Family history of alcoholism in schizophrenia

Previous research has shown that family history of alcoholism (FHA) is associated with several aspects of the development and expression of alcohol use disorder in people who are not mentally ill. This study examined FHA in a group of 66 schizophrenic outpatients who were well characterized in terms of their alcohol use and were followed prospectively in treatment for 4 years. The FHA-positive probands (42.4% of the group) were more likely to have alcohol use disorder. Contrary to our prediction, the relationship between FHA and alcoholism in the probands was significant for women but not for men. Among schizophrenic probands with alcoholism, positive FHA was associated with more severe alcoholism and with the use of other drugs. Probands with positive FHA also responded less well to alcoholism treatment than did probands with negative FHA. These exploratory findings have significant implications for understanding risk, for conducting assessment, and for studying treatment, but should be confirmed in larger and more representative samples of people with schizophrenia.

Rehabilitative day treatment vs. supported employment: I. Vocational outcomes

Day treatment remains a core component in many community mental health programs for persons with severe mental disorders throughout the United States. Many other mental health centers are moving away from day treatment toward psychosocial and vocational rehabilitation programs. Empirical research directly comparing these two systems of organizing outpatient services is needed. In this study the authors compared a rehabilitative day treatment program in one small city with a similar program in a nearby city that changed from day treatment to a supported employment model. Clients who were enrolled in community support services during a baseline year prior to the change and during a follow-up year after the change (71 in the program that changed and 112 in the other) were evaluated during both intervals. In the program that changed, competitive employment improved from 25.4% to 39.4% for all clients, and from 33.3% to 55.6% for those clients who had been regular attenders of day treatment during the baseline. Hours worked and wages earned similarly improved after the program change. For all work variables, clients who had not worked during the baseline year accounted for the improvements in outcome. Meanwhile, employment remained stable in the day treatment program. No negative outcomes were detected. These results indicate that eliminating day treatment and replacing it with a supported employment program can improve integration into competitive jobs in the community.

Increased lymphatic pressure without increased neck vein pressure during intravenous infusions

Postnodal intestinal lymphatic pressure increases during rapid intravenous infusions with Ringer solution in sheep. Part of the lymphatic pressure increase is due to increased venous pressure at the lymphatic outflow (the neck veins). We tested the hypothesis that other factors besides increased neck vein pressure may cause increased lymphatic pressure during intravenous infusions. We placed cannulas into postnodal lymphatic vessels in eight sheep. After the sheep recovered from the surgery, we infused Ringer solution [46 +/- 21 (SD) ml/kg body wt in 30 min] intravenously into the sheep and inflated a balloon in the inferior vena cava. We adjusted the balloon inflation to prevent any increase in neck vein pressure during the infusions. At baseline, the intestinal lymphatic pressure was 15.5 +/- 2.5 cmH2O. During the infusions, lymphatic pressure increased significantly, and for the last 10 min of the infusion period, intestinal lymphatic pressure was 24.0 +/- 6.1 cmH2O. These results are consistent with the hypothesis that factors in addition to increased neck vein pressure may cause increased intestinal lymphatic pressure during rapid intravenous infusions.

Individual Placement and Support: a community mental health center approach to vocational rehabilitation

Individual Placement and Support (IPS) is a vocational rehabilitation intervention for people with severe mental disabilities. IPS draws from components and philosophies of several other models. Employment specialists, who are part of the community mental health center team, provide services in the community. IPS emphasizes client preferences, rapid job finding, continuous assessment, competitive employment, integrated work settings, and follow-along supports. Initial research on IPS shows favorable results.

Potential health hazards of pornography consumption as viewed by psychiatric nurses

Adverse effects of pornography consumption (PC) have been identified from over 150 empirical studies conducted since 1970. Yet, the practice literature of psychiatric nurses does not address the health risks of PC. This study determines the perceptions of psychiatric nurses (n = 194) with regard to PC effects. A significant majority of psychiatric nurses agreed (72%) that there are potential adverse effects to PC, that there are risks for preadult consumers of pornography (78% agreement), and that PC risks need to be addressed by their profession (68% agreement). Agreement lends support for expanding nurses' knowledge concerning PC.

Expenditures of time and money by families of people with severe mental illness and substance use disorders

Families are typically a major source of support for people with mental illness, but substance abuse places an additional burden on family relations and could reduce the amount of direct support they give. Data from families of 169 people with co-occurring mental illness and substance abuse indicate that they give a substantial amount of time and money to their relatives with dual disorders. More severe current substance abuse appeared to reduce family spending but not direct caregiving. Clients with more severe alcohol problems were more likely to live with parents than with other family members.

Correlates and outcomes of alcohol use disorder among rural outpatients with schizophrenia

BACKGROUND

The use of alcohol by persons with schizophrenia is common and has been associated with increased severity of psychiatric symptoms, multiple psychosocial problems, abuse of other drugs, and poor treatment outcomes. Most of the previous research in this area has been with urban patients.

METHOD

The authors examined the correlates and outcomes of alcohol use in a rural sample of 75 DSM-III-R outpatients with schizophrenia. Based on multiple measures, 25% (N = 19) of 75 rural patients with schizophrenia were diagnosed with current co-occurring alcohol use disorders. Clinicians' ratings and self-reported symptoms were used to examine correlates of alcohol use, and the study group was followed prospectively for 1 year to identify all episodes of rehospitalization, incarceration, or literal homelessness.

RESULTS

Alcohol use disorder was statistically significantly associated with unstable housing, conceptual disorganization, denial of mental illness, and rehospitalization during 1-year follow-up. Several trends suggested that alcohol use was also related to positive symptoms of psychosis.

CONCLUSION

Among rural patients with schizophrenia, alcohol use appears to play a significant role in destabilizing psychosocial adjustment. These results replicate similar findings in urban settings.

Treatment of substance abuse in severely mentally ill patients

Substance abuse is the most common comorbid complication of severe mental illness. Current clinical research converges on several emerging principles of treatment that address the scope, pace, intensity, and structure of dual-diagnosis programs. They include a) assertive outreach to facilitate engagement and participation in substance abuse treatment, b) close monitoring to provide structure and social reinforcement, c) integrating substance abuse and mental health interventions in the same program, d) comprehensive, broad-based services to address other problems of adjustment, e) safe and protective living environments, f) flexibility of clinicians and programs, g) stage-wise treatment to ensure the appropriate timing of interventions, h) a longitudinal perspective that is congruent with the chronicity of dual disorders, and i) optimism.

Washout of protein in dog lung lymph

After an increase in microvascular filtration rate, lung lymph may contain protein washed from the tissue spaces plus protein from the filtrate. If so, then the lymphatic protein concentration may be significantly higher than the filtrate protein concentration (Cf). To test this hypothesis, we decreased the plasma protein concentration from 5.1 +/- 0.6 to 0.54 +/- 0.15 g/dl and increased the pulmonary microvascular filtration rate in four dogs. We estimated Cf to be 0.16 +/- 0.05 g/dl after we reduced the plasma protein concentration, and the lymphatic protein concentration (0.43 +/- 0.04 g/dl) was significantly greater than Cf. Our results indicate that lung microvascular membrane reflection coefficients estimated from lung lymph data may be too low. However, the amount of error caused by tissue protein washout is probably small. To account for the protein washout error, we estimated the lung microvascular membrane reflection coefficient to be approximately 0.74-0.76 instead of the approximately 0.70 previously reported for dogs (J. C. Gabel et al. J. Appl. Physiol. 55: 866-869, 1983).

Intestinal lymphatic pressure increases during intravenous infusions in awake sheep

Intravenous fluid infusions cause increased venous pressure and increased lymph flow throughout the body. Together the increased lymph flow and increased venous pressure (the outflow pressure to the lymphatic system) should increase the pressure within the postnodal intestinal lymphatics. To test this, we measured the pressure in postnodal intestinal lymphatics and the neck vein pressure in five awake sheep. At baseline, the neck vein pressure was 1.2 +/- 1.5 (SD) cmH2O and the lymphatic pressure was 12.5 +/- 1.7 cmH2O. When we infused Ringer solution intravenously (10% body weight in approximately 50 min), the neck vein pressure increased to 17.3 +/- 0.9 cmH2O and the lymphatic pressure increased to 24.6 +/- 3.8 cmH2O (both P < 0.05). In two additional sheep, the thoracic duct lymph flow rate increased from 0.8 +/- 0.4 ml/min at baseline to 5.5 +/- 2.0 ml/min during the infusions. Our results show that postnodal intestinal lymphatic pressure may increase substantially during intravenous fluid infusions. This is important because increases in postnodal lymphatic pressure may slow lymph flow from the intestine.

Estimation of lymph flow by relating lymphatic pump function to passive flow curves

Active pumping in postnodal lymphatic vessels is an important factor influencing lymph flow. However, the output of the lymphatic pump also depends on the rate of flow into the pump. This arrangement is similar to the blood circulation where cardiac output depends on the rate of blood flow through the veins into the heart (venous return) and on the pumping characteristics of the heart itself (cardiac function curves). One common way to analyze the blood circulation rate is to interrelate venous return and cardiac function curves. In this study, we used a similar technique to analyze lymph flow. We used lymphatic flow vs. outflow pressure (passive flow) relationships for nonpumping lymphatics to represent the inflow of lymph to the lymphatic pump. We used data on the pumping characteristics of postnodal lymphatic vessels to generate relationships between lymphatic pump outflow and pump inflow pressure (pump function curves), and then interrelated these curves. The results were not only similar to previously measured lymph flow data obtained from experimental animals, but also support the observation that under normal circumstances lymph flow is periodic and in surges (active pumping) but in edematogenic states lymph flows more continuously (i.e., passively).

Substance abuse in schizophrenia: service utilization and costs

Utilization and cost of institutional and outpatient services were prospectively measured over 1 year for three groups of schizophrenic patients: current substance abusers, past substance abusers, and those without a history of substance abuse. Current abusers had significantly greater utilization and cost of institutional (hospital and jail) services. Current abusers also had greater utilization of emergency services. There were no significant differences between the groups in utilization and cost of other services, including psychosocial rehabilitation, outpatient treatment (case management, psychotherapy, and psychiatric visits), and housing supports. The implications for developing cost-effective treatments for dually diagnosed individuals are discussed.

Detection of substance use disorders in severely mentally ill patients

Severe mental illness is frequently complicated by substance use disorder. Approximately half of the severely mentally ill patients treated in acute care psychiatric settings have abused one or more of these substances. Despite the high rate of comorbidity, substance use disorders are generally not detected in acute care psychiatric settings, leading to incorrect diagnoses and ineffective treatments. The reasons for nondetection are complex, and research is needed to refine instruments and procedures for the detection of substance abuse in the severely mentally ill population. Nevertheless, clinicians can make better use of existing techniques of multimodal assessment to increase significantly the rate of accurate detection.

Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes

In this pilot study, the authors assessed 4-year outcomes for 18 schizophrenic outpatients with alcoholism who were treated in an innovative dual-diagnosis program. Over half (61.1%) achieved stable remissions from alcoholism. The mean duration of remission was 26.5 months.

Detection of alcoholism in schizophrenia using the MAST

The classification accuracy of the Michigan Alcoholism Screening Test (MAST) for detecting alcoholism in a community sample of 75 schizophrenic outpatients was assessed, as a replication and extension of Searles et al. (1990). The criterion diagnosis of alcohol use disorder was based on the convergence of ratings from multiple sources. The MAST classified 85% of the sample correctly, and item-based analyses showed that various subsets were equally effective, indicating a high degree of redundancy among MAST items. Differences between our sample and that of Searles et al. influenced the choice of MAST items for optimal detection and classification, and males were consistently classified more correctly than females. These results suggest that the construction of a brief and accurate detection instrument for alcohol use among schizophrenic patients may be possible, although attention to subpopulation differences will be required.

Increased venous pressure causes increased thoracic duct pressure in awake sheep

The lymph from most organs drains through the thoracic duct and into veins in the neck. We hypothesized that increases in neck vein pressure (Pnv) are reflected through the thoracic duct to the lung lymphatic-thoracic duct junction. To test this, we cannulated the lung lymphatics in the direction of flow in four sheep. We advanced each cannula until it entered the thoracic duct. Thus the pressure at the tip of the lymphatic cannula (Px) was the pressure at the outflow of the lung lymphatics. We also placed a balloon into the superior vena cava. One to two days later, we measured Px in the awake sheep as we inflated the balloon and increased Pnv in steps to 25-45 cmH2O. We found no significant differences in Px and Pnv. Furthermore, Px closely followed Pnv after each step increase in Pnv. These results support our hypothesis that increases in Pnv cause increases in the outflow pressure to lung lymphatics.

Effect of increased neck vein pressure on intestinal lymphatic pressure in awake sheep

Lymphatic vessels from the intestines drain into the thoracic duct, and the thoracic duct empties into veins in the neck. Thus increases in neck vein pressure (PNV) might slow intestinal lymph flow, provided the increased pressure is reflected upstream through the lymphatic vessels. To test the effect of increases in PNV on lymphatic pressure, we cannulated intestinal lymphatics in the direction of flow in six sheep. After the sheep recovered from surgery, we measured the pressure in the lymphatics (Px) as we increased PNV in steps. Px increased only slightly (but significantly) from 7.4 +/- 2.0 to 11.4 +/- 5.2 (SD) cmH2O when we increased PNV from baseline (0.8 +/- 2.4 cmH2O) to 37.4 +/- 4.1 cmH2O. However, when we simulated an increased lymph flow by infusing Ringer solution into the lymphatics at 1,000 microliters/min, Px increased to 24.6 +/- 7.0 cmH2O at PNV equal to 37.1 +/- 5.3 cmH2O. These results indicate that, at normal lymph flow rates, increases in neck vein pressure cause only small increases in intestinal lymphatic pressure. On the other hand, when lymph flow is elevated, increases in neck vein pressure may substantially increase lymphatic pressure and thus slow intestinal lymph flow.

Alcohol abuse, depression, and suicidal behavior in schizophrenia

Alcohol use was correlated with depression and suicidal behavior in two independent studies of schizophrenic outpatients. Depression alone accounted for over 80% of the explained variance in suicidal behavior in both studies; alcohol use alone and the correlation between depression and alcohol use accounted for only small amounts of variance.

Mental patients' attraction to the hospital: correlates of living preference

Mental patients often show attraction to the hospital as a living alternative. In this study, 187 aftercare patients of an urban state hospital were examined for correlates of hospital attraction. Several variables, including background characteristics, psychosocial problems, psychiatric symptoms, substance abuse, and medication noncompliance, characterized the approximately 25% of the sample who showed hospital attraction. A logistic regression model for hospital attraction indicated that past hospital tenure, problems obtaining regular meals, positive symptoms of psychosis, and severe drug abuse contributed separately to the variance. The authors discuss the implications of these findings for treatment and public policy.

Diaphragmatic lymph vessel drainage of the peritoneal cavity

We have studied the drainage of peritoneal fluid through the diaphragmatic lymph vessels in sheep. To measure the lymphatic flow rate, we cannulated the lymphatic vessels and timed the flow from the cannula. After we infused Escherichia coli endotoxin into awake sheep, the diaphragmatic lymph flow rate increased substantially. However, we found no increase in lymph flow in anesthetized acutely operated sheep. This indicates that studies in anesthetized animals may yield underestimates of diaphragmatic lymph flow. In sheep, many of the diaphragmatic lymph vessels drain to the caudal mediastinal lymph node. We cannulated an efferent vessel from that node in 5 sheep. Several days later we infused 100 ml/kg of Ringer's solution into the abdominal space of each awake sheep. In response, the lymph flow rate increased from 0.15 +/- 0.16 ml/min (mean +/- SD) to 0.50 +/- 0.17 ml/min. Our results are important because they demonstrate that diaphragmatic lymph flow increases substantially after fluid infusions into the abdominal space.

Homelessness and dual diagnosis

People who are dually diagnosed with severe mental illness and substance use disorders constitute 10%-20% of homeless persons. They are a heterogeneous and extremely vulnerable subgroup with complex, poorly understood needs. In this article recent research on the epidemiology, subject characteristics, and service needs of the dually diagnosed homeless population is reviewed. Also, the range of evolving approaches to providing social services, housing, and mental health and substance-abuse treatments; the relevant system issues and legal issues; and problems with current research, as well as future research directions, are discussed. The importance of the distinction between providing appropriate living environments and mental health treatments emerges throughout.