Sustained outcomes of a peer-taught family education program on mental illness

OBJECTIVE

This study examines 6-month follow-up data from participants in a randomized trial of a peer-driven 12-session family support and education program, called family-to-family (FTF) and offered by the US National Alliance on Mental Illness, to determine whether improvements in distress, family functioning, coping and empowerment were sustained.

METHOD

Individuals randomized to the FTF condition were assessed after program completion and then 3 months later on measures of distress, family functioning, coping, and empowerment. We used a multilevel regression model (sas proc mixed) to test for significant changes over time (baseline, 3 and 9 months).

RESULTS

All significant benefits that FTF participants gained between baseline and immediately post-FTF were sustained at 9 months including reduced anxiety, improved family problem-solving, increased positive coping, and increased knowledge. Greater class attendance was associated with larger increases in empowerment and reductions in depression and displeasure with ill relative.

CONCLUSION

Evidence suggests that benefits of the FTF program were sustained for at least 6 months without any additional boosters or supports. Peer-based programs may produce sustained benefits for individuals seeking help in addressing challenges and stresses related to having a family member with a mental illness.

Oral cancer screening and dental care use among women from Ohio Appalachia

INTRODUCTION

Residents of Appalachia may benefit from oral cancer screening given the region's higher oral and pharyngeal cancer mortality rates. The current study examined the oral cancer screening behaviors and recent dental care (since dentists perform most screening examinations) of women from Ohio Appalachia.

METHODS

Women from Ohio Appalachia were surveyed for the Community Awareness Resources Education (CARE) study, which was completed in 2006. A secondary aim of the CARE baseline survey was to examine oral cancer screening and dental care use among women from this region. Outcomes included whether women (n=477; cooperation rate = 71%) had ever had an oral cancer screening examination and when their most recent dental visit had occurred. Various demographic characteristics, health behaviors and psychosocial factors were examined as potential correlates. Analyses used multivariate logistic regression.

RESULTS

Most women identified tobacco-related products as risk factors for oral cancer, but 43% of women did not know an early sign of oral cancer. Only 15% of women reported ever having had an oral cancer screening examination, with approximately 80% of these women indicating that a dentist had performed their most recent examination. Women were less likely to have reported a previous examination if they were from urban areas (OR=0.33, 95% CI: 0.13-0.85) or perceived a lower locus of health control (OR=0.94, 95% CI: 0.89-0.98). Women were more likely to have reported a previous examination if they had had a dental visit within the last year (OR=2.24, 95% CI: 1.03-4.88). Only 65% of women, however, indicated a dental visit within the last year. Women were more likely to have reported a recent dental visit if they were of a high socioeconomic status (OR=2.83, 95% CI: 1.58-5.06), had private health insurance (OR=2.20, 95% CI: 1.21-3.97) or had consumed alcohol in the last month (OR=2.03, 95% CI: 1.20-3.42).

CONCLUSION

Oral cancer screening was not common among women from Ohio Appalachia, with many missed opportunities having occurred at dental visits. Education programs targeting dentists and other healthcare providers (given dental providers are lacking in some areas of Ohio Appalachia) about opportunistic oral cancer screening may help to improve screening in Appalachia. These programs should include information about populations at high risk for oral cancer (eg smokers) and how screening may be especially beneficial for them. Future research is needed to examine the acceptability of such education programs to healthcare providers in the Appalachian region and to explore why screening was less common among women living in urban areas of Ohio Appalachia.

Interferon-alpha-2b induced signal transduction and gene regulation in patient immune cells is not enhanced by a dose increase from 5 MU/m2 to 10 MU/m2

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Background: High dose interferon-alpha-2b (IFN-a) is employed as an adjuvant in melanoma patients who have had surgery for high-risk lesions. It mediates its anti-tumor effects via activation of the transcription factor STAT1 (signal transducer and activator of transcription) within host immune cells. We hypothesized that intermediate doses of IFN-a would be just as effective as higher doses in stimulating the activation of STAT1 and gene transcription in immune cells. Methods: Samples for analysis were obtained from patients with metastatic melanoma who were enrolled in a clinical trial of bevacizumab in combination with escalating doses of IFN-a (5 MU/m^2 and then 10 MU/m^2). Peripheral blood mononuclear cells (PBMCs) were procured before and 1 hour after the administration of IFN-a and analyzed for the presence of phosphorylated STAT1 (P-STAT1) and P-STAT2 by intracellular flow cytometric analysis and the induction of interferon stimulated gene (ISG) transcripts by Real Time PCR. Results: P-STAT1 in response to 5 MU/m^2 IFN-a was higher than that for the 10 MU/m^2 dose (p = 0.0617). The 5 MU/m^2 dose also led to a greater activation of STAT2 (p = 0.0388). The induction of interferon stimulated genes (ISGs; IFIT1, IFIT2, OAS3) within PBMCs was not enhanced following the increase in IFN-a dose to 10 MU/m^2 at 2 weeks although inhibitors of IFN-a-signaling (SOCS1 and SOCS3) were activated to a greater degree. In addition, microarray analysis was performed on 4 patients and revealed that only one of 36 interferon regulated genes was expressed to a greater extent following treatment with 10 MU/m^2 IFN-a as compared to 5 MU/m^2. Conclusions: These results suggest that 5 MU/m^2 of IFN-a are as effective as higher doses with respect to the induction of STAT signal transduction and ISGs within immune effector cells.

No significant financial relationships to disclose.

MRI correlates of suicide attempt history in unipolar depression

BACKGROUND

Suicide represents a major health problem in the United States, and prediction of suicide attempts is difficult. No structural neuroimaging studies have been done to specifically examine findings in patients who have attempted suicide. The objective of this study was to compare MRI findings in unipolar patients with and without a history of a suicide attempt.

METHODS

In this post hoc analysis, 20 unipolar subjects with a history of a suicide attempt were matched by age and gender to unipolar subjects without a history of an attempt. Subjects were also matched on parameters such as cardiovascular history, electroconvulsive treatment history, and history of psychosis. Subjects with a history of any neurologic condition were excluded. There were no significant differences in age of onset of depression, number of episodes of depression, and Hamilton Depression scores between the two groups. T2-weighted magnetic resonance imaging (MRI) scans were rated using the Coffey and Boyko rating scales.

RESULTS

Unipolar patients with a history of a suicide attempt demonstrated significantly more subcortical gray matter hyperintensities compared with patients without such a history.

CONCLUSIONS

Patients with abnormal MRI findings may be at higher risk for mood disorders and suicide attempts because of disruption of critical neuroanatomic pathways. Gray matter hyperintensities in the basal ganglia may be especially associated with risk for suicide attempts.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia

OBJECTIVE

The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia.

METHODS

The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy.

RESULTS

For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people.

CONCLUSIONS

The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Prevalence and correlates of diabetes in national schizophrenia samples

People with schizophrenia may be at increased risk for Type II diabetes because of the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles, and poorer health care. The present study uses data bases collected by the Schizophrenia Patient Outcomes Research Team (PORT) to assess the prevalence and demographic and clinical correlates of diabetes within large populations of persons receiving treatment for schizophrenia. In the Schizophrenia PORT, Medicaid and Medicare data from 1991 and more recent interview data were collected regarding the comorbidity of schizophrenia and diabetes: prevalence, quality of life, physical health, and services utilization and costs. The study found that rates of diagnosed diabetes exceeded general population statistics well before the widespread use of the new antipsychotic drugs. Risk factors for diabetes were similar to those observed in the general population. The linkage of diabetes to poor physical health, medical morbidity, and increased service use and cost requires attention. This study of diabetes in the early 1990s suggests that even before the widespread use of the atypical antipsychotic drugs, diabetes was a major problem for persons with schizophrenia.

The impact of health status on work, symptoms, and functional outcomes in severe mental illness

This study evaluated the relationships between self-ratings of physical role functioning and general health, two components of the MOS SF-36, and a variety of demographic, quality of life, clinical, functional, and attitudinal variables in a cohort of adults living with severe and persistent mental illness (SPMI). We hypothesized that poorer self-perceptions of physical functioning and general health would be significantly related to more severe symptoms and poorer functioning and quality of life. Study subjects were 218 adults with SPMI enrolled in a randomized controlled trial comparing two vocational interventions for persons who were unemployed. Hierarchical regression analysis was used to determine whether psychiatric symptoms, poorer self-perceptions of role limitations due to physical health problems and overall general health independently contributed to more severe symptoms and poorer functioning and quality of life. Psychiatric symptoms were inversely related to size of social network and satisfaction with safety. Increased role limitations were associated with reduced medication compliance, general life satisfaction, and satisfaction with health, daily activities, and safety. Reduced general health was significantly associated with reduced work motivation, self-esteem, current inability to work, self-report of functioning, and almost all subjective life satisfaction domains. Within this group of people with severe mental illness, psychiatric symptoms were minimally associated with outcomes. Physical role limitations contributed more, and an integrated global measure of overall health perception was most important. If we are to help persons with severe mental illness maximize their quality of life and functioning, our clinical interventions should employ an approach that appreciates and recognizes the importance of the patients' experience of a holistic and integrated experience of health.

Correlates of long-term unemployment among inner-city adults with serious and persistent mental illness

This study identified demographic, clinical, and vocational rehabilitation-related correlates of long-term unemployment among 219 adults with severe mental illness. Fifty-one percent of the sample had been unemployed five or more years before enrollment. Older age, a diagnosis of psychosis, severity of negative symptoms, and more previous hospitalizations were all significantly related to long-term unemployment. Gender, race, education, substance disorder diagnosis, severity of negative symptoms, and vocational training experience were not. The findings underscore the relevance of clinical and neurocognitive impairments to long-term unemployment and point to the need to critically reevaluate the effectiveness of traditional vocational rehabilitation services.

[Evaluation of the quality of life of schizophrenic patients: validation of the brief version of the Quality of Life Interview]

The main objective of the study was to determine the psychometric properties (mainly, validity and reliability) of the French language version of the brief Quality of Life Interview (QoLI). That instrument evaluates both the subjective and objective aspects of quality of life.

METHODS

128 patients fulfilling the DSM IV criteria for schizophrenia were included. Quality of life was evaluated using the brief QoLI. Schizophrenic symptoms were evaluated using the Positive and Negative Syndrome Scale (PANSS). The validity of the internal structure of the QoLI was investigated by means of item analysis, study of the correlations between the items and between the item-dimensions and principal component analysis addressing the subjective fields. The validity of the external structure was mainly investigated through the nomological validity study. The reliability of the scale was evaluated by studying the internal consistency. In addition, the acceptability of the scale was documented.

RESULTS

The results of the study of the validity of the internal structure confirmed the pertinence of the pre-defined fields, particularly the subjective fields. Only some of the subjective fields of the QoLI showed significant correlations with the PANSS sub-scales. The acceptability of the scale was satisfactory.

CONCLUSIONS

The psychometric properties of the French language version of the brief QoLI appeared satisfactory. The brief QoLi was shown to be an easily used instrument for assessment of the various objective and subjective aspects of the quality of life of schizophrenic patients.

Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers

This study compared treatment of schizophrenia in two types of organization: a national, government-operated health care system, the Department of Veterans Affairs (VA), and in hospitals and clinics operated by state and local providers. Between 1994 and 1996, 746 male patients with a clinical diagnosis of schizophrenia residing in two states in the Southeast and Midwest were surveyed: 192 VA inpatients were compared with 96 non-VA inpatients, and 274 VA outpatients were compared with 184 non-VA outpatients. VA patients were older and had higher incomes than non-VA patients but did not differ significantly on measures of clinical status, satisfaction with providers, or community adjustment. VA outpatients were more likely to have been hospitalized during the previous year than non-VA outpatients and were less likely to have received services from a day hospital, from a case manager or social worker, or to have received crisis intervention services. On 5 of 26 Schizophrenic Patient Outcomes Research Team treatment recommendations, a smaller proportion of VA than non-VA patients adhered to standards. Four of these reflected reduced access among VA patients to psychosocial services such as work therapy, job training, or case management services. Cross-sectional surveys can be used to compare quality of care across service systems. VA care was associated with similar satisfaction and clinical outcomes but greater reliance on hospital treatment and less use of community-based psychosocial services.

The association of medical comorbidity in schizophrenia with poor physical and mental health

This study determined the prevalence of medical comorbidities in a cohort of persons receiving treatment for schizophrenia and the association of medical comorbidity with physical and mental health status. A total of 719 persons with schizophrenia sampled from a variety of community and treatment settings as part of the schizophrenia Patient Outcomes Research Team (PORT) participated in a survey interview. Multiple regression analyses were used to assess sociodemographic factors associated with the number of current medical comorbidities and the association of medical comorbidity count with patient ratings of physical health, mental health, symptoms, and quality of life. The majority of patients reported at least one medical problem. Problems with eyesight, teeth, and high blood pressure were most common. A greater number of current medical problems independently contributed to worse perceived physical health status, more severe psychosis and depression, and greater likelihood of a history of a suicide attempt. This study underscores the need to attend to somatic health care for persons with schizophrenia as well as the linkage of physical and mental health status.

A mathematical model for synergistic eukaryotic gene activation

The precise biochemical mechanism underlying the synergistic action of gene activators on eukaryotic transcription has eluded a solution, largely because of the technical difficulties inherent in analyzing the mechanics of a 2.5 MDa complex comprising greater than 50 polypeptide components. To complement the biochemical approach we have employed mathematical modeling as a means to understand the mechanism of synergy. Parameters relevant to activated transcription were varied in a simple biochemical system and the data were compared to the transcriptional response predicted by a multi-component statistical model. We found that the model achieved a consistent, semi-quantitative description of the measured transcriptional response, and enabled the characterization and measurement of thermodynamic parameters in the in vitro system. The results provide evidence for the existence of cooperativity in the activation process beyond what would be predicted from one current model suggesting that activators function solely by simple recruitment of the general transcription machinery to the promoter.

Services to families of adults with schizophrenia: from treatment recommendations to dissemination

OBJECTIVE

Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability.

METHODS

For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training.

RESULTS

In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services.

CONCLUSIONS

A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.

Medical-claims databases in the design of a health-outcomes comparison of quetiapine ('Seroquel') and usual-care antipsychotic medication

Treating schizophrenia is expensive. Preventing rehospitalization of patients with schizophrenia provides an attractive opportunity for cost savings, especially for patients with 'revolving-door' or multiple-episode schizophrenia. Reducing the occurrence of extrapyramidal symptoms and other adverse events associated with standard antipsychotic agents may increase compliance and reduce the rate of rehospitalization of patients with schizophrenia. Quetiapine ('Seroquel', ICI 204,636, Zeneca Pharmaceuticals) is a new dibenzothiazepine antipsychotic agent with a low propensity for extrapyramidal symptoms. We describe here a unique methodology to compare quetiapine with usual-care medications in real-world treatment settings. The trial objective is to determine if therapy with this new atypical antipsychotic agent can reduce the rate of rehospitalization and, therefore, treatment costs. Using two secondary medical-claims databases, we defined the minimal threshold for revolving-door status as 1.0 admission per year; this definition allows our trial to focus on the subpopulation of schizophrenic patients with the greatest potential for cost savings by either the new atypical antipsychotic quetiapine or usual-care therapy. We describe here the approach used in our trial.

The participation of families of homeless persons with severe mental illness in an outreach intervention

OBJECTIVES

This study describes how an Assertive Community Treatment (ACT) team which employs a family outreach worker (FOW) interacts with homeless persons with severe mental illness and their families.

METHODS

The team's ratings of the frequency and importance of clients' and treatment team's family contact are summarized and compared with independent research reports on patients' satisfaction with family relations, housing and hospitalization outcomes.

RESULTS

73% of clients had contact with their families. ACT worked with families of 61% of clients. ACT had less contact with the families of men (p < .01) and substance abusers (p < .01). Client days in stable housing were associated with increased ACT family contact (p < .05).

CONCLUSIONS

Most ACT clients had significant family contact. ACT established contact with most families, and the work with families appeared to be associated with higher levels of satisfaction with family relations and housing. The role of the FOW should be explored further.

Consumers as staff in assertive community treatment programs

The last decade has witnessed the increasing importance of consumers as providers of mental health services. Assertive Community Treatment (ACT) teams and ACT variants, with their emphasis on rehabilitation and support in the client's natural environment, have hosted consumer-professional collaborations. The authors discuss one such program in which an ACT program for homeless mentally ill adults employed consumer advocates (CAs). Consumer advocates were found to have a service profile similar to other staff. Further, there is suggestive evidence that the employment of CAs created a more positive attitude toward persons with mental illness. Issues of role definition, boundaries, support with supervision and the importance of CAs' experiences with mental illness are discussed.

One-year follow-up of secondary versus primary mental disorder in persons with comorbid substance use disorders

OBJECTIVE

Service utilization and outcomes of dually diagnosed patients with independent mental disorders and those with substance-induced mental disorders were compared.

METHOD

Diagnosis, service use, and severity of substance use problems at baseline and 1 year later were assessed in consecutively admitted inpatients with independent mental disorders plus substance use disorders (N = 71), substance-induced mental disorders plus substance use disorders (N = 38), and independent mental disorders only (N = 59).

RESULTS

At follow-up, patients with substance-induced mental disorders at baseline were more likely to have been rehospitalized than the other groups, were more likely to have used outpatient substance abuse services, were less likely to have an independent mental disorder, and had the most severe alcohol- and drug-related impairment.

CONCLUSIONS

Treatment programs for both types of dual diagnosis patients must address mental health concerns.

Assertive community treatment and medication compliance in the homeless mentally ill

OBJECTIVE

This study describes medication compliance rates among a group of homeless mentally ill subjects who received assertive community treatment.

METHOD

The medication compliance of 77 homeless persons who had been referred to an assertive community treatment program was prospectively evaluated at baseline and quarterly for 1 year.

RESULTS

A minority of the cohort (29%) was compliant at entry into the assertive community treatment program. Compliance significantly increased after 3 months (57%) and remained high through the year. Medication compliance was associated with fewer psychiatric symptoms but not with better housing placements or fewer days in the hospital.

CONCLUSIONS

Medication compliance rates among a cohort of homeless persons with severe mental illness were markedly higher after they entered a program of assertive community treatment.

HOOKLESS1, an ethylene response gene, is required for differential cell elongation in the Arabidopsis hypocotyl

Bending in plant tissues results from differential cell elongation. We have characterized Arabidopsis "hookless" mutants that are defective in differential growth in the hypocotyl. HOOKLESS1 was cloned and its predicted protein shows similarity to a diverse group of N-acetyltransferases. HOOKLESS1 mRNA is increased by treatment with ethylene and decreased in the ethylene-insensitive mutant ein2. High level expression of HOOKLESS1 mRNA results in constitutive hook curvature. The morphology of the hookless hypocotyl is phenocopied by inhibitors of auxin transport or by high levels of endogenous or exogenous auxin. Spatial patterns of expression of two immediate early auxin-responsive genes are altered in hookless1 mutants, suggesting that the ethylene response gene HOOKLESS1 controls differential cell growth by regulating auxin activity.

Cognitive therapy versus fluoxetine in the treatment of dysthymic disorder

We studied the effects of a fixed dose of fluoxetine (20 mg) or cognitive psychotherapy in a 16 week trial of patients with dysthymic disorder. More patients assigned to fluoxetine dropped out of the 16 week treatment (33%) than those assigned to cognitive therapy (9%), but this difference did not attain statistical significance. Both treatments showed improvement over baseline conditions at 8 weeks and further improvement at 16 weeks. There were no statistically significant group differences in treatment response. No follow-up data were collected so the enduring effects of the treatments are unknown. An optimal treatment for dysthymic disorder may be combined psychotherapy and pharmacotherapy for a longer period of time.