Associations of Mortality Outcomes With Employment Status at Discharge From VA Vocational Rehabilitation Service Programs

OBJECTIVE

The authors evaluated associations between employment at discharge from Veterans Health Administration Vocational Rehabilitation Service (VR) programs and suicide and other causes of death.

METHODS

For veterans receiving VR between October 1, 2005, and September 30, 2014 (N=78,293), proportional hazards analyses were used to test associations of employment with suicide, drug overdose, and external and natural cause mortality rates over 1 and 5 years postdischarge and through December 31, 2019. The analyses were adjusted for clinical and sociodemographic characteristics and propensity for employment.

RESULTS

Of the veterans, 94.1% had a psychiatric diagnosis, and 35.5% were employed at VR discharge. In proportional hazards analyses, employment was associated with lower mortality rates through 1 year (suicide, hazard ratio [HR]=0.54; overdose, HR=0.70; external causes, HR=0.62; and natural causes, HR=0.51) and 5 years postdischarge (overdose, HR=0.72; external causes, HR=0.81; and natural causes, HR=0.72). Through December 31, 2019, employment was associated with lower risks for overdose (HR=0.80) and death by external (HR=0.81) and natural (HR=0.80) causes.

CONCLUSIONS

Employment at VR discharge was associated with lower mortality risk among veterans with psychiatric diagnoses.

Care Retention Among Veterans with Serious Mental Illness who were once lost-to-Veterans Health Administration care

OBJECTIVE

To evaluate care retention among Veterans with serious mental illness (SMI) who were lost to Veterans Health Administration (VHA) care for at least one year and subsequently returned to VHA care via the SMI Re-Engagement program, an outreach program for Veterans with SMI who are lost-to-care.

METHODS

For the 410 Veterans with SMI who returned to care via SMI Re-Engagement between April 4th, 2016 and January 31, 2018, we assessed VHA in-person and telehealth utilization (overall, primary care, mental health care) for two years following the date of return to care.

RESULTS

Care retention was common: 70.2% of Veterans had at least one encounter in each year of the two-year follow-up period and an additional 22.7% had at least one encounter during one of the two years. During the two-year follow-up period, 72.4% of Veterans had at least one primary care encounter and 70.7% of Veterans had at least one mental health care encounter. Adjusted binomial logistic regression analyses found a return-to-care encounter in primary care (OR = 2.70; 95% CI: 1.34, 5.42) predicted primary care retention, and a return-to-care encounter in mental health care (OR = 4.01; 95% CI: 2.38, 6.75) predicted mental health care retention.

CONCLUSION

Most Veterans who return to care via the SMI Re-Engagement program remain in VHA care for the subsequent two years.

Behavioral Health Provider Burnout and Mental Health Care in the Veterans Health Administration

BACKGROUND

Although many studies assess predictors of provider burnout, few analyses provide high-quality, consistent evidence on the impact of provider burnout on patient outcomes exist, particularly among behavioral health providers (BHPs).

OBJECTIVE

To assess the impact of burnout among psychiatrists, psychologists, and social workers on access-related quality measures in the Veterans Health Administration (VHA).

DESIGN

This study used burnout in VA All Employee Survey (AES) and Mental Health Provider Survey (MHPS) data to predict metrics assessed by the Strategic Analytics for Improvement and Learning Value, Mental Health Domain (MH-SAIL), VHA's quality monitoring system. The study used prior year (2014-2018) facility-level burnout proportion among BHPs to predict subsequent year (2015-2019) facility-level MH-SAIL domain scores. Analyses used multiple regression models, adjusting for facility characteristics, including BHP staffing and productivity.

PARTICIPANTS

Psychologists, psychiatrists, and social workers who responded to the AES and MHPS at 127 VHA facilities.

MAIN MEASURES

Four compositive outcomes included two objective measures (population coverage, continuity of care), one subjective measure (experience of care), and one composite measure of the former three measures (mental health domain quality).

KEY RESULTS

Adjusted analyses showed prior year burnout generally had no impact on population coverage, continuity of care, and patient experiences of care but had a negative impact on provider experiences of care consistently across 5 years (p < 0.001). Pooled across years, a 5% higher facility-level burnout in AES and MHPS had a 0.05 and 0.09 standard deviation worse facility experiences of care from the prior year, respectively.

CONCLUSIONS

Burnout had a significant negative impact on provider-reported experiential outcome measures. This analysis showed that burnout had a negative effect on subjective but not on objective quality measures of Veteran access to care, which could inform future policies and interventions regarding provider burnout.

An examination of predisposing and enabling factors that predict dental utilization among individuals with serious mental illness in Detroit, Michigan

OBJECTIVES

This study evaluated which predisposing and enabling factors prospectively predicted dental utilization over 6 months among people with serious mental illness.

METHODS

A sample of individuals with serious mental illness (86.3% African American; 97.4% with public health insurance) was recruited from community mental health centres in Detroit, Michigan, and responded to questionnaires at baseline and at least one follow-up visit at 3 or 6 months (N = 190). Baseline assessments included demographic and clinical information, established measures of health literacy, health insurance literacy, stigma related to mental illness, experiences of racial discrimination and medical mistrust. Insurance coverage for dental care and the availability of dental services at the participants' mental health centres was recorded. At follow-up visits, participants reported healthcare utilization, including dental and primary care, since baseline.

RESULTS

Three factors emerged as meaningful predictors of having a dental visit in bivariate and multivariate analyses: more medical comorbidities and dental care co-located with mental health care predicted increased likelihood of a dental visit, whereas having experienced racial discrimination in a medical setting predicted lower odds of having a dental visit in the follow-up period. Co-location of dental care with mental health care was the strongest predictor of having a dental visit.

CONCLUSIONS

Co-locating dental care with mental health care may increase dental utilization among people with serious mental illness, possibly by mitigating known barriers to dental care for this population. Among African Americans, the co-location of dental care with mental health care may also attenuate the negative effect of prior racial discrimination in a medical setting on dental utilization.

Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration

Objective

To identify work–environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers.

Data Sources

The 2015–2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility‐level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities.

Study Design

For AES and MHPS separately, we used mixed‐effects logistic regression to predict BHP burnout using surveys from year pairs (2015–2016, 2016–2017, 2017–2018; six models). Within each year‐pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work–environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts.

Data Collection/Extraction Methods

We included work–environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS).

Principal Findings

In 2015–2018, 31.0%–38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well‐coordinated; and three reverse‐coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility‐level staffing ratios and productivity did not significantly predict individual‐level burnout. Workload represented the strongest predictor of burnout in both surveys.

Conclusions

This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.

Characterizing suicide-related self-disclosure by peer specialists: a qualitative analysis of audio-recorded sessions

Objective

We characterized peer support specialists' self-disclosures related to suicide and recipient responses to inform services for high-risk individuals that may include peer support.

Method

We used an inductive approach and thematic analysis to identify themes from audio recordings of initial sessions between peer support specialists trained in suicide-related self-disclosure and 10 study participants who were admitted to inpatient psychiatry units with suicidal ideation or a suicide attempt.

Results

The first theme, "I've been suicidal, but those details are not important", reflects that peers mentioned suicide-related aspects of their histories briefly, often as part of introductions, without participants responding specifically to those aspects. The second theme, "Being suicidal is one of the challenges I've faced", reflects that in more detailed disclosures by peer specialists and in participant responses, suicide is a part of the mental health challenges and life stressors discussed, not the focus. The third theme "Let's focus on my recovery and what I've learned" reflects that peers steered their self-disclosures away from suicide and towards what was helpful in their recovery.

Conclusions

Suicide-related self-disclosures embedded within peer specialists' introduction or overall recovery narrative convey a shared experience while focusing conversation on mental health challenges other than suicide.

Outreach to facilitate return to VA care for veterans with serious mental illness: A mixed-methods evaluation of best practices

Outreach to people with serious mental illness who are disengaged from treatment can facilitate return to care. However, little is known regarding what outreach strategies are effective. This mixed-methods evaluation assessed best practices for conducting outreach to Veterans with serious mental illness via the national Veterans Health Administration Re-Engaging Veterans with Serious Mental Illness program by comparing the strategies used by high-performing sites and low-performing sites. Quantitative data included the types and number of contact attempts used to reach Veterans. Qualitative data included interviews with clinicians from high- and low-performing sites. Results indicated making at least four contact attempts using methods of phone, certified letter, and next of kin differentiated high from low-performing facilities. Clinicians from high-performing sites also differed from low-performing sites in their expressed philosophy about outreach, demonstrated a broader array of strategies in attempting to contact Veterans, and described greater connections with others at their site, with clinicians around the country, and with national program resources. Implications of evaluation findings for outreach programs and research are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Access to timely mental health care treatment initiation among Veterans Health Administration patients with and without serious mental illness

Timely care initiation is a priority within the Veterans Health Administration (VHA). Patients with serious mental illnesses (SMI) are a group that benefits from timely care initiation due to elevated risks of negative outcomes with delayed care. However, no evaluation has assessed whether VHA SMI patients disproportionately experience delays in mental health care initiation. VHA administrative care data were used to compare delays in mental health care initiation for VHA patients with and without SMI who had newly identified mental health needs. Analyses assessed rates of delayed initial mental health appointments within five settings (General Mental Health [GMH], Primary Care Mental Health Integration [PC-MHI], Post-Traumatic Stress Disorder [PTSD], Substance Use Disorder [SUD], and Psychosocial Rehabilitation clinics [PSR]). SMI patients were more likely to receive delayed initial appointments in three of five clinical settings (PTSD, SUD, PSR) and had significantly longer average wait times for an initial appointment when referred to the PTSD clinic for an initial appointment. Overall, SMI patients were equally as likely to receive delayed initial appointments. While VHA SMI patients were not more likely to experience delayed mental health care initiation overall, they were more likely to experience delays within three of the five treatment settings. Findings suggest that the majority of VHA SMI patients experience equivalent timeliness, though those with more complex needs, and particularly those with trauma-related care needs, may be more likely to experience treatment initiation delays. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Employment After Vocational Rehabilitation Predicts Decreased Health Care Utilization in Veterans With Mental Health Diagnoses

INTRODUCTION

Although the benefits of employment for veterans with mental health conditions are well-known, the effect of veterans' employment on a health system has not been evaluated. The purpose of this study was to evaluate the effect of veterans' employment (versus unemployment) on subsequent health care utilization in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

This study used a sample of 29,022 veterans with mental health and substance use disorders who were discharged from VHA's employment services programs between fiscal years 2006 and 2010. Veterans' employment status (employed/unemployed) upon discharge from VHA employment programs was ascertained from program discharge forms and linked with VHA administrative health care utilization data for the subsequent 1- and 5-year periods.

RESULTS

Multivariable ordinary least-squares and logistic regression models adjusted for site clustering and covariates indicated that employment (versus unemployment) predicted less health care utilization 1 year and 5 years post-discharge from employment services, including fewer outpatient mental health visits, homelessness services visits, employment services visits, primary care visits, and lower odds of mental health hospitalizations, mental health or vocational rehabilitation residential stays, and medical hospitalizations. Employment did not predict emergency department visits.

CONCLUSIONS

VHA's investment in employment services for veterans with mental health and substance use disorders could reduce health care utilization system wide.

Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care

OBJECTIVE

This study tested whether computerized cognitive-behavioral therapy for depression supported by a peer specialist with lived experience of depression (PS-cCBT) improves mental health-related outcomes for primary care patients.

METHODS

In the U.S. Department of Veterans Affairs, primary care patients with a new diagnosis of depression (N=330) were randomly assigned to 3 months of PS-cCBT or a usual-care control condition. Linear mixed-effects models were used to assess differences in depression symptoms, general mental health status, quality of life, and mental health recovery measured at baseline and 3 and 6 months.

RESULTS

In adjusted analyses, participants who received PS-cCBT experienced 1.4 points' (95% confidence interval [CI]=0.3-2.5, p=0.01) greater improvement in depression symptoms on the Quick Inventory of Depression Symptomatology-Self Report at 3 months, compared with the control group, but no significant difference was noted at 6 months. PS-cCBT recipients also had 2.6 points' (95% CI=0.5-4.8, p=0.02) greater improvement in quality of life at 3 months on the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form and greater improvement in recovery on the Recovery Assessment Scale at 3 months (3.6 points; 95% CI=0.9-6.2, p=0.01) and 6 months (4.5 points; 95% CI=1.2-7.7, p=0.01).

CONCLUSIONS

PS-cCBT is an effective option for improving short-term depression symptoms and longer-term recovery among primary care patients newly diagnosed as having depression.

Peer mentorship to reduce suicide attempts among high-risk adults (PREVAIL): Rationale and design of a randomized controlled effectiveness-implementation trial

RATIONALE

Novel approaches to suicide prevention are needed to address increasing rates of suicide deaths. Research suggests that interventions led by certified Peer Specialists may improve suicide protective factors such as hope and connectedness; however, the effectiveness of a Peer Specialist intervention for reducing suicidal thoughts or behaviors has not previously been tested empirically.

DESIGN

We describe the methodology of a randomized controlled hybrid effectiveness-implementation trial of a peer specialist intervention known as PREVAIL (Peers for Valued Living). The primary effectiveness aim is to determine whether the 3-month peer mentorship intervention compared to a minimally enhanced usual care condition reduces suicide attempts and suicidal ideation among adults at high risk for suicide who have been psychiatrically hospitalized. Secondary effectiveness outcomes include medically serious suicide attempts according to chart review and self-reported self-efficacy to avoid suicide. We also describe suicide risk management, supervision, and fidelity monitoring in the context of Peer Specialist providers and our methods for assessing implementation barriers and facilitators.

CONCLUSION

The PREVAIL trial will demonstrate novel methods for incorporating peer providers into a suicide prevention effectiveness trial with high-risk study participants. PREVAIL's hybrid effectiveness-implementation design aims to maximize the likelihood of rapid implementation in the community if shown to be effective.

Unifying the Hydrogen Evolution and Oxidation Reactions Kinetics in Base by Identifying the Catalytic Roles of Hydroxyl-Water-Cation Adducts

Despite the fundamental and practical significance of the hydrogen evolution and oxidation reactions (HER/HOR), their kinetics in base remain unclear. Herein, we show that the alkaline HER/HOR kinetics can be unified by the catalytic roles of the adsorbed hydroxyl (OH_ad)-water-alkali metal cation (AM⁺) adducts, on the basis of the observations that enriching the OH_ad abundance via surface Ni benefits the HER/HOR; increasing the AM⁺ concentration only promotes the HER, while varying the identity of AM⁺ affects both HER/HOR. The presence of OH_ad-(H₂O) _x-AM⁺ in the double-layer region facilitates the OH_ad removal into the bulk, forming OH^--(H₂O) _x-AM⁺ as per the hard-soft acid-base theory, thereby selectively promoting the HER. It can be detrimental to the HOR as per the bifunctional mechanism, as the AM⁺ destabilizes the OH_ad, which is further supported by the CO oxidation results. This new notion may be important for alkaline electrochemistry.

Enhancing Treatment Reengagement for Veterans With Serious Mental Illness: Evaluating the Effectiveness of SMI Re-Engage

OBJECTIVE

This evaluation assessed the effectiveness of the Veterans Health Administration (VHA) program Reengaging Veterans With Serious Mental Illness in Treatment (SMI Re-Engage). The program serves veterans with serious mental illness who experience extended gaps in use of VHA care.

METHODS

Propensity score-weighted survival analysis that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage predicted return to VHA care within 18 months of when clinicians received patient contact information and, among veterans contacted, whether return to VHA care was associated with mortality risk within the 18-month follow-up period. Among all veterans who returned to care, a post hoc propensity score-weighted logistic regression that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage was associated with returning to outpatient care versus inpatient or emergency care.

RESULTS

Of veterans contacted (N=886), 42% returned to care, compared with 27% of veterans whom providers attempted to contact but could not reach (N=2,059). When analyses adjusted for covariates, veterans who were contacted had a higher risk of returning to care (hazard ratio (HR)=3.40, 95% confidence interval [CI]=2.70-4.28). Among veterans contacted, the association between return to VHA care and mortality risk was not significant. Post hoc analyses for veterans who returned to care (N=941) indicated that being contacted (versus not being contacted) was associated with higher odds of returning to outpatient care (versus inpatient or emergency care) (odds ratio=2.42, CI=1.68-3.47).

CONCLUSIONS

SMI Re-Engage contact facilitated return to VHA care. SMI Re-Engage exemplifies how population health strategies can address health care discontinuities among people with serious mental illness.

Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies

Background

Organizational culture and climate are considered key factors in implementation efforts but have not been examined as moderators of implementation strategy comparative effectiveness. We investigated organizational culture and climate as moderators of comparative effectiveness of two sequences of implementation strategies (Immediate vs. Delayed Enhanced Replicating Effective Programs [REP]) combining Standard REP and REP enhanced with facilitation on implementation of an outreach program for Veterans with serious mental illness lost to care at Veterans Health Administration (VA) facilities nationwide.

Methods

This study is a secondary analysis of the cluster-randomized Re-Engage implementation trial that assigned 3075 patients at 89 VA facilities to either the Immediate or Delayed Enhanced REP sequences. We hypothesized that sites with stronger entrepreneurial culture, task, or relational climate would benefit more from Enhanced REP than Standard REP. Veteran- and site-level data from the Re-Engage trial were combined with site-aggregated measures of entrepreneurial culture and task and relational climate from the 2012 VA All Employee Survey. Longitudinal mixed-effects logistic models examined whether the comparative effectiveness of the Immediate vs. Delayed Enhanced REP sequences were moderated by culture or climate measures at 6 and 12 months post-randomization. Three Veteran-level outcomes related to the engagement with the VA system were assessed: updated documentation, attempted contact by coordinator, and completed contact.

Results

For updated documentation and attempted contact, Veterans at sites with higher entrepreneurial culture and task climate scores benefitted more from Enhanced REP compared to Standard REP than Veterans at sites with lower scores. Few culture or climate moderation effects were detected for the comparative effectiveness of the full sequences of implementation strategies.

Conclusions

Implementation strategy effectiveness is highly intertwined with contextual factors, and implementation practitioners may use knowledge of contextual moderation to tailor strategy deployment. We found that facilitation strategies provided with Enhanced REP were more effective at improving uptake of a mental health outreach program at sites with stronger entrepreneurial culture and task climate; Veterans at sites with lower levels of these measures saw more similar improvement under Standard and Enhanced REP. Within resource-constrained systems, practitioners may choose to target more intensive implementation strategies to sites that will most benefit from them.

Trial registration

ISRCTN: ISRCTN21059161. Date registered: April 11, 2013.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0787-9) contains supplementary material, which is available to authorized users.

Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the Behavioral Health Interdisciplinary Program (BHIP)

In the past decade, the demand for Veterans Health Administration (VHA) mental health care has increased rapidly. In response to the increased demand, the VHA developed the Behavioral Health Interdisciplinary Program (BHIP) team model as an innovative approach to transform VHA general outpatient mental health delivery. The present formative evaluation gathered information about pilot implementation of BHIP to understand the struggles and successes that staff experienced during facility transitions to the BHIP model. Using a purposive, nonrandom sampling approach, we conducted 1-on-1, semistructured interviews with 37 licensed and nonlicensed clinical providers and 13 clerical support staff assigned to BHIP teams in 21 facilities across the VHA. Interviews revealed that having actively involved facility mental health leaders, obtaining adequate staffing for teams to meet the requirements of the BHIP model, creating clear descriptions and expectations for team member roles within the BHIP framework, and allocating designated time for BHIP team meetings challenged many VHA sites but are crucial for successful BHIP implementation. Despite the challenges, staff reported that the transition to BHIP improved team work and improved patient care. Staff specifically highlighted the potential for the BHIP model to improve staff working relationships and enhance communication, collaboration, morale, and veteran treatment consistency. Future evaluations of the BHIP implementation process and BHIP team functioning focusing on patient outcomes, organizational outcomes, and staff functioning are recommended for fully understanding effects of transitioning to the BHIP model within VHA general mental health clinics and to identify best practices and areas for improvement. (PsycINFO Database Record

Competitive Employment Outcomes Among Veterans in VHA Therapeutic and Supported Employment Services Programs

OBJECTIVE

The study assessed whether receiving specific types of Veterans Health Administration (VHA) Therapeutic and Supported Employment Services (TSES) between fiscal years (FYs) 2006 and 2010 (a time frame that encompasses the Great Recession) was associated with obtaining competitive employment among veterans with mental illnesses.

METHODS

The sample included 38,199 veterans discharged from the VHA's TSES program in FY 2006 through FY 2010. On the basis of program monitoring forms completed by TSES clinicians and workload data, veterans were classified as having received one main type of employment service: supported employment (SE), transitional work in the community (TW-community), transitional work in a Department of Veterans Affairs medical center (TW-VA), incentive therapy or sheltered workshop (IT/SW), and no main type of employment service.

RESULTS

Compared with veterans who received TW-VA, those who received SE (odds ratio [OR]=1.25) or TW-community (OR=1.24) were more likely to be competitively employed (p<.001), and veterans who received IT/SW were less likely (OR=.85) (p<.001). The predicted probabilities for obtaining competitive employment ranged from 27.2% (IT/SW) to 34.9% (SE). Odds of achieving competitive employment (ORs=.60-.97) were significantly lower during the years of the Great Recession (2007-2009) and in the subsequent year (2010), compared with the year prior (p<.001 to <.05).

CONCLUSIONS

Although rates of competitive employment were modest across all types of services, community-based employment services were associated with higher odds of achieving competitive employment, compared with services based in a medical center. The Great Recession negatively affected the likelihood of achieving competitive employment, regardless of the employment service received.

Resolving the Iron Phthalocyanine Redox Transitions for ORR Catalysis in Aqueous Media

Metal macrocycles are among the most important catalytic systems in electrocatalysis and biocatalysis owing to their rich redox chemistry. Precise understanding of the redox behavior of metal macrocycles in operando is essential for fundamental studies and practical applications of this catalytic system. Here we present electrochemical data for the representative iron phthalocyanine (FePc) in both aqueous and nonaqueous media coupled with in situ Raman and X-ray absorption analyses to challenge the traditional notion of the redox transition of FePc at the low potential end in aqueous media by showing that it arises from the redox transition of the ring. Our data unequivocally demonstrate that the electron is shuttled to the Pc ring via the Fe(II)/Fe(I) redox center. The Fe(II)/Fe(I) redox transition of FePc in aqueous media is indiscernible by normal spectroscopic methods owing to the lack of a suitable axial ligand to stabilize the Fe(I) state.

Employment status, employment functioning, and barriers to employment among VA primary care patients

BACKGROUND

Prior research found lower employment rates among working-aged patients who use the VA than among non-Veterans or Veterans who do not use the VA, with the lowest reported employment rates among VA patients with mental disorders. This study assessed employment status, employment functioning, and barriers to employment among VA patients treated in primary care settings, and examined how depression and anxiety were associated with these outcomes.

METHODS

The sample included 287 VA patients treated in primary care in a large Midwestern VA Medical Center. Bivariate and multivariable analyses were conducted examining associations between socio-demographic and clinical predictors of six employment domains, including: employment status, job search self-efficacy, work performance, concerns about job loss among employed Veterans, and employment barriers and likelihood of job seeking among not employed Veterans.

RESULTS

54% of respondents were employed, 36% were not employed, and 10% were economically inactive. In adjusted analyses, participants with depression or anxiety (43%) were less likely to be employed, had lower job search self-efficacy, had lower levels of work performance, and reported more employment barriers. Depression and anxiety were not associated with perceived likelihood of job loss among employed or likelihood of job seeking among not employed.

LIMITATIONS

Single VA primary care clinic; cross-sectional study.

DISCUSSION

Employment rates are low among working-aged VA primary care patients, particularly those with mental health conditions. Offering primary care interventions to patients that address mental health issues, job search self-efficacy, and work performance may be important in improving health, work, and economic outcomes.

Stress-related personal growth among emerging adults whose mothers have been diagnosed with mental illness

OBJECTIVE

This study explored whether emerging adults' reports of their relationships with their mothers who have been diagnosed with mental illness and their attempts to make meaning of the experience of having a mother with mental illness were associated with stress-related personal growth.

METHODS

Fifty-two emerging adult children with mothers who have been diagnosed with mental illness responded to a self-report questionnaire containing measures of adult parent-child relationships, meaning making, and stress-related personal growth.

RESULTS

Hierarchical multiple linear regression analysis of the cross-sectional data indicated that meaning making contributed to stress-related personal growth after accounting for emerging adult-mother relationship factors. Aspects of the emerging adult-mother relationship did not contribute to growth.

CONCLUSIONS

Efforts to make meaning of having a mother with mental illness may facilitate growth among emerging adult children. Longitudinal investigations in larger samples are needed to better understand the relationship among interpersonal relationships, meaning making, and growth in this population.

IMPLICATIONS FOR PRACTICE

Interventions with adult children of people with mental illness should address their capacity for personal growth.

Prospects and Limits of Energy Storage in Batteries

Energy densities of Li ion batteries, limited by the capacities of cathode materials, must increase by a factor of 2 or more to give all-electric automobiles a 300 mile driving range on a single charge. Battery chemical couples with very low equivalent weights have to be sought to produce such batteries. Advanced Li ion batteries may not be able to meet this challenge in the near term. The state-of-the-art of Li ion batteries is discussed, and the challenges of developing ultrahigh energy density rechargeable batteries are identified. Examples of ultrahigh energy density battery chemical couples include Li/O2, Li/S, Li/metal halide, and Li/metal oxide systems. Future efforts are also expected to involve all-solid-state batteries with performance similar to their liquid electrolyte counterparts, biodegradable batteries to address environmental challenges, and low-cost long cycle-life batteries for large-scale energy storage. Ultimately, energy densities of electrochemical energy storage systems are limited by chemistry constraints.

Reengaging veterans with serious mental illness into care: preliminary results from a national randomized trial

OBJECTIVE

This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness.

METHODS

Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N=88) were randomized to receive six months of facilitation (enhanced REP) or continued standard REP. Site-level uptake was defined as percentage of patients (N=1,531) with updated documentation or with whom contact was attempted.

RESULTS

Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p=.01). Total REP facilitation time was 7.3 hours per site for six months.

CONCLUSIONS

Added facilitation improved short-term uptake of a national mental health program.

Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy

Background

Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy.

Methods

One mental health provider from each U.S. VA site (N = 158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N = 89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N = 40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N = 49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization.

Results

Patients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR = 2.13; 95% CI: 1.09–4.19, P = 0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites.

Conclusions

Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes.

Trial registration

ISRCTN: ISRCTN21059161

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0163-3) contains supplementary material, which is available to authorized users.

Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness

Background

Persons with serious mental illness (SMI) are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage.

Methods/Design

This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services.

Discussion

Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site’s uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies.

Trial registration

Current Controlled Trials ISRCTN21059161.

Pain conditions among veterans with schizophrenia or bipolar disorder

OBJECTIVE

The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.

METHOD

This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N=5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses.

RESULTS

Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain.

CONCLUSIONS

Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.

Health care utilization prior to loss to care among veterans with serious mental illness

OBJECTIVE

This study examined the association between utilization of Veterans Affairs (VA) health services and the probability of treatment dropout among veterans with serious mental illness.

METHODS

Utilization of VA health services in the fiscal year (FY) before treatment dropout among veterans with serious mental illness who were lost to care for at least 12 months beginning in FYs 2008 or 2009 (N=6,687) was compared with utilization in FYs 2007 or 2008 among veterans with serious mental illness who remained in care (N=6,687).

RESULTS

The veterans (mean age=54) were predominantly male (91%) and Caucasian (76%). After accounting for demographic and clinical variables, the analyses found that more primary care and mental health outpatient visits and fewer general medical and mental health hospitalizations were associated with lower odds of dropout.

CONCLUSIONS

Engagement in outpatient health care was associated with lower odds of loss to care among veterans with serious mental illness.

Quality of life among patients with bipolar disorder in primary care versus community mental health settings

INTRODUCTION

Bipolar disorder is associated with functional impairment across a number of domains, including health-related quality of life (HRQOL). Many patients are treated exclusively in primary care (PC) settings, yet little is known how HRQOL outcomes compare between PC and community mental health (CMH) settings. This study aimed to explore the correlates of HRQOL across treatment settings using baseline data from a multisite, randomized controlled trial for adults with bipolar disorder.

METHODS

HRQOL was measured using the SF-12 physical (PCS) and mental (MCS) composite scale scores. Independent sample t-tests were calculated to compare differences in HRQOL between settings. Multivariate regression models then examined the effect of treatment setting on HRQOL, adjusting for covariate demographic factors, mood symptoms (Internal State Scale), hazardous drinking (AUDIT-C), and substance abuse.

RESULTS

A total of 384 enrolled participants completed baseline surveys. MCS and PCS scores reflected similar impairment in HRQOL across PC and CMH settings (p=0.98 and p=0.49, respectively). Depressive symptoms were associated with lower MCS scores (B=-0.68, p<0.001) while arthritis/chronic pain was strongly related to lower PCS scores (B=-5.23, p<0.001).

LIMITATIONS

This study lacked a formal diagnostic interview, relied on cross-sectional self-report, and sampled from a small number of sites in two states.

DISCUSSION

Participants reported similar impairments in both mental and physical HRQOL in PC and CMH treatment settings, emphasizing the need for integrated care for patients with bipolar disorder regardless of where they present for treatment.

Emerging adults' perspectives on their relationships with mothers with mental illness: implications for caregiving

Guided by a life course perspective, the current study examined whether emerging adults with and without mothers with affective disorders viewed their relationships with their mothers differently, and whether aspects of the emerging adult-mother relationship were associated with reports of caregiving for mothers. Reports from emerging adults with mothers with affective disorders (n = 46) were compared to reports from emerging adults with mothers without mental illness (n = 64). Results indicated that emerging adults with mothers with affective disorders reported significantly lower levels of affection, felt obligation, reciprocity, and future caregiving intentions, and significantly higher levels of role reversal in their relationships with their mothers. Reported current caregiving levels did not differ between emerging adults with and without mothers with affective disorders. Hierarchical multiple regression analyses generally indicated higher levels of felt obligation were associated with higher levels of caregiving, regardless of maternal mental health status. Results and future research directions are discussed from a life course perspective.

Family ties in tough times: how young adults and their parents view the U.S. economic crisis

The present intergenerational study examined the perceived impact of the recent U.S. economic crisis on a sample of 68 young adult-parent dyads. The relative contribution of perceived economic pressure, reports of adult child-parent relationship quality, and concerns about the economic future in accounting for variation in self-reports of psychological distress for adult children and their middle-aged parents were examined. Parents' concerns about their children's economic future accounted for variation in their reports of anxiety and depressed mood above and beyond that of perceived economic pressures and their views of the parent-child relationship. In contrast, for young adults, reports of personal economic pressure were generally related to self-reported anxiety and depressed mood. Implications of findings for research and practice are discussed.

Staying connected: young adults' felt obligation toward parents with and without mental illness

The present study compares 94 young adults' self-reported felt obligation toward parents, psychological symptoms, psychological well-being, and interpersonal loneliness in three family types: families where a mother has serious mental illness, families where a father has serious mental illness, and families with nondistressed parents. Results indicated no significant differences in felt obligation toward mothers or fathers as a function of family type. Young adults with a mother with serious mental illness reported significantly more psychological adjustment difficulties than their peers with a father with serious mental illness or nondistressed parents. Young adults' reports of felt obligation toward both parents were significantly positively correlated with young adults' psychological adjustment in families with a parent with serious mental illness, but were not significantly correlated in families with nondistressed parents. Study limitations, future directions for research, and implications for clinical practice are discussed.

Regulation of Src-family protein tyrosine kinase transcription during lymphocyte ontogeny

The distribution and quantity of cellular signaling elements influence response patterns to a variety of stimuli. As protein tyrosine phosphorylation is a requisite event induced by a majority of surface receptors, and protein tyrosine kinases of the src-family (src-PTKs) act as proximal transducers for many hematopoietic receptors, we have designed a quantitative RT-PCR assay to measure src-family PTK expression during critical stages of lymphocyte ontogeny. With this assay we demonstrate that the distal promoter element regulating expression of lck, a src-PTK essential for T-cell development and activation, is similarly regulated during ontogeny of T and B cells. However, lck transcript abundance is drastically reduced in B lineage cells, suggesting that transcriptional elements influencing lck promoter activity are modulated in these cells. Moreover, although transcripts encoding the src-PTK fyn accumulate at 0.1% of lck mRNA levels in thymocytes, diminished activity of the lck distal promoter in the B-cell background brings lck and fyn transcript levels to near equivalence in this population. Importantly, transcripts arising from the lck distal promoter element and the fyn locus are similarly upregulated during developmental transitions associated with antigen-receptor expression in both B and T cells. These findings suggest that although the magnitude of lck and fyn expression is differentially regulated in B and T cells, expression at these loci is similarly developmentally programmed during ontogeny of both lymphocyte lineages.

Targets of p56(lck) activity in immature thymoblasts: stimulation of the Ras/Raf/MAPK pathway

Previous studies suggest that p56(lck) activity influences thymocyte development at a stage prior to TCR alphabeta expression. Transgenic mice that express high levels of p56(lck) activity during thymopoiesis develop thymic lymphomas consisting of cells with immature surface phenotypes. We have utilized cell lines derived from lck-induced thymic tumors to define biochemical pathways regulated by p56(lck) activity in immature thymocytes. Here we report that components of the Ras/Raf/MAPK pathway are constitutively activated in these lck-transformed immature thymoblasts. p56(lck) utilizes Shc and Grb2 adaptors to mediate activation of p21(ras) in the thymoblast lines by promoting tyrosine phosphorylation of the Shc protein and constitutive interaction between Shc and Grb2. The putative guanine nucleotide exchange factor p95(vav) is also maintained in constitutively tyrosine phosphorylated form as a result of elevated Lck activity. One target of activated Ras, the Raf-1 kinase, is hyperphosphorylated and downstream targets of activated Raf-1, Erk1 and Erk2, are hyperphosphorylated and activated in Lck-transformed thymocytes. Forskolin treatment reverses Raf-1 hyperphosphorylation in the cells and inhibits proliferation by blocking G1/S transition. In contrast, conventional protein tyrosine kinase inhibitors block proliferation by arresting Lck thymoblasts at G2/M. Lck-mediated stimulation of the Ras/Raf/MAPK pathway is also required to maintain cell viability by preventing programmed cell death. In summary, p56(lck) activity stimulates G1/S transition in immature thymoblasts and maintains cell viability via transduction of constitutive activation signals downstream to components of the Ras/Raf/MAPK pathway.

Decreased signaling competence as a result of receptor overexpression: overexpression of CD4 reduces its ability to activate p56lck tyrosine kinase and to regulate T-cell antigen receptor expression in immature CD4+CD8+ thymocytes

Thymic selection of the developing T-cell repertoire occurs in immature CD4+CD8+ thymocytes, with the fate of individual thymocytes determined by the specificity of T-cell antigen receptor they express. However, T-cell antigen receptor expression in immature CD4+CD8+ thymocytes is actively down-regulated in CD4+CD8+ thymocytes by CD4-mediated tyrosine kinase signals that are generated in the thymus as a result of CD4 engagement by intrathymic ligands. In the present study we have examined the effect of CD4 overexpression in CD4+CD8+ thymocytes on activation of CD4-associated p56lck tyrosine kinase and regulation of T-cell antigen receptor expression. Augmented CD4 expression in CD4+CD8+ thymocytes did not result in commensurate increases in associated p56lck molecules, so that CD4 expression was quantitatively disproportionate to that of its associated signaling molecule p56lck. Interestingly, we found that CD4 overexpression significantly interfered with the ability of CD4 crosslinking to activate associated p56lck molecules and significantly interfered with the ability of CD4 to regulate T-cell antigen receptor expression. Thus, this study provides an example in which receptor overexpression leads to decreased receptor signaling competence.

The protein tyrosine kinase p56lck regulates thymocyte development independently of its interaction with CD4 and CD8 coreceptors [corrected]

The lck gene encodes a lymphocyte-specific protein tyrosine kinase of the nonreceptor type that is implicated in signal transduction pathways emanating from the CD4 and CD8 coreceptors. Previous studies also support a role for p56lck in regulating T cell receptor beta gene rearrangements and, more generally, thymocyte development. Here we report that a mutant form of p56lck, which is incapable of interacting with CD4 or CD8, behaves indistinguishably from association-competent p56lck with respect to its ability to affect thymocyte maturation. The effects of p56lck remained specific in that the closely related src-family kinase p59hck was incapable of substituting for p56lck in arresting beta locus gene rearrangements. These data support the view that src-family kinases perform highly specialized and often nonoverlapping functions in hematopoietic cells, and that p56lck acts independently of its association with CD4 and CD8 to regulate thymocyte development.

Inhibition of T-cell receptor beta-chain gene rearrangement by overexpression of the non-receptor protein tyrosine kinase p56lck

The variable region genes of the T cell receptor (TCR) alpha and beta chains are assembled by somatic recombination of separate germline elements. During thymocyte development, gene rearrangements display both an ordered progression, with beta chain formation preceding alpha chain, and allelic exclusion, with each cell containing a single functional beta chain rearrangement. Although considerable evidence supports the view that the individual loci are regulated independently, signaling molecules that may participate in controlling TCR gene recombination remain unidentified. Here we report that the lymphocyte-specific protein tyrosine kinase p56lck, when overexpressed in developing thymocytes, provokes a reduction in V beta--D beta rearrangement while permitting normal juxtaposition of other TCR gene segments. Our data support a model in which p56lck activity impinges upon a signaling process that ordinarily permits allelic exclusion at the beta-chain locus.

Delayed thymocyte development induced by augmented expression of p56lck

Accumulating evidence supports the contention that CD4 and CD8 receptor molecules play a critical signaling role during thymocyte development. The lymphocyte-specific protein tyrosine kinase (p56lck), by virtue of its physical association with these surface components, provides a likely candidate for the biochemical signal transducing element required for these effects. To investigate the function of p56lck in T lymphocytes, transgenic mice were produced that carry either the wild-type lck gene or a mutated lck gene encoding a constitutively activated form of p56lck (p56lckF505). Both transgenes were expressed in thymocytes under the control of the lck proximal promoter element. A large set of founder animals was obtained in which steady-state accumulation of lck transgene mRNA directly correlated with transgene copy number, suggesting that this transgene contains a dominant control region. Progeny of these founders exhibited a transgene-dependent dose-related decrease in the production of thymocytes bearing functional antigen receptors. This effect was strictly dependent on p56lck activity, in that both wild-type and mutated versions of the genes induced similar effects with differing efficiencies. Remarkably, even a twofold increase in p56lck abundance was sufficient to substantially disrupt the appearance of functional thymocytes. These results indicate that thymocyte maturation is regulated in part by signals derived from p56lck.

Thymic tumorigenesis induced by overexpression of p56lck

The lck gene encodes a membrane-associated protein tyrosine kinase (p56lck) that is believed to participate in lymphocyte-specific signal transduction pathways. To investigate the function of this molecule, transgenic mice were generated carrying the wild-type lck gene or a mutated lck gene encoding a constitutively activated form of p56lck (p56lckF505). Transgene expression in thymocytes was achieved in each case using the lck proximal promoter element. Mice expressing high levels of either p56lckF505 or p56lckY505 reproducibly developed thymic tumors. The sensitivity of thymocytes to p56lck-induced transformation suggests that disturbances in lck expression may contribute to the pathogenesis of some human neoplastic diseases.

Regulation of T cell receptor signaling by a src family protein-tyrosine kinase (p59fyn)

Engagement of the clonotypic antigen receptor (TCR) on T lymphocytes provokes an activation response leading to cell proliferation and lymphokine secretion. To examine the molecular basis of T cell signaling, we generated transgenic animals in which a lymphocyte-specific nonreceptor protein-tyrosine kinase p59fyn(T) is 20-fold overexpressed in developing T lineage cells. Thymocytes from these mice, analyzed using both cellular and biochemical assays, were remarkably hyperstimulable. Moreover, the responsiveness of normal thymocytes to TCR-derived signals correlated well with the extent to which p59fyn was expressed in these cells. Overexpression of a catalytically inactive form of p59fyn substantially inhibited TCR-mediated activation in otherwise normal thymocytes. These effects are unique to p59fyn; overexpression of a closely related T cell-specific tyrosine kinase, p56lck, elicits dramatically different phenotypes. Our results suggest that p59fyn is a critically important component of the TCR signal transduction apparatus.

Developmental regulation of lck gene expression in T lymphocytes

In the mouse and human, mRNA transcripts encoding the lymphocyte-specific protein tyrosine kinase p56lck are derived from two separate promoters resulting in heterogeneity in the 5' untranslated region sequence. The proximal promoter lies just 5' to the coding region for the gene and is active only in thymocytes. In contrast, the distal promoter lies 34 kilobases (kb) 5' in the human, and is active both in thymocytes and mature peripheral T cells. As previously reported, transgenic mice bearing functional proximal promoter sequence juxtaposed with the SV40 large T antigen gene invariably develop lymphoid tumors confined to the thymus. In the current work, transgenic mice bearing a 2.6-kb fragment of the human distal promoter fused to the SV40 large T antigen gene express large T antigen in thymocytes and in peripheral lymphoid cells, and develop tumors of both the thymus and the peripheral lymphoid organs. The ability of the human distal promoter to function appropriately in transgenic mice is consistent with the strong similarity observed between the mouse and human distal promoter sequences. With the exception of a single short interval that serves as a target for binding of nuclear factors, significant sequence similarity is not seen when the distal and proximal promoter sequences are compared. Hence, developmentally regulated, lineage-specific transcription of the lck gene is mediated by distinct promoter sequences that appear to be capable of functioning independently.

The isotype potential of B cells present in BALB/c mice chronically infected with Mesocestoides corti

Infection of BALB/c mice with Mesocestoides corti results in a chronic infection with a pronounced splenomegaly and hypergammaglobulinemia. A prominent feature of this infection is that the vast majority of serum immunoglobulin produced is restricted to IgG1 and IgM. As much as 30-fold increases in serum IgG1 levels have been noted. To ascertain whether, as a result of infection, the resident B cell pool is committed to IgG1, B cells from infected animals were tested for their ability to produce various isotypes after stimulation. In one series of experiments, B cells from normal and infected animals were used as donor cells in the splenic fragment assay. The results show that the frequency of 2,4-dinitrophenyl-specific and phosphorylcholine-specific B cells remains unaltered in infected animals compared to controls. Importantly, the hapten-specific B cell clones induced were found to express multiple isotypes. These results demonstrate that the nonactivated B cell pool in spleens of infected mice is not committed to IgG1 and IgM production.

Disruption of thymocyte development and lymphomagenesis induced by SV40 T-antigen

The lck gene encodes a membrane-associated protein tyrosine kinase that is expressed specifically in lymphoid cells, especially thymocytes. Structural analysis of the murine and human lck genes previously identified conserved 5' flanking sequences that were proposed to represent transcriptional regulatory elements. Here we demonstrate that a murine lck promoter construct containing these sequences directs the expression of the SV40 T-antigen gene in lymphoid cells. Remarkably, expression of SV40 T-antigen in transgenic animals dramatically disturbs thymic development, resulting in preferential loss of CD4+CD8+ thymocytes. In contrast, immature cells lacking both CD4 and CD8 markers are present in near-normal numbers. Thus SV40 T-antigen expression appears partially to arrest thymopoiesis. Mice bearing the lck-SV40 transgene develop readily explantable thymic tumors at 12-18 weeks of age. Fluorocytometric analyses of lck-SV40 tumor cells reveal that immature thymocytes are frequently immortalized. The lck-SV40 mouse may therefore provide materials for the in vitro investigation of thymocyte differentiation.