Barriers to the treatment of social anxiety

OBJECTIVE

This article evaluates barriers to treatment reported by adults with social anxiety who participated in the 1996 National Anxiety Disorders Screening Day.

METHOD

The background characteristics of screening day participants with symptoms of social anxiety (N=6,130) were compared with those of participants without social anxiety (N=4,507). Barriers to previous mental health treatment reported by participants with and without symptoms of social anxiety were compared.

RESULTS

Social anxiety was strongly associated with functional impairment, feelings of social isolation, and suicidal ideation. Compared to participants without social anxiety, those with social anxiety were significantly more likely to report that financial barriers, uncertainty over where to go for help, and fear of what others might think or say prevented them from seeking treatment. However, they were significantly less likely to report they avoided treatment because they did not believe they had an anxiety disorder. Roughly one-third (N=1,400 of 3,682, 38.0%) of the participants with symptoms of social anxiety who were referred for further evaluation were specifically referred for an evaluation for social phobia.

CONCLUSIONS

Social anxiety is associated with a distinct pattern of treatment barriers. Treatment access may be improved by building public awareness of locally available services, easing the psychological and financial burden of entering treatment, and increasing health care professionals' awareness of its clinical significance.

Burden experienced by care-givers of persons with bipolar affective disorder

BACKGROUND

Family members of patients with schizophrenia frequently report burdens associated with caring for their relatives.

AIMS

We evaluate the impact of illness beliefs on the burden reported by family care-givers of people with bipolar illness.

METHOD

The multivariate relationships between patient symptomatology and family illness beliefs and report of burden were examined at baseline among care-givers of 266 patients with Research Diagnostic Criteria-diagnosed bipolar illness who were subsequently followed for 15 months.

RESULTS

At baseline, 93% of care-givers reported moderate or greater distress in at least one burden domain. As a group, care-giver illness beliefs (illness awareness, perception of patient and family control) explained an additional 18-28% of variance in burden experienced beyond the effects of the patient's clinical state and history.

CONCLUSIONS

Care-givers of patients with bipolar illness report widespread burden that is influenced by beliefs about the illness.

Mentally ill chemical abusers in residential treatment programs: effects of psychopathology on levels of functioning

Measures of psychopathology among mentally ill chemical abusers (MICAs) were examined as predictors of levels of functioning in two types of community based, residential programs: therapeutic community (TC) and community residence (CR). Non-significant associations were generally observed between scales of psychiatric symptoms (e.g., depression, psychotic ideation, cognitive disorientation, and hostility) and counselors' ratings of the residents' capacity to meet the social and interpersonal expectations of the programs (e.g., personal care, involvement in interpersonal relationships, and development of work skills). The study suggests that individuals with moderately severe psychopathology can be successfully engaged in residential treatment, even in programs with relatively high expectations for interpersonal involvement and functioning, such as the therapeutic community.

Effects of diagnosis, demographic characteristics, and case management on rehospitalization

OBJECTIVES

A randomized controlled study was conducted to assess the effects of case management and patients' characteristics on the use of inpatient psychiatric services.

METHODS

Inpatients discharged from Harlem Hospital Center in 1984-1985 were randomly assigned to an outreach case management team or standard aftercare. Analysis of variance was used to assess the main effects and two- and three-way interaction effects of treatment status, gender, age, substance abuse, and diagnosis on the number of days of psychiatric rehospitalization in state and city community hospitals.

RESULTS

In the follow-up period, 75 of the 146 patients in the case management group (51.4 percent) and 51 of the 143 patients in the control group (35.7 percent) were rehospitalized for psychiatric care. On average, patients spent 31.1 days in city hospitals and 26.6 days in state hospitals. Members of the case management team spent a mean total of 18.1 hours a month in direct and indirect care for each patient. They spent most time with substance-abusing older women. Significant three-way interaction effects were found between treatment status and diagnosis and gender, diagnosis and age, and diagnosis and substance abuse on the number of days patients spent rehospitalized for psychiatric care in city and state hospitals.

CONCLUSIONS

It is unlikely that case management intervention will reduce rehospitalization rates unless appropriate and effective outpatient and community services are available. Effective surveillance of patient populations by case managers frequently results in rehospitalization as the only treatment alternative if other options for meeting the needs and resolving the crises of patients are not available.

Deaths among former psychiatric inpatients in an outreach case management program

OBJECTIVE

The mortality rate of discharged psychiatric inpatients has long been known to be higher than that of persons in the general population. This study assessed the effectiveness of outreach case management in reducing the mortality rate of recently discharged psychiatric inpatients in New York City.

METHODS

A sample of 292 patients discharged from an inpatient psychiatry service at an urban general hospital were randomly assigned either to an intervention group (N = 147), which received intensive outreach case management for periods ranging from 15 to 52 months after discharge, or to a control group (N = 145), which received standard aftercare services. Both groups were offered and received regular aftercare and other services during the study period. Both groups were followed for comparable periods of time to determine their rate of mortality.

RESULTS

The overall mortality rate for the total group of 292 patients was 7.2 percent, 2.25 times higher than among persons in the general population matched for age, sex, and race. The mortality rates for the intervention group and the control group were 7.5 percent and 6.9 percent, respectively, not a significant difference.

CONCLUSIONS

Discharged psychiatric inpatients who received outreach case management did not have a lower mortality rate than similar patients who did not receive this intervention.

Reliability and validity of a measure of sexual and physical abuse histories among women with serious mental illness

OBJECTIVE

The purpose of this paper is to describe a standardized questionnaire of histories of abuse among women with serious and persistent mental illness, and to assess its test-retest reliability and its validity.

METHODS

Seventy women enrolled in an outpatient clinic were asked about childhood histories of physical and sexual abuse in a structured clinical interviews at two times.

RESULTS

Test-retest reliability yielded a Kappa of .63 for the measure of physical abuse, and .82 for the measure of sexual abuse. Validity, assessed as consistency with an independent clinical assessment, showed 75% agreement for reports of physical abuse, and 93% agreement for reports of sexual abuse.

CONCLUSIONS

Childhood histories of physical and sexual abuse can be reliably and validly assessed in women with severe and persistent mental illness using a standardized instrument.

Public knowledge, attitudes, and beliefs about homeless people: evidence for compassion fatigue

Media reports suggest that the public is becoming impatient with the homeless--that so-called "compassion fatigue" has gripped the nation. This characterization of public sentiment could have important policy consequences-- restrictive measures can be justified by growing public impatience, and progressive housing policies seem feasible within a hostile climate of opinion. But evidence to support the compassion fatigue notion is anecdotal. We examine the issue by tracking the results of public opinion polls and by reporting detailed evidence from a nationwide random-digit dial telephone survey (N = 1,507) concerning knowledge attitudes and beliefs about homeless people. To be sure, the public sees homelessness as an undesirable social problem and wants something done about it. However, although the homeless are clearly stigmatized, there is little evidence to suggest that the public has lost compassion and is unwilling to support policies to help homeless people.

Prediction of special education placement from birth certificate data

The overall goal of this research effort was to develop procedures for accurately identifying children at high risk for special education placement, based on information available at the time of birth. A file containing information on all births in New York City between 1976 and 1986 was matched against the 1992 BIOFILE, which contains information on all children enrolled in the New York City public school system in 1992. A matched file containing birth and school information on 471,165 children resulted from this process. Three sets of risk factors were derived from birth certificate data: parental, pregnancy-related, and child-related. Using these risk factors as independent variables, a survival analysis model was developed predicting special education placement for each of three major disability categories: learning disability, emotional disorder, and mental retardation. A model combining all disability categories was also developed. The significant predictors of special education placement were Medicaid payment for birth (a poverty indicator), unmarried status of mother, large family size, low parental education, a mother born in the United States, a low level of prenatal care, male gender, low birthweight, and a low Apgar score. Male gender was the strongest risk factor in all models. Examination of selected survival curves indicated that the predictive power of the models is substantial. The methodology described in this article can be used to identify at-risk children for whom screening and other early interventions, including preschool programs, may be appropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

Lifetime and five-year prevalence of homelessness in the United States

OBJECTIVE

Intense debate exists concerning the number of homeless people in the United States. Previous studies, counting currently homeless people, have provided point-prevalence estimates of homelessness but have been criticized on methodological grounds. This study reports lifetime and 5-year prevalence estimates of homelessness using a different methodological approach.

METHODS

Random-digit dialing was used to interview 1507 adults living in households with telephones in the 48 contiguous states in the fall of 1990. Respondents were asked whether they had ever been homeless and if so, where they had slept while homeless.

RESULTS

Lifetime and 5-year prevalence of all types of homelessness combined were 14.0% (26 million people) and 4.6% (8.5 million people), respectively. Lifetime "literal homelessness" (sleeping in shelters, abandoned buildings, bus and train stations, etc.) was 7.4% (13.5 million people). Five-year (1985 through 1990) prevalence of self-reported homelessness among those who had ever been literally homeless was 3.1% (5.7 million people).

CONCLUSIONS

The magnitude of the problem of homelessness is much greater than most previous attempts to enumerate homeless people have led us to believe. This finding requires reconsideration of inferences about the causes of homelessness that were derived from point-prevalence studies of currently homeless people.

Using census and mortality data to target small areas for breast, colorectal, and cervical cancer screening

OBJECTIVES

The goal of this study was to develop and validate quantitative models for estimating cancer incidence in small areas.

METHODS

The outcome for each cancer site was the incidence of disease that had reached a late stage at the time of diagnosis. Two sets of predictors were used: (1) census-based demographic variables and (2) census-based demographic variables together with the cancer-specific mortality rate.

RESULTS

The best models accounted for a substantial percentage of between area variability in late-stage rates for cancer of the breast (46%), cervix (61%), and colon/rectum (58%). A validation procedure indicated that correct identification of small areas with high rates of late-stage disease was two to three times more likely when model-based estimates were used than when areas were selected at random.

CONCLUSIONS

Additional testing is needed to establish the generality of the geographic targeting methodology developed in this paper. However, there are strong indications that small-area estimation models will be useful in many regions where planners wish to target cancer screening programs on a geographic basis.

Childhood abuse and neglect among women outpatients with chronic mental illness

OBJECTIVE

The purposes of the study were to determine the prevalence of childhood sexual abuse, physical abuse, and neglect among women outpatients with severe and persistent mental illness; to examine patterns of co-occurrence of the various types of abuse; and to explore the relationships between childhood abuse and adult psychiatric symptomatology.

METHODS

Childhood histories of abuse and data on clinical characteristics of 78 women enrolled in a New York State outpatient clinic were elicited in face-to-face interviews using a structured questionnaire.

RESULTS

Sixty-five percent of the women reported histories of some type of abuse or neglect during childhood. Forty-five percent of the sample had been sexually abused, 51 percent had been physically abused, and 22 percent had experienced neglect. Seventy-four percent of the sexually abused women, 70 percent of the physically abused women, and 94 percent of the women who experienced neglect reported at least one additional form of abuse or neglect. Respondents who had been abused in childhood had higher levels of depressive and psychotic symptoms and higher rates of sexual victimization in adulthood than those who had not been abused. Women who experienced neglect as children had higher rates of homelessness in adulthood.

CONCLUSIONS

Chronic mentally ill women seem to experience higher rates of abuse and more types of abuse than the general population. Clinicians should try to determine whether chronic mentally ill women have histories of abuse and to develop interventions to meet their special needs.

Effect of case management on rehospitalization and utilization of ambulatory care services

To explore whether intensive case management would reduce discharged psychiatric inpatients' rates of rehospitalization and increase their use of outpatient ambulatory care services, the authors assigned 435 patients discharged from a public general hospital in New York City to three types of postdischarge services: multidisciplinary intensive outreach case management, less intensive Community Support System (CSS) case management services, or routine aftercare but no case management. Patients eligible for CSS were generally more impaired and had more extensive histories of psychiatric hospitalization. At follow-up 18 to 52 months after entering the study, patients who received intensive outreach case management had twice as many psychiatric hospitalizations as the routine aftercare group and had a pattern of utilization of hospital-based ambulatory care services similar to the more impaired CSS group. Intensive outreach case management did not appear to stimulate sufficient use of ambulatory care services to reduce patients' frequency of psychiatric hospitalization.

Diagnosis of dementia in a heterogeneous population. A comparison of paradigm-based diagnosis and physician's diagnosis

Each of 430 subjects received a diagnosis using two independent methods: a test-based quantitative paradigm and a semistructured neurological examination by a physician. The paradigm diagnosis was based on a battery of tests that assessed short- and long-term verbal memory and short-term nonverbal memory, orientation, construction, abstract reasoning, and language. The subjects came from a community in Manhattan County, in New York City, and were characterized by diversity with respect to both ethnicity (29.1% black, 33.4% Hispanic) and educational level (23.5% with 6 or fewer years of education, 25.6% college educated). Based on the paradigm, 10.5% of subjects received diagnoses of dementia, 29.1% of cognitive impairment, and 60.5% of normal. Based on the physician's diagnosis, 9.8% were demented, 21.6% cognitively impaired, and 68.6% normal. There was agreement between the two diagnostic methods for 71.8% of subjects. Diagnostic disagreement (n = 121) was in most cases between normal and cognitively impaired (71.0%) or between cognitively impaired and demented (21.5%). There were only nine cases (7.5%) in which a subject was judged demented by one method and normal by the other. The reliability of each method with respect to the other was moderate (intraclass correlation coefficient, .62), while the reliability of a composite diagnosis based on both methods was much higher (.77). The paradigm was more likely than the physician to give the diagnosis of dementia to patients with low educational levels. The physician's diagnosis was strongly influenced by measures of functioning and by the mental status test administered in the semistructured neurological examination. Race and diagnosis were not related when the effect of education was controlled.(ABSTRACT TRUNCATED AT 250 WORDS)

A typology based on measures of substance abuse and mental disorder

The data of this study were derived from comprehensive interviews of 311 women and 949 men residing in the New York City public shelters for homeless adults during the summer of 1987. Interviews, guided by a 57 page interview protocol, were conducted by thoroughly trained interviewers who had worked in agencies and service systems focused on mental disorders, child abuse, substance abuse and problems of homeless people. Included in the content of the interview were seven dichotomous measures of substance use, substance abuse and mental disorder. A typology of ten groups comprised of individuals with similar profiles on the seven measures served as the independent variable. Three pairs of dependent variables were suicide attempts and current thoughts of suicide, a need for medical services reported by shelter residents and by their interviewers, and disclosure of a drug problem and a need for help in treating it. Consistently meaningful associations between group memberships and the 3 pairs of dependent variables, and 16 measures of health status in previous work, were interpreted as evidence for predictive validity of the typology.

Diagnosis of physical illness in psychiatric patients using axis III and a standardized medical history

Psychiatrists' axis III diagnoses of physical illnesses in 357 psychiatric patients were compared with diagnoses by a physician's assistant using a standardized medical history form. The physician's assistant detected nearly three times as many physical illnesses as the psychiatrists. The psychiatrists were significantly more likely to miss diagnoses among older patients and women. Patients who met criteria for depressive disorders appeared to be at greatest risk for undetected illnesses, followed by patients with bipolar disorders and schizophrenia. Patients with a secondary diagnosis of substance abuse had significantly more undetected illness than those who did not abuse substances. The authors suggest that current axis III guidelines are inadequate and that a systematic review of physical health problems should be part of the psychiatric diagnostic assessment.

Geographically-based cancer control: methods for targeting and evaluating the impact of screening interventions on defined populations

Successful implementation of cancer control programs depends on efficient targeting to those at highest risk of developing and dying from the disease. This study presents a methodology for targeting cancer screening on the basis of population and disease variation among small geographic areas. Techniques for quantifying the impact of targeting on the predictive value of a positive test are demonstrated, using 329 New York City health areas. Age-truncated crude incidence, late-stage incidence and mortality rates for breast, cervix, and colorectal cancer are used, using site-specific truncation points relevant to the age groups appropriate for screening. Coefficient alpha was used to determine rate stability with 2, 3, 5 and 7 years of data. The stability of most small area rates was found to reach acceptable levels only with 5 and 7 years of data. Targeting into areas where breast cancer prevalence was high increased the expected predictive value of a positive test by as much as 50% when compared with areas of average prevalence. Geographic targeting will be most useful where between-area variability in prevalence is large and within-area variability is small. The implications of these results are discussed and future studies are suggested.

The use of zip coded population data in social area studies of service utilization

Social area analysis (SAA) is a well-established methodology for geographically based analysis of service delivery and other health related outcome measures. However, SAA has been limited in application by the complexities of computerized geocoding and difficulties in obtaining appropriate measures of community characteristics. In this paper we demonstrate that these problems can be overcome by employing zip code as well as the unit of analysis for SAA and obtaining commercially available measures of community characteristics. Regression analyses, using New York City zip code populations as the unit of observation were used to illustrate the role of epidemiologic risk factors in predicting rates of inpatient discharge and ambulatory care visits.

Race, poverty, and survival in multiple myeloma

To identify possible interracial differences in the behavior of multiple myeloma, the records of 52 black myeloma patients at Harlem Hospital Center (HHC) and 46 black and 46 white patients at Columbia-Presbyterian Medical Center (CPMC) were reviewed. In addition to clinical variables such as tumor burden, azotemia, and hypoalbuminemia, the effect of poverty on prognosis was examined, using socioeconomic indices from the United States census block group data of each patient. The median survival of CPMC black and white patients was comparable (34 and 29 months, respectively) whereas that of the HHC group was 12 months (Breslow test, P less than 0.0001). Overcrowding and hypoalbuminemia were the most significant prognostic factors by multivariate regression analysis on all 144 patients (P = 0.001); for HHC patients, overcrowding was the single significant variable affecting survival (P = 0.004). By all socioeconomic indices, HHC patients were more impoverished than CPMC patients (P less than 0.001); they also presented with more advanced disease. Race is not a significant prognostic factor in myeloma, whereas the effect of socioeconomic status on survival appears to equal that of previously described clinical features.

Measurements of social support in schizophrenia

A selective review of the literature reveals some methods and instruments that show promise for the investigation of social support as a factor in the course and treatment of schizophrenia. Approaches are divided into social-psychological questionnaires, anthropological network studies, ethnographies, and clinical epidemiological investigations. Social support measures designed for the general population probably have little relevance in schizophrenia. It appears that the most useful information comes from immersion in the experience of the patients, families, and caretakers rather than from an effort to develop a measure of social support in general that would be applicable to them.

Some indications of the long-term health effects of a natural disaster

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Emotional and physical distress following Hurricane Agnes in Wyoming Valley of Pennsylvania

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Prognostic correlates of psychotherapy in psychiatric outpatients

The authors examined the follow-up data for 113 psychiatric outpatients who had been treated for up to a year in an outpatient community mental health center. Correlations between therapist and patient ratings of improvement were generally low, and anlayses were done separately for therapist and patient ratings. The strongest confirmed hypothesis was the relationship between therapist and patient ratings of improvement and therapist and patient evaluations of each other as likable, physically attractive, and either a good patient for treatment or a competent therapist. The authors discuss the advantages and disadvantages of multivariate statistics for the analysis of psychotherapy data.