more sensitive measures of psychopathology would have demonstrated a significant relationship between psychopathology and the need for money management assistance. Another limitation is that the response rate Table 2 Logistic regression analysis of whether clinican would assign a payee showing effects of sociodemographic, substance use and psychiatric characteristics (N 236) Characteristic
Exp (B)
95% Confidence interval
Age (10 year increments) Caucasian Male Married Public support recipient Alcohol problem severity (ASI Composite Score) Drug problem severity (ASI Composite Score) Number of psychiatric symptoms Axis 1 Schiz, bipolar or psychosis NOS Interaction of ASI substance abuse measures and major axis I diagnosis Interaction of ASI substance abuse measures and number of psychiatric symptoms
0.91 2 2 1.2 1.3 1.6
0.94 /1.04 0.8 /9.4 0.2 /21 0.3 /5.0 0.4 /3.7 0.9 /2.8
1.7*
1.0 /2.9
0.6 2.8 5.7
0.4 /1.1 1.0 /8.3 0.3 /1.2
0.8
0.2 /2.6
t -test
0.09 0.05 0.02 0.21 0.13 0.21
1.2 0.7 0.3 3.3*** 1.8 2.9**
0.17 0.02 0.05 0.28
2.4* 0.32 0.7 3.5***
0.10
1
*P B 0.05.
334
M.I. Rosen et al. / Drug and Alcohol Dependence 67 (2002) 331 /334
was low, although our analyses revealed only minor differences between patients who completed the surveys and those who did not. These findings support the assertion that substance abuse contributes to funds being misspent; that this effect is especially pronounced in patients with severe psychopathology; and that a substantial population of patients need money management interventions that specifically address problems related to substance use.
Acknowledgements This project was a multi-site collaboration among the following: VA Connecticut Healthcare System, Susan Harman; Bedford VA Medical Center, Charles Drebing and Alice Van Ormer; Northampton VA Medical Center, Christopher Cryan and Lynn Gordon; Veterans Affairs Medical Center, West Los Angeles. This project was supported in part by the Department of Veterans Affairs VISN 1 and VISN 22 Mental Illness Research Education and Clinical Care Center, Northeast Program Evaluation Center, R01-DA12952 (MIR) and P50DA09241.
References Alterman, A.I., Brown, L., Zabahero, L. 1984. The interviewer severity ratings of the ASI: a further look. Drug Alcohol Depend. 34, 201 / 209. Luchins, D.J., Hanrahan, P., Conrad, K.J., Savage, C., Matters, M.D., Shinderman, M. 1998. An agency-based representative payee program and improved community tenure of persons with mental illness. Psychiatr. Serv. 49 (9), 1218 /1222. McClellan, A.T., Kushner, H., Metzger, D., Peters, R., Smith, L., Grissom, G., Pettinati, H., Argerious, M. 1992. The fifth edition of the addiction severity index. J. Subst. Abuse Treat. 9, 199 / 213. Ries, R.K., Dyck, D.G. 1997. Representative payee practices of community mental health centers in Washington State. Psychiatr. Serv. 48, 811 /814. Rosen, M.I., Rosenheck, R.A. 1999. Substance abuse and the assignment of representative payees. Psychiatr. Serv. 50, 95 /98. Rosen, M.I., Rosenheck, R.A., Shaner, A., Eckman, T., Gamache, G., Krebs, C., 2002. Veterans potentially in need of a payee to prevent misuse of funds for drugs, Psychiatr. Serv., in press. Satel, S. 1995. When disability benefits make patients sicker. New Engl. J. Med. 33 (9), 794 /796. Shaner, A., Eckman, T.A., Roberts, L.J., Wilkins, J.N., Tucker, D.E., Tsuang, J., Mintz, J. 1995. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers: A government sponsored revolving door? New Engl. J. Med. 333, 777 /783.