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					Treatment Patterns for Schizoaffective
Disorder and Schizophrenia
Among Medicaid Patients
Mark Olfson, M.D., M.P.H.
Steven C. Marcus, Ph.D.
George J. Wan, Ph.D., M.P.H.




                                                                                           N
Objective: This study compared background characteristics, pharmaco-                                  osologic uncertainty surrounds
logic treatment, and service use of adults treated for schizoaffective dis-                           the diagnosis of schizoaffective
order and adults treated for schizophrenia. Methods: Medicaid claims                                  disorder. Problems have been
data from two states were analyzed with a focus on adults treated for                       reported with its interrater reliability
schizoaffective disorder or schizophrenia. Patient groups were com-                         (1,2) and diagnostic stability (3). Fur-
pared regarding demographic characteristics, pharmacologic treat-                           ther adding to the uncertainty, schiz-
ment, and health service use during 180 days before and after a claim                       ophrenia and bipolar disorder share
for either schizophrenia or schizoaffective disorder. Results: A larger                     with schizoaffective disorder specific
proportion of patients were treated for schizophrenia (N=38,760;                            clinical symptoms (4), structural brain
70.1%) than for schizoaffective disorder (N=16,570; 29.9%). During the                      abnormalities (5,6), and family histo-
180 days before the index diagnosis claim, significantly more patients                      ry (7). Some researchers have even
with schizoaffective disorder than those with schizophrenia were treat-                     urged abolishing schizoaffective dis-
ed for depressive disorder (19.6% versus 11.4%, p<.001), bipolar disor-                     order as a diagnostic classification (8).
der (14.8% versus 5.8%, p<.001), substance use disorder (11.8% versus                       In view of these concerns, we sought
9.7%, p<.001), and anxiety disorder (6.9% versus 5.3%, p<.001). After                       to compare the treatment patterns of
the index claim, a similar proportion of both diagnostic groups were                        patients diagnosed as having schizoaf-
treated with antipsychotic medications (schizoaffective disorder, 87.3%;                    fective disorder with those of patients
schizophrenia, 87.0%), although patients with schizoaffective disorder                      diagnosed as having schizophrenia to
were significantly more likely than patients with schizophrenia to re-                      assess the extent to which these two
ceive antidepressants (61.7% versus 44.0%, p<.001), mood stabilizers                        patient groups receive different pat-
(55.2% versus 34.4%, p<.001), and anxiolytics (43.2% versus 35.1%,                          terns of care.
p<.001). Patients with schizoaffective disorder were also significantly                        Schizoaffective disorder, although
more likely than patients with schizophrenia to receive psychotherapy                       relatively rare in the general popula-
(23.4% versus 13.0%, p<.001) and inpatient mental health care (9.4%                         tion, is prevalent in mental health
versus 6.2%, p<.001), although the latter was not significant after the                     treatment settings (9). In the general
analysis controlled for background characteristics. Conclusions:                            population, schizoaffective disorder is
Schizoaffective disorder is commonly diagnosed among Medicaid bene-                         roughly one-third (10) to one-sixth
ficiaries. These patients often receive complex pharmacologic regi-                         (11) as common as schizophrenia.
mens, and many also receive treatment for mood disorders. Differences                       Among heavy users of mental health
in service use patterns between schizoaffective disorder and schizo-                        services, however, the percentage of
phrenia argue for separate consideration of their health care needs.                        patients diagnosed as having schizoaf-
(Psychiatric Services 60:210–216, 2009)                                                     fective disorder (24%) approaches
                                                                                            that of schizophrenia (32%) (12).
                                                                                            Within U.S. community hospitals,
                                                                                            more patients are discharged with a
                                                                                            diagnosis of schizoaffective disorder
                                                                                            than schizophrenia (13).
Dr. Olfson is affiliated with the Department of Psychiatry, Columbia University, New           Schizoaffective disorder is a het-
York State Psychiatric Institute, 1051 Riverside Dr., New York, NY 10032 (e-mail:           erogeneous clinical condition that en-
mo49@columbia.edu). Dr. Marcus is with the University of Pennsylvania School of Social      compasses psychotic, depressive, and
Policy and Practice, Philadelphia. Dr. Wan is with Ortho-McNeil Janssen Scientific Af-      manic symptoms. Despite its clinical
fairs, LLC, Titusville, New Jersey.                                                         severity and common occurrence in
210                                                    PSYCHIATRIC SERVICES   ' ps.psychiatryonline.org ' February 2009 Vol. 60 No. 2
clinical practice, the pharmacologic           Methods                                     month period and to end six months
treatment of schizoaffective disorder          Participant selection                       after the first of these claims. A sepa-
has received far less attention than           Enrollment, service claims, and phar-       rate variable, episode status, parti-
that of schizophrenia or the major             macy data files from two state Medic-       tioned patients into new or continuing
mood disorders (14). As a result, few          aid programs (2002–2005) served as          cases by the presence of one or more
well-defined clinical principles exist         the data sources. In 2005 the total         claims for the same disorder (schizoaf-
to guide the treatment of schizoaffec-         combined Medicaid enrollment of the         fective disorder or schizophrenia) dur-
tive disorder.                                 two states was approximately 9.0 mil-       ing the six-month period before the
   Little is also known about the phar-        lion. Two study groups were created:        start of the treatment episode.
macologic management that patients             one with service claims for the treat-         Among 77,849 patients who met
with schizoaffective disorder actually         ment of schizoaffective disorder but        the diagnostic criteria, 12,555 (16.1%)
receive in community practice. Some            not schizophrenia and one with claims       were excluded because they were not
evidence suggests that complex phar-           for the treatment of schizophrenia but      eligible for Medicaid for six consecu-
macologic regimens are common. In              not schizoaffective disorder.               tive months before and after the in-
one sample of consecutive inpatients              Patients treated for schizoaffective     dex claim, 2,694 (3.5%) were exclud-
treated for schizoaffective disorder           disorder or schizophrenia were select-      ed because they had been admitted
(N=70), 90% of patients received an-           ed in several stages. Each selected pa-     for at least 30 inpatient days during
tipsychotic medications and 79% re-            tient had at least two claims with a pri-   the six-month prestudy period, 7,011
ceived either mood stabilizers or anti-        mary diagnosis for either schizoaffec-      (9.0%) were excluded because they
depressant medications during their            tive disorder or schizophrenia during       were 65 years or older on the index
inpatient stay (15). Comparable data           a six-month study period and no             date, and 2,685 (3.4%) were excluded
for outpatients are not available at           claims with primary diagnoses for the       because they were younger than 18
present.                                       other disorder during a preceding six-      years on the index date. (Some per-
   Clinical characteristics of patient         month prestudy period. First, patients      sons were excluded for more than one
samples with schizoaffective disorder          were selected if they had service           reason.) This project was approved by
vary with the treatment setting (16).          claims with a primary diagnosis of ei-      the institutional review board of the
In one long-term study of inpatients           ther schizoaffective disorder (ICD-9-       New York State Psychiatric Institute.
with persistent illness, for example,          CM code indicating DSM-IV diagno-
the outcomes of patients with                  sis: 295.7) or schizophrenia (295.1–        Demographic and
schizoaffective disorder closely paral-        295.3, 295.6, 295.9) and at least six       clinical characteristics
leled those of patients with schizo-           months of Medicaid eligibility before       Patients were characterized with re-
phrenia (17). In another study of pa-          and after this index claim. Second, pa-     spect to demographic variables, in-
tients treated within a lithium clinic,        tients were selected if they had at least   cluding age, sex, and race or ethnicity
there were few clinical differences            one additional service claim with a         (white, African American, Hispanic,
between patients with schizoaffective          primary schizophrenia or schizoaffec-       and other). The two study groups
disorder and those with bipolar disor-         tive disorder diagnosis during their        were also characterized with respect
der (18). One means of reducing sam-           six-month study period. Third, pa-          to clinical, psychotropic medication,
pling bias related to treatment setting        tients were excluded if they had at         and service use variables.
and deriving a more representative             least one primary diagnosis service            On the basis of one or more service
characterization of schizoaffective            claim for the other disorder (schizo-       claims during the study period, patients
disorder is through the assessment of          phrenia or schizoaffective disorder)        were also dichotomously classified with
patients within large and diverse sys-         during the six-month study period or        respect to treatment of substance use
tems of care.                                  the six-month prestudy period.              disorder (ICD-9-CM: 291, 292, and
   The study presented here com-               Fourth, because service and prescrip-       303–305), anxiety disorder (300.0,
pared the demographic, pharmaco-               tion claims are not available during in-    300.2, 300.3, and 308.3), depressive dis-
logic, cotreated diagnostic, and serv-         patient treatment episodes, patients        order (296.2, 296.3, 300.4, and 311),
ice use characteristics of patients            were excluded if they had been admit-       bipolar disorder (296.0, 296.1, 296.4–
from Medicaid programs in two states           ted for inpatient treatment for at least    296.9, and 301.13), and other mental
who were treated for schizoaffective           30 inpatient days during the six-           disorders (290–319, except as noted
disorder or schizophrenia. We esti-            month prestudy period. Finally, pa-         above). (Service claims could be listed
mated the relative treated prevalence          tients who were younger than 18 years       in any position on the claim—that is, as
of schizoaffective disorder and schiz-         or older than 64 years were excluded.       a first-listed diagnosis, as a second-list-
ophrenia in two statewide Medicaid                Previous research indicates that pa-     ed diagnosis, etc.) These groups were
populations and characterized servic-          tients with two outpatient claims for       not mutually exclusive.
es received by each diagnostic group.          schizophrenia are likely to have schiz-        Pharmacy claims during the study
Substantial differences in treatment           ophrenia (19). The treatment episode        period were used to classify patients di-
patterns might help to illuminate the          of each patient was defined to start on     chotomously with respect to antipsy-
distinctive service needs of patients          the date of the first of at least two       chotic medication, antidepressant, anx-
treated for either schizoaffective dis-        schizoaffective disorder or schizophre-     iolytic, and mood stabilizer treatment.
order or schizophrenia.                        nia diagnosis claims to occur in a six-     Mood stabilizers included lithium
PSYCHIATRIC SERVICES   ' ps.psychiatryonline.org ' February 2009 Vol. 60 No. 2                                                    211
preparations and antiepileptic medica-      the study diagnostic group as inde-            fective disorder and schizophrenia re-
tions prescribed in the absence of          pendent variables. The binary out-             ceived antipsychotic medications
claims for a seizure disorder (ICD-9-       comes included inpatient admission,            (Table 2). The proportion in each di-
CM code 345). Among patients who            psychiatric emergency department               agnostic group that was treated with
were given a prescription for each of       visit, psychotherapy use, and several          antipsychotic medications did not sig-
these medication classes, the mean          pharmacotherapy treatments. The                nificantly differ in the bivariate or
medication possession ratio (MPR) was       continuous outcomes included num-              multivariate analysis (Table 2).
determined during the study period.         ber of mental health and general               Roughly one-half of patients treated
MPR was defined as the number of            medical visits, as well as number of           for schizoaffective disorder with an-
days of medication dispensed as a per-      treated general medical disorders              tipsychotic medications also filled
centage of the 180-day study period         within the Charlson Comorbidity In-            prescriptions for antidepressants, and
(20). Among patients given a prescrip-      dex during the study period.                   roughly one-half also received mood
tion for antipsychotic medications, a di-      We considered group differences             stabilizers during the study period.
chotomous variable, antipsychotic           with a two-tailed alpha <.01 to be statis-     Compared with treatment for schizo-
MPR ≥.70 during the study period,           tically significant and those with a risk      phrenia, treatment for schizoaffective
was defined to represent at least mod-      ratio of >1.10 or <.90 to be potentially       disorder was significantly more
erate antipsychotic adherence (21).         substantial from a policy perspective.         strongly associated with antidepres-
   Three dichotomous mental health                                                         sant, mood stabilizer, and anxiolytic
service use variables during the study      Results                                        treatment in the bivariate and multi-
period were constructed to signify,         Demographic and                                variate analyses (Table 2). Even
respectively, hospital admissions and       clinical characteristics                       among patients without a bipolar di-
emergency department visits with            Approximately 29.9% (N=16,570) of              agnosis in the prestudy period, pa-
primary mental disorders (ICD-9-            the study sample received treatment            tients treated for schizoaffective dis-
CM: 290–319) and psychotherapy              for schizoaffective disorder, and the          order (N=7,316 of 14,112, or 51.8%)
visits (Current Procedural Terminol-        remaining 70.1% (N=38,760) re-                 were significantly more likely than
ogy codes: 90804–90829, 90841–              ceived treatment for schizophrenia.            those treated for schizophrenia
90847, 90849, 90853, 90855, 90857,          Compared with patients with schizo-            N=11,869 of 36,511, or 32.5%) to re-
90875, and 90876). In addition, con-        phrenia, patients with schizoaffective         ceive a mood stabilizer (χ2=1,616.6,
tinuous variables were defined to           disorder had a significantly younger           df=1, p<.001). Similarly, among pa-
measure the total number of visits for      mean age, were more likely to be fe-           tients not treated for a depressive dis-
a primary mental disorder and pri-          male, and were more likely to be               order during the prestudy period, pa-
mary general medical disorder (all          white, Hispanic, or of other non–Afri-         tients with schizoaffective disorder
other codes) during each study peri-        can-American race or ethnicity (Table          (N=7,684 of 13,327, or 57.7%) were
od. A comorbidity count was defined         1). In bivariate analyses, patients            also more likely than those with schiz-
as the number of general medical dis-       treated for schizoaffective disorder           ophrenia (N=14,136 of 34,346, or
orders within the Charlson Comor-           were also significantly more likely            41.2%) to receive an antidepressant
bidity Index (22) for which patients        than their counterparts with schizo-           (χ2=1,053.1, df=1, p<.001) (data not
received treatment during the study         phrenia to receive cotreatment of a            shown).
period (theoretical range of 0 to 17,       substance use disorder, anxiety disor-            Among patients treated with an-
with higher scores denoting greater         der, depressive disorder, bipolar dis-         tipsychotic medications, a similar pro-
medical comorbidity) (23).                  order, and other mental disorder dur-          portion of patients treated for schizo-
                                            ing the prestudy period, although the          affective disorder and schizophrenia
Analytic strategy                           risk ratio for other mental disorders          had an antipsychotic MPR of at least
The two study groups were compared          was not substantial (Table 1). During          .70 (Table 2).
with respect to demographic, clinical,      this period, compared with patients
pharmacologic treatment, and service        with schizophrenia, patients with              Mental health service use
use characteristics in chi square analy-    schizoaffective disorder were also sig-        Patients treated for schizoaffective
ses to measure the strength of associa-     nificantly more likely to be treated           disorder were significantly more like-
tions between each categorical inde-        with mood stabilizers, antidepres-             ly than those treated for schizophre-
pendent variable and with t tests for       sants, and anxiolytics. For both diag-         nia to receive psychotherapy or to
continuous independent variables. Un-       nostic groups, most treatment                  have an inpatient psychiatric admis-
adjusted risk ratios are also presented.    episodes were new, although patients           sion (Table 2). Although the associa-
   The PROC GENMOD in SAS ver-              with schizophrenia were proportion-            tion between schizoaffective disorder
sion 9.13 was used to conduct a series      ately more likely than those with              and psychotherapy remained signifi-
of log linear regression models (bina-      schizoaffective disorder to have new           cant after adjustment for background
ry outcomes) and Poisson regression         treatment episodes.                            characteristics, the association with
models (continuous count data) with                                                        psychiatric admission reversed after
the demographic, clinical, pharmaco-        Psychotropic medication use                    adjustment for the background char-
logic treatment, and service use char-      During the study period, a great ma-           acteristics (Table 2). In the model of
acteristics; episode status; state; and     jority of patients treated for schizoaf-       inpatient psychiatric admission, sev-
212                                                   PSYCHIATRIC SERVICES   ' ps.psychiatryonline.org ' February 2009 Vol. 60 No. 2
Table 1
Background characteristics of adults treated for schizophrenia or for schizoaffective disorder in two state Medicaid programsa

                                            Schizoaffective               Schizophrenia
                                            disorder (N=16,570)           (N=38,760)
                                                                                                         Relative     Test
Characteristic                              N               %             N                %             risk         stastic           df       p

Age                                                                                                                   χ2=49.2           2        <.001
  18–35                                     4,411           26.6           9,560            24.7         1.08                                    <.001
  36-50                                     7,976           48.1          18,382            47.4         1.02                                     .126
  51-64                                     4,183           25.2          10,818            27.9          .90                                    <.001
Gender                                                                                                                χ2=1,472.3        1        <.001
  Male                                      7,711           46.7          24,836            64.2          .73
  Female                                    8,806           53.3          13,832            35.8         1.49
Race or ethnicity                                                                                                     χ2=438.7          3        <.001
  White                                     8,031           49.5          16,430            43.1         1.14                                    <.001
  African American                          3,071           18.9           8,821            23.1          .81                                    <.001
  Hispanic                                  1,988           12.3           3,517             9.2         1.32                                    <.001
  Other                                     3,119           19.2           9,352            24.5          .78
Other treated mental disorderb
  Substance use                             1,947           11.8            3,747            9.7         1.22         χ2=54.6           1        <.001
  Anxiety                                   1,149            6.9            2,043            5.3         1.32         χ2=59.1           1        <.001
  Depressive                                3,243           19.6            4,414           11.4         1.72         χ2=651.9          1        <.001
  Bipolar                                   2,458           14.8            2,249            5.8         2.56         χ2=1216.5         1        <.001
  Other                                     4,180           25.2            9,178           23.7         1.07         χ2=15.2           1        <.001
Psychotropic useb
  Antipsychotic                             9,834           59.3          23,085            59.6         1.00         χ2=.2             1         .644
  Mood stabilizer                           6,146           37.1           8,644            22.3         1.66         χ2=1,296.4        1        <.001
  Antidepressant                            6,469           39.0          10,634            27.4         1.42         χ2=732.0          1        <.001
  Anxiolytic                                3,853           23.3           7,309            18.9         1.23         χ2=139.3          1        <.001
Episode status                                                                                                        χ2=58.5           1        <.001
  New                                      11,663           70.4          28,509            73.6          .96
  Continuing                                4,907           29.6          10,251            26.4         1.12
Age (mean±SD years)                         42.5±11.1                     43.2±11.1                                   t=7.4       55,328         <.001
a   Data are from Medicaid claims. Because of missing data, total sample sizes for the gender variable are 16,517 for schizoaffective disorder and 38,668
    for schizophrenia. For the race or ethnicity variable, total sample sizes are 16,209 for schizoaffective disorder and 38,120 for schizophrenia.
b   Treated disorders and psychotropic medication use during the six-month period before the index claim for schizoaffective disorder or schizophrenia



eral covariates were significantly re-                any of the major medical disorders in               had a significantly lower mean number
lated to hospital admission and had                   the Charlson Comorbidity Index. In                  of general medical visits than did pa-
adjusted risk ratios greater than 1.40,               both groups, the most commonly                      tients treated for schizophrenia, al-
including bipolar disorder, other                     treated major medical disorders were                though a significant group difference
mental disorders, state, and episode                  chronic pulmonary disease (N=2,116,                 was no longer evident after adjustment
status (data not shown). Patients                     or 12.8%, for patients with schizoaf-               for background patient characteristics
treated for schizophrenia were signif-                fective disorder and N=5,095, or                    (Table 2).
icantly more likely than those treated                13.1%, for patients with schizophre-
for schizoaffective disorder to receive               nia). This was followed by diabetes                 Discussion
mental health emergency department                    mellitus without chronic complica-                  Consistent with the results of clinical
visits in the bivariate and multivariate              tions (N=1,752, or 10.6%, and N=                    trials (24), our study findings showed
analyses.                                             3,512, or 9.1%) (p<.001). Diabetes mel-             that most outpatients with schizoaf-
   Compared with patients treated for                 litus with chronic complications was                fective disorder or schizophrenia re-
schizophrenia, those treated for                      also significantly more commonly                    ceived antipsychotic medications. In
schizoaffective disorder received a                   treated among patients treated for                  accord with a previous small inpa-
slightly larger mean number of men-                   schizoaffective disorder (N=168, or                 tient study (15), most of the patients
tal health visits during the study peri-              1.0%) than for schizophrenia (N=274,                with schizoaffective disorder also re-
od (Tables 2).                                        or .7%) (p<.001). The mean medical                  ceived either mood stabilizers or an-
                                                      comorbidity count did not significant-              tidepressant medications, although
General medical service use                           ly differ between patients diagnosed as             often in the absence of a mood disor-
A majority of patients treated for ei-                having schizoaffective disorder or                  der diagnosis.
ther schizoaffective disorder (N=                     those diagnosed as having schizophre-                  There is a paucity of clinical trial
12,308, or 74.3%) or schizophrenia                    nia in either the bivariate or multivari-           data to guide the pharmacologic man-
(N=28,999, or 74.8%) did not receive                  ate analysis (Table 2). Patients treated            agement of schizoaffective disorder.
treatment during the study period for                 for schizoaffective disorder, however,              One review discouraged routine use
PSYCHIATRIC SERVICES      ' ps.psychiatryonline.org ' February 2009 Vol. 60 No. 2                                                                    213
Table 2
Mental health treatment characteristics of adults in two state Medicaid programs during the six months after an index claim
for schizoaffective disorder or schizophreniaa

                                                 Schizoaffective
                                                 disorder              Schizophrenia          Unadjusted                      Adjusted
                                                 (N=16,570)            (N=38,760)             models estimate                 models estimateb

Treatment                                        N           %         N             %        Estimate        99% CI          Estimate         99% CI

Mental health service
  Psychotherapy                                   3,871      23.4        5,047      13.0      RR=1.80         1.70–1.90       RR=1.70          1.61–1.80
  Emergency visit                                   953       5.8        3,159       8.2      RR=.70           .64–.77        RR=.58            .52–.64
  Inpatient care                                  1,554       9.4        2,384       6.2      RR=1.53         1.41–1.67       RR=.90            .82–.99
Psychotropic use
  Antipsychotic                                 14,467       87.3       33,705      87.0     RR=1.00           .98–1.03       RR=1.02           .99–1.04
  Antipsychotic and antidepressant               9,307       56.2       15,730      40.6     RR=1.38          1.34–1.43       RR=1.33          1.29–1.38
  Antipsychotic and mood stabilizer              8,556       51.6       12,569      32.4     RR=1.59          1.53–1.65       RR=1.61          1.55–1.67
  Mood stabilizer                                9,142       55.2       13,350      34.4     RR=1.60          1.54–1.65       RR=1.59          1.53–1.65
  Mood stabilizer and antidepressant             5,594       33.8        6,724      17.3     RR=1.94          1.85–2.04       RR=1.84          1.75–1.94
  Antidepressant                                10,216       61.7       17,043      44.0     RR=1.40          1.36–1.45       RR=1.33          1.28–1.38
  Anxiolytic                                     7,162       43.2       13,612      35.1     RR=1.23          1.18–1.28       RR=1.18          1.13–1.23
MPR ≥.70c for antipsychotics                     8,557       59.2       21,491      63.8     RR=.97            .94–1.00       RR=1.00           .97–1.03
Outpatient visit (M±SD)
  Mental health                                  16.3±26.0             15.8±25.2             Exp (β)=1.03 1.01–1.06           Exp (β)=1.05 1.02–1.08
  General medical                                21.5±36.7             25.7±44.0             Exp (β)=.84 .81–.87              Exp (β)=1.03 .99–1.06
Comorbidity count (M±SD)                         .35±.71               .34±.34               Exp(β)=1.05 1.00–1.10            Exp (β)=99    .94–1.04
a   Data are from Medicaid claims. Schizophrenia is the reference group for all regressions. Results with binary dependent variables are from log linear
    models risk ratios (RR), and those with continuous count dependent variables are from Poisson regression models Exp (β).
b   The adjusted models control for patient age, gender, race or ethnicity, state, comorbidity count, episode status, and treatment of substance use disor-
    ders, anxiety disorders, depressive disorders, bipolar disorders, and other mental disorders during the preindex claim period.
c   MPR=medication possession ratio. The MPR analysis is limited to patients prescribed antipsychotic medication.



of adjunctive antidepressants or                      important sources of morbidity in                    ceive inpatient psychiatric treatment.
mood stabilizers among patients with                  schizophrenia (31). The study pre-                      Patients with schizoaffective disor-
schizoaffective disorder without full                 sented here suggests that widespread                 der were significantly more likely
major depressive or manic episodes,                   problems with antipsychotic medica-                  than patients with schizophrenia to
respectively (25). Because several                    tion adherence also exist for schizoaf-              receive psychotherapy. Clinical trials
second-generation antipsychotic med-                  fective disorder. Among patients re-                 with mixed populations of patients
ications are effective as monotherapy                 ceiving antipsychotic medications,                   with schizophrenia and those with
for manic and depressive symptoms                     those with schizoaffective disorder                  schizoaffective disorder have demon-
in bipolar mania (26–29), the mood-                   were as likely as those with schizo-                 strated that a variety of intensive psy-
stabilizing properties of these med-                  phrenia to have antipsychotic MPRs                   chotherapies and psychosocial inter-
ications may be helpful in schizoaf-                  below levels associated with in-                     ventions significantly improve symp-
fective disorder. The unadjusted find-                creased risks of psychiatric hospital-               tom, social, and vocational outcomes
ings presented here suggest that com-                 ization (20,32) and increased mental                 (35–37). The extent to which commu-
pared with outpatients with schizo-                   health care costs (33).                              nity-based psychotherapies for pa-
phrenia, those with schizoaffective                      Patients treated for schizoaffective              tients with psychotic disorders incor-
disorder who are treated with an-                     disorder and those treated for schizo-               porate evidence-based techniques re-
tipsychotic medications are approxi-                  phrenia place different demands on                   mains largely unknown (38,39).
mately 38% more likely to receive an-                 the health care system. In keeping                      Consistent with community epi-
tidepressants and 60% more likely to                  with previous research (34), our study               demiological studies (10,11), our
receive mood stabilizers. At a mental                 found that outpatients treated for                   study found that most patients treat-
health care system level, medication                  schizoaffective disorder were signifi-               ed for schizoaffective disorder were
management differences of this mag-                   cantly more likely than outpatients                  female. In community and clinical
nitude may have significant financial                 treated for schizophrenia to be admit-               samples, females account for a major-
implications and may come under in-                   ted for inpatient psychiatric care.                  ity of patients with bipolar disorder
creasingly close scrutiny from payers                 However, after the analysis controlled               (40,41) and major depression (42,43).
given continuing overall growth in                    for the higher level of cotreated disor-             The affective dimension of schizoaf-
spending on psychotropic medica-                      ders and other covariates, patients                  fective disorder may contribute to its
tions (30).                                           treated for schizoaffective disorder                 observed gender distribution. De-
   Antipsychotic medication nonad-                    were significantly less likely than their            spite this gender distribution, pa-
herence and partial adherence are                     counterparts with schizophrenia to re-               tients with schizoaffective disorder
214                                                                 PSYCHIATRIC SERVICES   ' ps.psychiatryonline.org ' February 2009 Vol. 60 No. 2
were more likely than those with               present with a combination of psy-        schizoaffective disorder may benefit
schizophrenia to receive treatment             chotic and mood symptoms (5), and         from programs aimed at improving
for a substance use disorder (44).             questions persist concerning the wis-     medication adherence in community
   An important strength of the study          dom of distinguishing schizoaffective     settings (52).
presented here is that it is based on          disorder from schizophrenia. Com-
large, ethnically and geographically           pared with patients treated for schiz-    Acknowledgments and disclosures
diverse clinical populations. The              ophrenia, patients treated for            This research was supported by Ortho-McNeil
study also has several limitations. Per-       schizoaffective disorder place distinc-   Janssen Scientific Affairs.
haps most important, the diagnostic            tive stresses on the health care sys-     Dr. Olfson has received research support from
classifications are based entirely on          tem. Specifically, compared with pa-      Bristol-Myers Squibb, Eli Lilly and Company,
clinical diagnoses that are not subject        tients with schizophrenia, those with     AstraZeneca, and Ortho-McNeil Janssen Sci-
                                                                                         entific Affairs, LLC. Dr. Olfson has also
to expert diagnostic validation. Prob-         schizoaffective disorder utilize a        worked as a consultant for Pfizer, Janssen, Bris-
lems with the diagnostic consistency           broader range of classes of psy-          tol-Myers Squibb, and Eli Lilly and Company.
of schizoaffective disorder are well           chotropic medications and are more        Dr. Marcus has received research support from
                                                                                         Bristol-Myers Squibb, Eli Lilly and Company,
known (1,3). The results portray serv-         likely to receive psychotherapy and
                                                                                         AstraZeneca, and Ortho-McNeil Janssen Sci-
ice use among patients treated for             inpatient psychiatric care, although      entific Affairs, LLC. Dr. Wan is an employee of
schizoaffective disorder and those             they are less likely to use emergency     Ortho-McNeil Janssen Scientific Affairs, LLC.
treated for schizophrenia rather than          psychiatric services. These distinctive
among patients who meet DSM-IV-                health care service patterns may re-      References
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