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.

Job preferences of clients with severe psychiatric disorders participating in supported employment programs

OBJECTIVE

The job preferences of adults with severe mental illness who were participating in supported employment programs were examined.

METHODS

Data were collected on job preferences, attainment of competitive employment, job satisfaction, and job tenure of 135 adults who participated in two supported employment programs in New Hampshire. Data obtained at baseline and at six-month follow-up were analyzed.

RESULTS

When the clients entered the supported employment programs, 81 percent expressed job preferences, and their preferences tended to be realistic and stable. People who obtained employment in preferred areas were more satisfied with their jobs and remained in their jobs twice as long as those who worked in nonpreferred areas. Clients were more likely to develop a new job preference or to change their preference if they participated in a program that emphasized rapid job search than if they participated in a prevocational skills training program. They were also more likely to develop a preference or change their preference if they obtained a competitive job.

CONCLUSIONS

Helping people with severe mental illness obtain competitive jobs that correspond with their explicit job preferences increases job satisfaction and tenure. Job preferences are more likely to develop or change through searching for a job or working at a job than through prevocational training.

Helping depressed clients discover personal power

TOPIC

Alleviating depression through cognitive therapy.

SOURCE

The author's clinical work and review of the literature.

GOAL

To describe the empowerment of depressed clients.

CONCLUSION

Clients who are depressed can be helped by examining "who they are" as compared to "who they believe they are."

Day treatment versus supported employment for persons with severe mental illness: a replication study

Outcomes for 112 clients with severe mental disorders in a community mental health center that converted its rehabilitative day treatment program to a supported employment program were assessed during the year after the program conversion. The study replicated a previous study in showing that the rate of competitive employment improved, especially among clients who had formerly attended the day treatment program, without evidence of adverse effects.

Tissue protein washout in sheep lung lymph

At high microvascular filtration rates, the lung lymph protein concentration (C1) may be higher than the filtrate protein concentration due to protein washed into the lymph from the lung tissue space. To test that hypothesis, we increased the microvascular filtration rate in 5 anesthetized sheep and determined the relationship between C1, and the plasma protein concentration (Cp). Then we extrapolated the data to estimate C1 at Cp = 0. Because the filtrate protein concentration should be zero at Cp = 0, we recorded the extrapolated C1, as the concentration of tissue protein in the lymph (C1). Our C1 estimate (0.92 +/- 0.38g/dl) was significantly greater than zero (P < 0.05). This result is important because tissue protein in lymph may cause errors when investigators use lung lymph to study microvascular permeability. However, our technique to estimate Ct may allow investigators to correct for the tissue protein problem.

New directions for treatment research on sequelae of sexual abuse in persons with severe mental illness

Sexual abuse in childhood is increasingly recognized as an important etiologic component in a number of psychiatric disorders. One-quarter to one-third of all female children suffer sexual abuse before their eighteenth birthday, and at least one half of women with severe mental illness acknowledge such events. An even higher percentage of a particularly vulnerable group, dually diagnosed homeless women, appear to have a premorbid history of childhood victimization. In this paper, we review the emergent literature on childhood abuse, its sequelae and treatment; and discuss the implications of these data for the development of new approaches to trauma recovery in people with severe mental illness.

Renal lymphatic function following venous pressure elevation

The renal lymphatic system plays an important role in removing excess fluid from the kidneys. Unfortunately, the factors influencing lymphatic flow are difficult to measure. We used a simple model to represent renal lymphatics as a single pressure source (PL) pushing lymph through a single resistance (RL). In anesthetized dogs, we cannulated renal lymphatics and measured lymph flow rate (QL) as we varied pressure (PO) at the outflow end of the lymphatics. There was no significant change in QL as we increased PO from -5 to 0 cm H2O. In other words, there was a plateau in the QL vs. PO relationship. At higher PO's, QL decreased linearly with increases in PO. From this linear relationship, we calculated RL as -delta PO/ delta QL and we took PL as the PO at which QL = 0 microliter/min. At baseline, RL = 0.34 +/- 0.14 (SD) cm H2O.min/microliter and PL = 8.2 +/- 4.4 cm H2O. When we increased renal venous pressure (PV) from baseline (3.5 +/- 3.0 cm H2O), the plateau in the QL vs. PO relationship extended to higher PO's, RL decreased, and PL increased. Renal interstitial fluid volume and interstitial pressure increased following elevation of PV. The extension of the QL vs. PO plateau with increasing PV suggests that renal interstitial pressure may partially collapse intrarenal collecting lymphatics which may compromise lymph flow.

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.

The role of self-help programs in the rehabilitation of persons with severe mental illness and substance use disorders

Substance abuse treatment programs in the United States frequently incorporate self-help approaches, but little is known about the use of self-help groups by individuals with dual disorders. This paper brings together several current studies on the role of self-help programs in treating substance use disorders among individuals with severe mental illness. These studies indicate that only a minority of individuals with dual disorders become closely linked to self-help. Psychiatric diagnosis and possibly social skills are correlates of participation. Dually disorders consumers often experience the use of 12-step philosophy and jargon by mental health professionals as alienating and unempathic. The authors propose suggestions for incorporating self-help approaches into the comprehensive community care of individuals with dual disorders.

Lymphatic pump function curves in awake sheep

We determined the relationship between flow rate and inflow pressure for intestinal lymphatic vessels in six sheep. First we anesthetized the sheep and cannulated both ends of a 6- to 10-cm-long segment of intestinal lymphatic. We allowed the sheep to recover from the anesthesia for 2-24 h. To determine the flow rate-inflow pressure relationship, we recorded the inflow pressure and infused Ringer solution into the lymphatic at rates from 34 to 510 microliters/min. The flow rate-pressure relationship was not linear and it had two regions. For flow rates less than approximately 150 microliters/min, inflow pressure was greater than outflow pressure. Thus the lymphatic pumped fluid against a pressure gradient. For flow rates > 150 microliters/min, inflow pressure was greater than outflow pressure, and we attributed most of the flow to the favorable inflow-outflow pressure gradient (passive flow). When we used verapamil to inhibit lymphatic pumping, we found no flow for inflow pressure less than outflow pressure, and flow increased linearly for inflow pressure greater than outflow pressure. Our data for actively pumping lymphatic vessels are consistent with the flow vs. pressure relationships derived from mathematical models of the lymphatic pump. Furthermore, our data with verapamil confirm that active lymphatic pumping was responsible for the nonlinear flow vs. pressure relationship for the lymphatic vessels.

The course, treatment, and outcome of substance disorder in persons with severe mental illness

Individuals with co-occurring substance abuse and severe mental illness are particularly vulnerable to negative outcomes. This paper reviews findings on the longitudinal course of dual disorders in traditional treatment systems, which provide separate mental health and substance-abuse programs; describes the movement toward programs that integrate both types of treatment at the clinical level; reviews evidence related to outcomes in integrated treatment programs; and discusses health-care policy changes that would encourage effective treatments.

Assessing substance use disorder in persons with severe mental illness

Assessment of dually diagnosed patients consists of three steps: detection, diagnosis, and specialized assessment for treatment planning. Each of these is informed by recent research.

Reversing a history of unmet needs: approaches to care for persons with co-occurring addictive and mental disorders

Individuals with co-occurring addictive and mental disorders are particularly vulnerable to negative outcomes. Historically, they have been treated either in mental health or addiction service settings and sometimes excluded from receiving any services at all. This article presents an overview of the prevalence and clinical correlates of co-occurring disorders, and of the historical development of separate care systems for mental and addictive disorders. The articles that follow address future treatment and service system development.

A scale for assessing the stage of substance abuse treatment in persons with severe mental illness

Substance abuse is common among persons with severe mental illness, but few measures exist for clinicians to evaluate treatment progress. The Substance Abuse Treatment Scale (SATS) combines a motivational hierarchy with explicit substance use criteria to form an eight-stage model of the recovery process. Data are presented supporting the reliability and validity of the SATS, based on its use in a community-based sample of persons with dual disorders. The SATS can be used as either a process or an outcome measure, for individuals or for groups, and its value in making explicit the stages of substance abuse treatment is discussed.

Evaluating use of continuous treatment teams for persons with mental illness and substance abuse

OBJECTIVE

Continuous treatment teams serving persons with co-occurring severe mental disorders and substance abuse disorders at seven sites in New Hampshire were evaluated to determine their fidelity to a model based on the Program for Assertive Community Treatment.

METHODS

Continuous treatment teams and standard case management programs at the seven sites were evaluated on 13 criteria for fidelity to the continuous treatment team model over a 27-month period. Data sources included clinicians' activity logs, agencies' management information systems, interviews, observation of staff activity and practices, and clinical records and other documents.

RESULTS

The continuous treatment teams scored significantly higher than the case management programs on ten of the 13 criteria. The teams were more effective than the case management programs in implementing substance abuse treatment.

CONCLUSIONS

Evaluation of the programs' fidelity to the model criteria allowed differentiation of successfully implemented continuous treatment teams from standard case management and from an unsuccessfully implemented team. The results confirm the need for careful measurement of model implementation and for investigation of organizational issues such as administrative support and clarity of program mission.

Incentives for community treatment. Mental illness management services

Serving people with mental and other chronic illnesses in community settings may improve compliance and satisfaction with treatment, but existing payment mechanisms often favor office-based treatment. This study examines the effect of a change in Medicaid payment on the location and amount of service provided by case managers. Amounts of service given by treatment providers to 185 of their clients in community settings and in mental health centers were compared before and after reimbursement changed from an all-inclusive prospective rate to a mixed prospective/retrospective payment. Clients were enrolled in two different treatment programs: continuous treatment teams with extensive training in in vivo treatment, and a case management program that emphasized office-based treatment. In-community service increased, and the amount of office-based treatment decreased. Continuous treatment teams increased in-community services more than case managers did; case managers decreased office-based treatment more. There was no change in total amount of services provided. It was concluded that mixed prospective and retrospective reimbursement can remove financial barriers to in-community treatment, but it works best in combination with a training program. Additional research is needed to determine the precise financial impact of such changes.

Pulmonary Edema Fluid Clearance Pathways

Lymphatic vessels normally remove excess fluid from the lung tissue and thus prevent pulmonary edema. However, when lungs do become edematous, the edema fluid may be cleared via several pathways. Each clearance pathway has unique properties, and recent studies have helped to define those properties.

Long-term course of substance use disorders among patients with severe mental illness

OBJECTIVE

This study assessed the long-term course of substance abuse and dependence among severely mentally ill patients.

METHODS

A prospective, naturalistic, seven-year follow-up of severely mentally ill outpatients (most with schizophrenia and schizoaffective disorder) successfully located and reassessed 79.1 percent (N = 148) of the patients from the original study group. The follow-up study group was assessed for alcohol and drug use at baseline and seven-year follow-up by their case manager or primary clinician using the Case Manager Rating Scale (CMRS) for the assessment of substance-related problems among severely mentally ill patients.

RESULTS

The prevalence of active substance use disorder changed little from baseline to follow-up. Alcohol abuse or dependence was present in 24 percent of the patients at baseline and 21 percent at follow-up, and drug abuse or dependence was present in 20 percent at baseline and 17 percent at follow-up. However, those with initial alcohol abuse had a higher rate of remission (67 percent) than those with initial alcohol dependence (33 percent). Similarly, those with initial drug abuse had a higher rate of remission (54 percent) than those with initial drug dependence (31 percent).

CONCLUSIONS

The higher rates of change for those with initial substance abuse compared with substance dependence suggest that distinguishing between abuse and dependence may have important implications for assessment and prognosis of individuals with a dual diagnosis of a substance use disorder and severe mental illness.

The test-retest reliability of standardized instruments among homeless persons with substance use disorders

OBJECTIVE

Standardized instruments are widely used to assess homeless persons, but basic data on their reliability and validity in these populations have not been available. The purpose of this study was to examine the reliability of standardized instruments used in a cooperative agreement on homeless persons with substance use disorder.

METHOD

This study examined the 1-week test-retest reliability of the Alcohol Dependence Scale, the Addiction Severity Index and the Personal History Form, using 189 randomly selected subjects participating in a multisite study of services for homeless persons with alcohol and other drug abuse problems. In addition to scales and items, factors hypothesized to influence reliability related so subject, interviewer and setting were examined.

RESULTS

Results showed substantial reliability for scale scores (> .60) but mixed reliability for individual items. Reliability was greater when items were factual and based on a recent time interval, and when subjects were interviewed in a protected setting. Higher reliability was also related to younger age, female gender, a first episode of homelessness and lower severity of psychiatric problems.

CONCLUSIONS

Reliability should be examined in individual studies of homeless persons, and efforts should be made to minimize controllable sources of unreliability.