Methodological issues in assertive community treatment studies

Recent evaluations of ACT programs have produced equivocal findings, often leading to the invocation of methodological problems as responsible for the lack of positive results. This paper discusses issues of theory and methodology as they pertain to improving research of ACT, with particular attention paid to issues of sampling, process evaluation, measurement, and data analysis.

Program fidelity in assertive community treatment: development and use of a measure

Assertive community treatment (ACT) is a complex community-based service approach to helping people with severe mental disorders live successfully in the community. Effective replication of the model and research on critical elements require explicit criteria and measurement. A measure of program fidelity to ACT and the results of its application to fifty diverse programs are presented.

Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.

Models of community care for severe mental illness: a review of research on case management

We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

Job terminations among persons with severe mental illness participating in supported employment

For persons with psychiatric disabilities, maintaining a job is often more difficult than acquiring a job. A large proportion of jobs end unsatisfactorily. This study explored job terminations among 63 persons with severe mental illness who participated in competitive jobs through supported employment programs. More than half of the job terminations were unsatisfactory, defined as the client quitting without having other job plans or being fired. Baseline ratings of demographic and clinical characteristics, preemployment skills training, and early ratings of job satisfaction and work environment did not predict unsatisfactory terminations. Clients with better work histories were less likely to experience unsatisfactory terminations. In addition, unsatisfactory terminations were associated retrospectively with multiple problems on the job that were related to interpersonal functioning, mental illness, dissatisfaction with jobs, quality of work, medical illnesses, dependability, and substance abuse. These results suggest that supported employment programs need to address job maintenance with interventions that identify and address different types of difficulties as they arise on the job.

Effect of sheep plasma and lymph on fibroblast proliferation

Blood plasma contains many factors that influence cellular proliferation. However, cells within the tissue spaces of most organs are exposed to interstitial fluid, and the composition of interstitial fluid may be much different from plasma. Accordingly, the effect of interstitial fluid on cellular proliferation may be much different from the effect of plasma. The aim of this study was to test the effect of blood plasma and interstitial fluid (lymph) from the lung and intestine on the proliferation of fibroblasts. Plasma and lung and intestinal lymph were collected from anesthetized sheep and added to standard culture medium (final concentration = 10%). Cells (fibroblasts) were cultured from the lungs of the sheep and grown to confluence. Then the cells were subcultured at low density and incubated with the medium containing plasma or lymph. Control dishes contained only cells and medium. The cells were counted over a 6-day period. Cells incubated with medium alone grew very little over the 6-day period, but cells exposed to plasma increased approximately 100-fold, and cells exposed to lymph increased approximately 10-fold. We found no significant difference in cell growth for cells incubated with lung versus intestinal lymph. Our results show lung and intestinal lymph are less effective than plasma in stimulating cell growth.

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness

OBJECTIVE

Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness.

METHOD

On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients.

RESULTS

The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders.

CONCLUSIONS

Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

Benefits and costs of supported employment from three perspectives

Administrators, consumers, and policy makers are increasingly interested in supported employment as a way of helping persons with severe mental illness get and keep competitive jobs. However, in an atmosphere of increased expectations for performance and declining public financing, administrators want to know the costs and benefits of different approaches before they reallocate scarce treatment or rehabilitative dollars. This article discusses the net benefits of two approaches to supported employment that were compared in a randomized trial: Individual Placement and Support (IPS) and Group Skills Training (GST). The authors analyze costs and benefits from societal, government, and consumer perspectives. Although a previous analysis showed that IPS participants were significantly more likely to find work, worked more hours, and had higher earnings, net benefits of the two programs were not significantly different. The authors also discuss some of the strengths and weaknesses of cost-benefit analysis in mental health care and suggest future directions for policy and research.

Complications of severe mental illness related to alcohol and drug use disorders

In this chapter we review research on the relationships between substance use disorder and 11 domains of adjustment for people with severe mental illness. Studies are divided into correlational research and prospective, longitudinal research, with greater weight given to those in the latter category. The weight of the evidence indicates that substance abuse severely complicates severe mental illness in the following domains: relapse of psychiatric illness, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, and medication noncompliance. We discuss the limits of causal inference in these studies and the possible mechanisms that relate substance abuse to various complications.

Organizational guidelines for dual disorders programs

Dual disorders--combined severe mental disorders and substance use disorders--were barely recognized two decades ago. As a result of the high prevalence and serious consequences of these disorders, they have received considerable attention over the last two decades. Knowledge has accumulated about dual disorders and their treatment, and treatment providers may now consider numerous options for clinical interventions and program designs. In this article, we offer guidelines concerning these options. We review the current knowledge about dual disorders and the results of recent research on the assessment and treatment of these disorders. We present treatment principles, recommendations on the components and organization of dual disorders programs, and suggestions for dealing with clinical issues that remain controversial. We conclude with comments on the demands of the managed care environment and the heightened importance of continued research in this area.

Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions

An emerging body of research on the physical and sexual abuse of seriously mentally ill (SMI) women documents a high incidence and prevalence of victimization within this population. While causal links are not well understood, there is convergent evidence that victimization of SMI women is associated with increased symptom levels, HIV-related risk behaviors, and such comorbid conditions as homelessness and substance abuse. These abuse correlates may influence chronicity, service utilization patterns, and treatment alliance. This article reviews the research literature on the prevalence, symptomatic and behavioral correlates, and treatment of abuse among SMI women, particularly women with schizophrenia. Within each topic, we discuss relevant research findings, limitations of available studies, and key questions that remain unanswered. We also discuss mechanisms that may underlie the relationship between trauma and schizophrenia-spectrum disorders. We conclude by outlining directions for future research in this area.

Recent advances in psychiatric rehabilitation for patients with severe mental illness

Over the past decade substantial advances have been made in the psychiatric rehabilitation of persons with severe mental illnesses such as schizophrenia and bipolar disorder. In this review we highlight progress in several areas that have been the focus of extensive research, including case management, social skills training, supported employment, family intervention, and integrated treatment for comorbid substance use disorders. We also identify characteristics of successful psychiatric rehabilitation programs: (1) effective interventions tend to be direct and behavioral; (2) rehabilitation programs have specific effects on related outcomes, with limited generalization to other domains; (3) short-term interventions are less effective than long-term ones; (4) interventions need to be delivered close to patients' natural environments; and (5) effective programs often combine skills training and environmental support.

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial behavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems.

Protein osmotic pressure gradients and microvascular reflection coefficients

Microvascular membranes are heteroporous, so the mean osmotic reflection coefficient for a microvascular membrane (sigma d) is a function of the reflection coefficient for each pore. Investigators have derived equations for sigma d based on the assumption that the protein osmotic pressure gradient across the membrane (delta II) does not vary from pore to pore. However, for most microvascular membranes, delta II probably does vary from pore to pore. In this study, we derived a new equation for sigma d. According to our equation, pore-to-pore differences in delta II increase the effect of small pores and decrease the effect of large pores on the overall membrane osmotic reflection coefficient. Thus sigma d for a heteroporous membrane may be much higher than previously derived equations indicate. Furthermore, pore-to-pore delta II differences increase the effect of plasma protein osmotic pressure to oppose microvascular fluid filtration.

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

Housing status among formerly homeless dually diagnosed adults

OBJECTIVE

Residential outcomes of homeless adults with severe mental illness and a substance use disorder were studied over 18 months during which participants received integrated dual diagnosis services and housing supports based on a continuum model.

METHODS

Interviews with 158 participants at baseline and at six-, 12-, and 18-month follow-ups assessed housing status, residential history, substance abuse and progress toward recovery, psychiatric symptoms, and quality of life. Complete data were available for 122 participants. If participants lived continuously in high-quality housing with no housing loss or nights of homelessness during the final six months of the study, they were classified as having stable housing.

RESULTS

Of the 122 participants for whom complete data were available, 64 (52 percent) achieved stable housing. Most participants who achieved stable housing first entered staffed and supervised housing and then moved to independent arrangements by the end of the study. Stable housing during the final evaluation period was associated with lower substance use, greater progress toward substance abuse recovery, and higher quality of life. Final housing status was not predicted by baseline variables but was predicted by progress toward recovery during months 0 to 6 and 6 to 12 and by less severe drug use during months 6 to 12. Participants who abused no illicit drugs during months 6 to 12 were almost three times as likely to achieve stable housing as those who abused illicit drugs.

CONCLUSIONS

Housing stability is strongly mediated by substance abuse and progress toward recovery. Nevertheless, when formerly homeless persons with dual diagnoses are provided integrated dual diagnosis treatment, they can gradually achieve stable housing.

Lymph flow in sheep with rapid cardiac ventricular pacing

Increases in systemic venous pressure (Pv) associated with heart failure cause an increase in microvascular fluid filtration into the tissue spaces. By removing this excess filtrate from the tissues, lymphatic vessels help to prevent edema. However, the lymphatics drain into systemic veins and an increase in Pv may interfere with lymphatic flow. To test this, we cannulated caudal mediastinal node efferent lymphatics in sheep. We used rapid cardiac ventricular pacing (240-275 beats/min) to cause heart failure for 4-7 days. Each day we determined the lymph flow rate two ways. First, we adjusted the lymph cannula height so that the pressure at the outflow end of the lymphatic was zero. After we determined the lymph flow with zero outflow pressure, we raised the cannula so that outflow pressure was equal to the actual venous pressure. We quantitated the effect of venous pressure on lymph flow rate by comparing the flow rate with outflow pressure = Pv to the flow rate with zero out low pressure. At baseline, Pv = 5.0 +/- 2.5 (SD) cmH2O and we found no difference in the two lymph flow rates. Pacing caused Pv and both lymph flow rates to increase significantly. However for Pv < 15 cmH2O, we found little difference in the two lymph flow rates. Thus increases in Pv to 15 cmH2O at the outflow to the lymphatics had little effect on lymph flow. By comparison, Pv > 15 cmH2O slowed lymph flow by 55 +/- 29% relative to the lymph flow rate with zero outflow pressure. Thus Pv values > 15 cmH2O interfere with lymph flow from the sheep caudal mediastinal lymph node.

Integrated treatment for dually diagnosed homeless adults

This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.

Gender differences in patients with schizophrenia and substance abuse

Co-occurring substance abuse is common among people with chronic mental illnesses such as schizophrenia. Although gender differences have been established among substance abusers in the general population and among people with schizophrenia, little is known about gender differences in people with the dual disorders of schizophrenia and substance abuse. This study examines gender differences in 37 women and 135 men with dual disorders, and finds many differences consistent with those found in people with single disorders: dually diagnosed women had more social contact and fewer legal problems but greater problems with victimization and medical illness compared with dually diagnosed men. Unexpectedly, men and women had similar courses and severities of substance abuse. These findings may be critical in planning effective services that explicitly address women's family and social needs, issues related to victimization, and high rates of medical illness.

An update on supported employment for people with severe mental illness

OBJECTIVE

This review examines the effectiveness of supported employment for people with severe mental illness.

METHODS

A comprehensive search was made for quantitative studies, primarily in the published literature.

RESULTS

Seven descriptive studies, three surveys, one quasi-experimental study, and six experimental studies were found. All studies suggested significant gains in obtaining employment for persons enrolled in supported employment programs. In experimental studies, a mean of 58 percent of clients in supported employment programs achieved competitive employment, compared with 21 percent for control subjects, who typically received traditional vocational services. Employment outcomes relating to time employed and employment earnings also favored clients in supported employment over control subjects. No evidence was found that supported employment led to stress levels precipitating higher rehospitalization rates. Two features of many supported employment programs have the most empirical support: integration of mental health and vocational services within a single service team and the avoidance of preplacement training. Two other widely held principles-ongoing support and attention to client preferences-have not been systematically evaluated.

CONCLUSIONS

Supported employment appears to be a promising approach for people with severe mental illness, but more studies are needed, with close attention to program implementation and long-term follow-up.

The New Hampshire study of supported employment for people with severe mental illness

This study compared supported employment services in 2 contrasting programs: (a) Group Skills Training, a professional rehabilitation agency outside of the mental health center that provided pre-employment skills training and support in obtaining and maintaining jobs, or (b) the Individual Placement and Support (IPS) model, which integrated clinical and vocational services within the mental health center. People with severe mental disorders who expressed interest in competitive employment (N = 143) were randomly assigned to 1 of these 2 programs. Results showed that clients in the IPS program were more likely to be competitively employed throughout most of the 18-month follow-up. Among those who obtained jobs, there were few group differences, although workers in the IPS program did work more total hours and earn more total wages during the 18-month follow-up. There were no group differences on nonvocational outcomes.

Relationships between symptoms of schizophrenia and substance abuse

Previous work posits that severity of substance abuse and severity of schizophrenic symptoms should be linked by either or both of two mechanisms: self-regulation of symptoms and drug-induced exacerbation of symptoms. Research on these relationships has yielded mixed results. We examined the interrelationships of schizophrenic symptoms and substance abuse in 172 patients with co-occurring disorders. Relationships were weak or nonexistent, without any consistent pattern. Our findings do not support the view that substances are used to self-regulate symptoms. In addition, our results suggest that substance abuse may lead to higher rates of institutionalization through mechanisms other than by exacerbating symptoms.

Pulmonary microvascular reflection coefficients estimated with modified lymphatic washdown technique

Many investigators have used the lymphatic protein washdown technique to estimate the pulmonary microvascular membrane reflection coefficient to protein (sigma d). With that technique, the investigator causes a high microvascular filtration rate then estimates sigma d from the lymph and plasma protein concentrations. However the lymph may contain protein washed from the lung tissue, and the tissue protein may cause investigators to underestimate sigma d. Plasma protein osmotic pressure (IIc) may cause investigators to underestimate sigma d because IIc opposes fluid filtration. To minimize the effect of IIc, we decreased IIc to 5.6 +/- 1.1 mmHg in five anesthetized sheep. We increased the microvascular filtration rate by increasing pulmonary microvascular pressure to 22 +/- 3 mmHg. Then we tagged plasma protein with Evans blue dye and estimated sigma d from the lymph and plasma dye concentrations. Because tissue protein was not tagged, it did not interfere with our sigma d estimate. Our sigma d estimate (0.79 +/- 0.08) was much higher than previous estimates in anesthetized animals.