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 Medicaidfinanced 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 longacting 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 longacting 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.