Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals

OBJECTIVE

Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals.

DESIGN

Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program.

SETTING

Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia.

PARTICIPANTS

In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals.

MAIN MEASURES

Hospital- and patient-level mood management processes.

RESULTS

Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay.

CONCLUSIONS

Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Clinical management of individuals with Intellectual Disability: The outbreak of Covid-19 pandemic as experienced in a clinical and research center Research in Developmental Disabilities

During the COVID-19 pandemic, the Oasi Research Institute of Troina (Italy) became an important hotbed for infection; in fact, 109 patients with different levels of Intellectual Disability (ID) tested positive for COVID-19. The procedures and interventions put in place at the Oasi Research Institute due to the COVID-19 pandemic are exhaustively reported in this paper. The description of the clinical procedures as well as remote/in person psychological support services provided to people with ID and their families are here divided into three different sections: Phase I (or Acute phase), Phase II (or Activity planning), and Phase III (or Activity consolidation). In each section, the main psycho-pathological characteristics of patients, the reactions of family members and the multidisciplinary interventions put in place are also described.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

IMPORTANCE

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking.

OBJECTIVE

To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018.

EXPOSURE

Incident diagnosis of mood or common mental disorder.

MAIN OUTCOMES AND MEASURES

Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used.

RESULTS

In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]).

CONCLUSIONS AND RELEVANCE

This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

The impact of substance use on treatment as a compulsory patient

OBJECTIVES

This paper considers the impact of having a diagnosis of substance use disorder on the utilisation of compulsory orders under the Victorian Mental Health Act (2014).

METHODS

We analysed the subsequent treatment episodes over 2 years of people who had been on a community treatment order for at least 3 months and determined the odds of a further treatment order if there was a diagnosis of substance use at or about the time the index community treatment order ended.

RESULTS

An additional diagnosis of a substance use disorder was coded in 47.7% and was associated with significantly increased odds of a subsequent treatment order in the following 2 years for those with a main diagnosis of schizophrenia (AOR = 3.03, p<0.001) and 'other' disorders (AOR = 11.60, p=0.002). Those with a main diagnosis of mood disorder had a significant increase in odds for an inpatient treatment order if there was an additional substance use disorder diagnosis (AOR = 3.81, p=0.006).

CONCLUSIONS

Having an additional diagnosis of substance use disorder was associated with increased likelihood of being placed on an order. This study supports greater emphasis being given to treatment of substance use concurrently with that of mental illness.

Trajectories of Return to Work Among People on Sick Leave with Mood or Anxiety Disorders: Secondary Analysis from a Randomized Controlled Trial

Purpose The return to work (RTW) of people with mood and anxiety disorders is a heterogeneous process. We aimed to identify prototypical trajectories of RTW over a two-year period in people on sick leave with mood and anxiety disorders, and investigate if socio-demographic or clinical factors predicted trajectory membership. Methods We used data from the randomized IPS-MA trial (n = 283), evaluating a supported employment intervention for participants with recently diagnosed mood or anxiety disorders. Information on "weeks in employment in the past 6 months" was measured after 1/2, 1, 1 ½ and 2 years, using data from a nationwide Danish register (DREAM). Latent growth mixture modelling analysis was carried out to identify trajectories of RTW and logistic regression analyses were used to estimate predictors for trajectory membership. Results Four trajectory classes of RTW were identified; non-RTW [70% (196/283)] (practically no return to work); delayed-RTW [19% (56/283)] (6 months delay before full RTW); rapid-unstable-RTW [7% (19/283)] (members rapidly returned to work, but only worked half the time); and the smallest class, rapid-RTW [4% (12/283)] (members rapidly reached full employment, but later experienced a decrease in weeks of employment). Self-reported disability score according to the SDS, not living with a partner, and readiness to change on the CQ scale were found to be significantly associated with RTW. Conclusion The trajectories identified support that many do not benefit from vocational rehabilitation, or experience difficulties sustaining employment; enhanced support of this patient group is still warranted.Trial registration: http://www.clinicaltrials.gov (Identifier: NCT01721824).

Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders

OBJECTIVE

This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment of co-occurring emotional disorders compared to established single disorder protocols (SDPs) that target specific disorders (e.g., panic disorder).

METHOD

Participants included 179 adults seeking outpatient psychotherapy. Participant age ranged from 18 to 66 years, with an average of 30.66 years (SD = 10.77). The sample was 55% female and mostly Caucasian (83%). Diagnostic assessments were completed with the Anxiety Disorder Interview Schedule (ADIS), and disorder-specific, clinician-rated measures for the comorbid diagnoses of interest.

RESULTS

In both treatment conditions, participants' mean number of diagnoses dropped significantly from baseline to posttreatment, and baseline to 12-month follow-up. Additionally, large effects were observed for changes in comorbid generalized anxiety (ESSG: UP = -1.72; SDP = -1.98), social anxiety (ESSG: UP = -1.33, -0.86; SDP = -1.60, -1.54), and depression (ESSG: UP = -0.83; SDP = -0.84). Significant differences were not observed in between-group comparisons.

CONCLUSIONS

Results suggest that both the UP and SDPs are efficacious in reducing symptoms of comorbid emotional disorders. The clinical, practical, and cost-effective advantages of transdiagnostic CBT are discussed.

Effectiveness of Graded Return to Work After Multimodal Rehabilitation in Patients with Mental Disorders: A Propensity Score Analysis

Purpose Graded return to work (GRTW) is a strategy aimed at bringing people gradually back to coping with a full workload after an extended period of sick leave. This study aims to determine the effect of GRTW in addition to a multimodal rehabilitation on longer-term work participation in people with chronic mental disorders (CMDs). Methods Patients filled out questionnaires at the start of a multimodal rehabilitation and 15 months later. Balanced groups (GRTW, no GRTW) were formed by propensity score matching based on 27 covariates. The primary outcome measures were the return to work (RTW) status at follow-up and the number of days on sick leave during follow-up. Results From 1062 data sets (GRTW 508, no GRTW 554), 381 pairs were matched (age: 47.8 years; 78% female; 65% affective disorders, 28% neurotic or somatic disorders). At follow-up, 88% of the GRTW group had returned to work compared to only 73% of the controls (RR = 1.22, 1.13-1.31). The mean sick leave duration during the follow-up period was 7.0 weeks in the GRTW group compared to 13.4 weeks in the control group (p < 0.001). Additional explorative analyses showed that these effects were only observed in patients with an unsure or negative subjective RTW prognosis. Conclusions Based on this analysis, GRTW in addition to a multimodal rehabilitation is effective in enhancing successful work participation in people with CMDs. Earlier studies showing larger effects in people with a higher risk of a non-RTW were confirmed.

Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment

Intensive pain rehabilitation programs for children with chronic pain are effective for many patients. However, characteristics associated with treatment response have not been well documented. In this article we report trajectories of pain and functional impairment in patients with chronic pain up to 1 year after intensive pain rehabilitation and examine baseline factors associated with treatment response. Patients (n = 253) with chronic pain and functional disability were assessed at 5 time points (admission, discharge, 1-month, 4-month, and 12-month follow-ups). Individual trajectories were empirically grouped using SAS PROC TRAJ. For functional disability, 2 groups emerged: treatment responders (88%) and nonresponders (12%). Using a binomial logistic regression model to predict disability trajectory group, no baseline variables were significant predictors for the disability trajectory group. For pain, 3 groups emerged: early treatment responders (35%), late treatment responders (38%), and nonresponders (27%). Using multinomial regression analyses to predict pain trajectory group, older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristics that distinguished nonresponders from responders; no significant predictors distinguished the late responders from the early responders. These results provide key information on the baseline factors that influence intensive pain rehabilitation outcomes, including risk factors that predict treatment nonresponse. Our findings have implications for developing more targeted treatment interventions.

PERSPECTIVE

Deriving groups of individuals with differing treatment response trajectories stimulates new thinking regarding potential mechanisms that may be driving these outcomes.

Modeling Avoidance in Mood and Anxiety Disorders Using Reinforcement Learning

BACKGROUND

Serious and debilitating symptoms of anxiety are the most common mental health problem worldwide, accounting for around 5% of all adult years lived with disability in the developed world. Avoidance behavior-avoiding social situations for fear of embarrassment, for instance-is a core feature of such anxiety. However, as for many other psychiatric symptoms the biological mechanisms underlying avoidance remain unclear.

METHODS

Reinforcement learning models provide formal and testable characterizations of the mechanisms of decision making; here, we examine avoidance in these terms. A total of 101 healthy participants and individuals with mood and anxiety disorders completed an approach-avoidance go/no-go task under stress induced by threat of unpredictable shock.

RESULTS

We show an increased reliance in the mood and anxiety group on a parameter of our reinforcement learning model that characterizes a prepotent (pavlovian) bias to withhold responding in the face of negative outcomes. This was particularly the case when the mood and anxiety group was under stress.

CONCLUSIONS

This formal description of avoidance within the reinforcement learning framework provides a new means of linking clinical symptoms with biophysically plausible models of neural circuitry and, as such, takes us closer to a mechanistic understanding of mood and anxiety disorders.

The Therapeutic Potential of Exercise to Improve Mood, Cognition, and Sleep in Parkinson's Disease

In addition to the classic motor symptoms, Parkinson's disease (PD) is associated with a variety of nonmotor symptoms that significantly reduce quality of life, even in the early stages of the disease. There is an urgent need to develop evidence-based treatments for these symptoms, which include mood disturbances, cognitive dysfunction, and sleep disruption. We focus here on exercise interventions, which have been used to improve mood, cognition, and sleep in healthy older adults and clinical populations, but to date have primarily targeted motor symptoms in PD. We synthesize the existing literature on the benefits of aerobic exercise and strength training on mood, sleep, and cognition as demonstrated in healthy older adults and adults with PD, and suggest that these types of exercise offer a feasible and promising adjunct treatment for mood, cognition, and sleep difficulties in PD. Across stages of the disease, exercise interventions represent a treatment strategy with the unique ability to improve a range of nonmotor symptoms while also alleviating the classic motor symptoms of the disease. Future research in PD should include nonmotor outcomes in exercise trials with the goal of developing evidence-based exercise interventions as a safe, broad-spectrum treatment approach to improve mood, cognition, and sleep for individuals with PD.

Effect of endurance training on seizure susceptibility, behavioral changes and neuronal damage after kainate-induced status epilepticus in spontaneously hypertensive rats

The therapeutic efficacy of regular physical exercises in an animal model of epilepsy and depression comorbidity has been confirmed previously. In the present study, we examined the effects of endurance training on susceptibility to kainate (KA)-induced status epilepticus (SE), behavioral changes and neuronal damage in spontaneously hypertensive rats (SHRs). Male SHRs were randomly divided into two groups. One group was exercised on a treadmill with submaximal loading for four weeks and the other group was sedentary. Immediately after the training period, SE was evoked in half of the sedentary and trained rats by KA, while the other half of the two groups received saline. Basal systolic (SP), diastolic (DP) and mean arterial pressure (MAP) of all rats were measured at the beginning and at the end of the training period. Anxiety, memory and depression-like behaviour were evaluated a month after SE. The release of 5-HT in the hippocampus was measured using a liquid scintillation method and neuronal damage was analyzed by hematoxylin and eosin staining. SP and MAP of exercised SHRs decreased in comparison with the initial values. The increased resistance of SHRs to KA-induced SE was accompanied by an elongated latent seizure-free period, improved object recognition memory and antidepressant effect after the training program. While the anticonvulsant and positive behavioral effects of endurance training were accompanied by an increase of 5-HT release in the hippocampus, it did not exert neuroprotective activity. Our results indicate that prior exercise is an effective means to attenuate KA-induced seizures and comorbid behavioral changes in a model of hypertension and epilepsy suggesting a potential influence of hippocampal 5-HT on a comorbid depression. However, this beneficial impact does not prevent the development of epilepsy and concomitant brain damage.

[Remissions in affective disorders: epidemiology, psychopathology, clinical and social prognosis, treatment]

OBJECTIVE

Although there is some evidence on heterogeneity of remissions in affective disorders (partial and full), many aspects of their comparative epidemiology, psychopathology, comorbidity and treatment are still unclear. According to our hypothesis, partial/symptomatic and full/syndromal remissions are not just consecutive stages of disease with spontaneous or treatment related interchange, but independent clinical entities with different essence. The distinction reflects a predominant pattern of disease development, based on interaction of two comorbid axes -- recurrent depression and personality disorder (PD).

METHODS

A random epidemiological sample of 450 subjects (314 women and 136 men) with affective disorders was examined cross-sectionally and retrospectively.

RESULTS

In the epidemiological sample, the prevalence was distributed as follows: verified remissions -- 36.2% (n=163): partial -- 27.5% (n=124), full - 8.7% (n=39). It has been shown that partial remission is a result of overlapping of recurrent depression and PD with affective diathesis (cycloid, hyperthymic, borderline) or PD prone to close interrelations with affective disorders (avoidant, obsessive-compulsive, narcissistic, histrionic). Thus, most residual symptoms (RS) reflect the association and are heterogeneous -- combined, affective, personal. Combined RS (dysthymic, phobic/anxious, somatoform) are "joint" presentations of depression and PD. Affective RS are depressive "blips" or brief depressive flares. Personal RS are pathological postdepressive personality traits (depressive, hypochondriacal, avoidant, dependent, histrionic), emerged or enhanced after depression. Full remission develops in "dissociation" of recurrent depression and PD without affective diathesis (schizotypal, schizoid, obsessive-compulsive, histrionic). Some common personality dimensions are relevant here: perfectionism, work addiction, hyperactivity, and psychological detachment from vital depressive symptoms ("alexithymia for depression").

CONCLUSIONS

The discussed remissions division suggests different prognosis and treatment approach.

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: a randomized control trial

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.

Sensponsive architecture as a tool to stimulate the senses and alleviate the psychological disorders of an individual

The paper presents an ongoing research project that aims to help individuals with mild psychological disorders, like depression, to reduce the use of medication and escape a possible addiction to drugs by transforming their immediate or broader living space into a sensponsive environment. It is an innovative, multidisciplinary, non-invasive approach through the domains of architecture, computer science, psychology and endocrinology. Initially, the paper presents the connections between space and human behavior, and specifically, the ways in which the spatial qualities of the surrounding environment affect the human senses and consequently the hormonal changes and the production of the corresponding emotions and actions. As a next step, the paper outlines the creation of sensponsive environments that are programmed to sense human discomfort by monitoring changes in facial expression and body movement and respond to them accordingly by transforming their spatial elements in order to make people feel better. The proposed sensponsive spaces are equipped with biomedical monitoring systems, smart materials and sensor-actuator assemblies with programmed re-actions (haptic, olfactory, chromatic and so on) that help people refine their feeling of the surrounding space, guiding its smooth transition to a comfortable--for the body and the mind-place. The paper concludes with the next step of this research initiative, the sensponsive suit, a personalized wearable assembly enhanced with technology to positively affect the psychological health of the wearer.

[Similarities and differences between pathological gambling and substance dependance: A clarification]

Similarities and differences between pathological gambling and substance dependence: a clarification. A critical analysis of a French review of the international literature on gambling.

INTRODUCTION

The integration of pathological gambling in the spectrum of addictive disorders modeled by substance dependence is currently discussed.

OBJECTIVE

To perform a systematic review of the similarities and differences between pathological gambling and substance dependence, and to classify and analyze them, based on the data collected by a previously published French systematic analysis of the international literature on pathological gambling.

METHOD

We established a checklist of each comparison of pathological gambling with substance dependence within the report. Then, every entry was classified as similarity or difference, analyzed and discussed.

RESULTS

Similarities retrieved were epidemiological characteristics (gender, age, socio-demographic characteristics of subjects), diagnostic criteria from DSM-IV (five criteria in common), frequent co-occurrence of pathological gambling and substance dependence, neurobiological and genetic characteristics, cases of spontaneous recovery, and similarities of therapeutic care. Differences retrieved were a more elevated prevalence of mood disorders and suicide among pathological gamblers, intrinsic risk factors related to gambling activity (delay between bid and result, gambling device, big win), cognitive distortion of pathological gamblers (notably chasing), specificities of cognitive behavioral therapies focused on these cognitive distortions, and specificities of social care of pathological gamblers.

DISCUSSION

Pathological gambling shared many similarities with substance dependence, but also some differences. However, our critical analysis of these elements, reported to be specific to pathological gambling, showed significant commonalities with substance dependence. Also, the existence of key symptoms of substance dependence such as craving and loss of control in pathological gambling was not discussed in the review, although other data suggest a common ground. These could be key elements to group together pathological gambling and substance dependence within the addictive disorders.

Earth of Wellbeing: a place to live positive emotions

EARTH of Wellbeing is a technological application to induce and train positive emotions and enhance different psychological strengths. The system contains 3 modules of activities: Park of Wellbeing, Wellbeing in the Nature and Book of Life. The objective of this paper is to describe the system and to offer data about its efficacy to induce positive affect in a sample of 30 participants who use EARTH three times a week along one month. This is a work in progress.

How do prescription opioid users differ from users of heroin or other drugs in psychopathology: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES

To study substance use and psychiatric disorders among prescription opioid users, heroin users, and non-opioid drug users in a national sample of adults.

METHODS

Analyses of data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093).

RESULTS

Four groups were identified among 9140 illicit or non-prescribed drug users: heroin-other opioid users (1.0%; used heroin and other opioids), other opioid-only users (19.8%; used other opioids but never heroin), heroin-only users (0.5%; used heroin but never other opioids), and non-opioid drug users (78.7%; used drugs but never heroin or other opioids). After adjusting for variations in socioeconomic characteristics, history of substance abuse treatment, and familial substance abuse, heroin-other opioid users had greater odds of several substance use disorders (cocaine, hallucinogen, sedative, amphetamine, and tranquilizer) as compared with the other groups; heroin-only users had reduced odds of sedative and tranquilizer use disorders as compared with other opioid-only users. Non-opioid drug users had reduced odds of all substance use disorders and other mental disorders (mood, anxiety, pathological gambling, and personality) as compared with other opioid-only users. Past-year other opioid-only users also reported slightly lower scores on quality of life than past-year non-opioid drug users.

CONCLUSIONS

All opioid use groups had higher rates of substance use disorders than non-opioid drug users, and these rates were particularly elevated among heroin-other opioid users. Findings suggest the need to distinguish between these four groups in research and treatment as they may have different natural histories and treatment needs.

The SCIRehab project: treatment time spent in SCI rehabilitation. Psychology treatment time during inpatient spinal cord injury rehabilitation

BACKGROUND

Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams.

OBJECTIVE

To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI.

METHODS

Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models.

RESULTS

Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent.

CONCLUSIONS

Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.

Criminal justice involvement, behavioral health service use, and costs of forensic assertive community treatment: a randomized trial

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.

Enrollment in mental health courts: voluntariness, knowingness, and adjudicative competence

Mental health courts (MHCs) are rapidly expanding as a form of diversion from jails and prisons for persons with mental illness charged with crimes. Although intended to be voluntary, little is known about this aspect of the courts. We examined perceptions of voluntariness, and levels of knowingness and legal competence among 200 newly enrolled clients of MHCs at two courts. Although most clients claimed to have chosen to enroll, at the same time, most claimed not to have been told the court was voluntary or told of the requirements prior to entering. The majority knew the "basics" of the courts, but fewer knew more nuanced information. A minority also were found to have impairments in legal competence. Implications are discussed.

Evaluation of neuropsychological functions in patients with Friedreich ataxia before and after cognitive therapy

Friedreich ataxia (FA) is a neurodegenerative disease characterized by progressive nervous system damage resulting in severe disability. Cognitive functions and mood disorders in FA have been studied little and with conflicting results. The aim of this study was to investigate cognitive functions and mood disorders in FA subjects and the role of cognitive rehabilitation therapy (sequential treatments) performed during a scheduled study period. The executive functions of 24 subjects with FA were evaluated over one year during three separate periods of in-hospital rehabilitation. The neuropsychological evaluations performed before and after cognitive therapy did not reveal differences in the mean test scores of the MMSE, the Rey 15-item Memorization Test for long-term memory, Raven's Colored Progressive Matrices, the Phonemic Verbal Fluency Test, the Symbol Digit Modalities Test, or the Zung scale. The mean scores of the Stroop color-word interference task and of the Rey 15-item Memorization Test for short-term memory were increased at the final evaluation. This finding of long-lasting stability of neuropsychological test scores is noteworthy, as it suggests that one-year cognitive rehabilitation therapy (sequential treatments) may at least contribute to reducing cognitive decline. A cognitive rehabilitation therapy in addition to the conventional neuromotor rehabilitation treatment may improve the management of subjects with FA.

Mental disorders as risk factors for later substance dependence: estimates of optimal prevention and treatment benefits

BACKGROUND

Although mental disorders have been shown to predict subsequent substance disorders, it is not known whether substance disorders could be cost-effectively prevented by large-scale interventions aimed at prior mental disorders. Although experimental intervention is the only way to resolve this uncertainty, a logically prior question is whether the associations of mental disorders with subsequent substance disorders are strong enough to justify mounting such an intervention. We investigated this question in this study using simulations to estimate the number of substance disorders that might be prevented under several hypothetical intervention scenarios focused on mental disorders.

METHOD

Data came from the National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey that retrospectively assessed lifetime history and age of onset of DSM-IV mental and substance disorders. Survival analysis using retrospective age-of-onset reports was used to estimate associations of mental disorders with subsequent substance dependence. Simulations based on the models estimated effect sizes in several hypothetical intervention scenarios.

RESULTS

Although successful intervention aimed at mental disorders might prevent some proportion of substance dependence, the number of cases of mental disorder that would have to be treated to prevent a single case of substance dependence is estimated to be so high that this would not be a cost-effective way to prevent substance dependence (in the range 76-177 for anxiety-mood disorders and 40-47 for externalizing disorders).

CONCLUSIONS

Treatment of prior mental disorders would not be a cost-effective way to prevent substance dependence. However, prevention of substance dependence might be considered an important secondary outcome of interventions for early-onset mental disorders.

Estimating the changes in demand for public mental health services following changes in eligibility: analysis of national survey data

BACKGROUND

Numerous national surveys have shown that the rate of use of mental health services in a population lags behind the prevalence rate of psychiatric disorder. The preparations to provide universal coverage in Israel require estimates of the utilization levels likely to be reached once mental health care becomes a legal right of each resident.

AIMS

This paper aims to provide an estimate of the size of the population which not only will be eligible for specialty mental health care, but which will also demand ambulatory mental health specialty care from public providers

METHODS

Data for this study were extracted from a national survey conducted during 2003-2004 in Israel as part of the WMH2000 initiative. Use and perceived need to use services among eligible respondents was used to estimate likely levels of demand.

RESULTS

The estimates for future demands on public mental health clinics ranged between 1.2%--the size of the population that is eligible by law and is currently using public mental health services to 5.5%--the size of the eligible population that is currently using some type of service or perceives the need for care in mental health.

DISCUSSION

The estimate of the expected use falls in the range of other universal access systems. CONCLUSIONS AND IMPLICATIONS FOR POLICY: The present study provides estimates that are much higher than the estimated size of the population currently using public mental health services, yet the upper limit of the range of estimates is close to those on which the new legislation is based.

Stroke rehabilitation in a patient with cerebellar cognitive affective syndrome

OBJECTIVE

It has become evident that the cerebellum plays a role in cognitive function, and Schmahmann et al. have introduced the term "Cerebellar cognitive affective syndrome (CCAS)." In the present paper we report a patient with cerebellar hemorrhage who developed CCAS.

DESIGN

A case study.

METHODS

The patient was a 61-year-old right-handed man who was admitted to our hospital because of sudden headache, dizziness and vomiting. The patient showed ataxia of the trunk and the extremities, but no paralysis and disturbance of sensation. He was disoriented in time and showed recent memory disturbance, disturbance of attention, impairment of executive functions and reduced volition, and due to these symptoms, his daily living was also severely impaired.

RESULTS

With the aim of returning home, the patient received exercise therapy and cognitive rehabilitation, while home modification was performed, and living at home under the supervision of his family became possible. Cognitive function improved, while memory and attention disturbance, impairment of executive function remained.

CONCLUSION

Cognitive dysfunction in patients with cerebellar damage is assumed to develop from disturbance of the cerebrocerebellar circuit, and that rehabilitation of these patients must include assessment of not only the motor function, but also of detailed assessment of cerebral function.

Jackson's Indiana: state hospital competence restoration in Indiana

Restoration to competence (RTC) of mentally disordered defendants has become increasingly important for state hospitals. In Indiana, most RTC admissions are sent to one primarily forensic state hospital, but many are admitted to other state hospitals. A state database of defendants admitted for RTC between 1988 and 2005 was analyzed for trends in annual admissions, length of stay (LOS), and success of restoration by hospital and by diagnostic category. Regression models were developed to identify factors associated with RTC success. Analysis of 1,475 RTC admissions showed increased annual admissions over the study period. While the forensic hospital restored a higher percentage of individuals than the other state hospitals, the percentage of RTC success decreased over time in all hospitals. Admission to the forensic hospital, female gender, and mood disorder diagnosis were associated with increased restoration success. Older age and psychotic disorder or mental retardation diagnoses were associated with decreased likelihood of restoration. Race was not significantly associated with RTC at six months, but white defendants were less likely to be restored within one year.

Validation of the mood and anxiety semi-structured (MASS) interview for patients with intellectual disabilities

BACKGROUND

When assessing people with intellectual disabilities (ID), using the DSM-IV-TR can be challenging. Frequently, significant clinical data must be obtained from interviews with key informants. A new semi-structured interview tool was developed including behavioural descriptions of each DSM-IV-TR symptom criterion for a number of mood and anxiety disorders. A goal was to provide mental health clinicians with an instrument easy to use in clinical practice that would increase reliable identification of diagnostically important mood and anxiety symptoms. This is especially important given the fact that many experts believe these 'internalizing' clinical syndromes may often be missed in this population, because of characteristic limitations in expressive language skills.

METHOD

To establish validity, the Mood and Anxiety Semi-structured (MASS) Interview-derived diagnoses were compared with clinical DSM-IV diagnoses derived from an extensive inpatient evaluation and classifications based on the Hamilton Depression Rating Scale for 93 psychiatric inpatients served on a specialized unit for people with ID and major mental health disorders.

RESULTS

Agreement with the MASS Interview was high yielding significant kappa coefficients ranging from 0.42 to 0.78.

CONCLUSIONS

The MASS Interview, a semi-structured interview containing behavioural descriptions of DSM-IV symptom criteria, shows promise as a potentially helpful tool in the psychiatric diagnostic evaluation of persons with ID and limited expressive language skills, in the detection of mood and anxiety disorders. The tool also yields a wide breadth of clinical information and is easy for mental health clinicians to use.

Predictors and course of vocational status, income, and quality of life in people with severe mental illness: A naturalistic study

Due to high unemployment rates, people with mental illness are at risk of poverty and are deprived of the social and psychological functions of work, such as the provision of social support, structuring of time, and self-esteem, with a negative effect on their perceived quality of life (QoL). Two distinct processes are held responsible for the low work force participation of people with mental illness: 'Social underachievement' and 'social decline'. Social underachievement signifies that, due to early illness onset, the educational attainment of people with mental illness is low and entry to the labor market fails. Social decline, on the other hand, describes the loss of competitive employment after illness onset, followed by prolonged periods of unemployment and difficulties to re-enter the labor market. This study examines how social underachievement and decline are reflected in the course of vocational status, income, and QoL of people with severe mental illness in the years after a psychiatric admission in a naturalistic longitudinal design. A total of 176 participants diagnosed with schizophrenia or affective disorders were interviewed during an index hospitalization in two large psychiatric hospitals in Zurich. Follow-up interviews were conducted 12 and 30 months after. Random coefficient models (multilevel models) were used to examine simultaneously the predictors and course of the variables of interest. A low number of psychiatric hospitalizations, a higher educational degree, a diagnosis of schizophrenia, and years of work experience predicted a higher vocational status. Vocational status decreased in first-admission participants with prolonged hospitalizations during the follow-up period. Income did not change over time and was positively influenced by a higher age of illness onset, competitive employment, higher education, and not having had a longer hospitalization recently. Subjective QoL significantly improved and was rated higher by people with any kind of employment than by participants without a job. Participants with an affective disorder, those with few hospitalizations but a recent inpatient stay of longer duration, showed lower QoL. Including employment issues early in treatment is especially important for people with an early illness onset and those with more severe forms of psychiatric disorder. A life course perspective enhances the understanding of patients' vocational potential and needs for support.

Diagnostic stability 2 years after treatment initiation in the early psychosis intervention programme in Singapore

OBJECTIVE

To evaluate the diagnostic stability of psychotic disorders over a 2 year period in patients presenting with first-episode psychosis.

METHODS

One hundred and fifty-four patients were recruited from an early psychosis intervention programme (EPIP). They were diagnosed by the attending psychiatrist using the Structured Clinical Interview for DSM-IV Axis I at first contact (baseline) and after 24 months. The diagnoses were classified into the following categories: schizophrenia spectrum disorders (schizophrenia, schizophreniform disorder and schizoaffective disorder), affective psychosis (bipolar and major depressive disorders with psychotic symptoms), and other non-affective psychosis (delusional disorder, psychosis not otherwise specified and brief psychotic disorder). Two measures of stability, the prospective and the retrospective consistency were determined for each diagnosis.

RESULTS

The diagnoses with the best prospective consistency were schizophrenia (87.0%) and affective psychosis (54.5%). The shift into schizophrenia spectrum disorder was the most frequent diagnostic change. Duration of untreated psychosis was found to be the only significant predictor of shift.

CONCLUSION

It is difficult to make a definitive diagnosis at first contact. The clinical need to review the diagnosis throughout the period of follow up is emphasized.

The effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005

BACKGROUND

Physical activity is a healthful behavior that has promise for combating feelings of low energy and fatigue. Despite evidence suggesting that fatigue is a prodromal symptom of major cardiac events, improvements in feelings of energy and fatigue have largely been ignored by reviewers of cardiac rehabilitation literature who have focused on anxiety, depression and general measures of quality of life.

DESIGN

A meta-analytical review.

METHODS AND RESULTS

Computer databases were searched from January 1945 to May 2005 to identify relevant literature. A total of 36 studies consisting of 4765 subjects were included. Cardiac rehabilitation exercise programs were consistently associated with increases in energy and decreases in fatigue. The magnitude of the effect was moderately large (mean delta 0.51; 95% confidence interval 0.42-0.61) but was heterogeneous and modified by features of the research design. Comparison of effect sizes in cardiac rehabilitation studies concurrently measuring energy/fatigue, anxiety and depression suggest that exercise-based cardiac rehabilitation programs have larger effects on feelings of energy and fatigue compared with anxiety and depression.

CONCLUSION

This review quantifies the potential benefit of cardiac rehabilitation exercise programs on feelings of energy and fatigue, and suggests that cardiac rehabilitation researchers and practitioners may benefit from examining, and perhaps even focusing on, feelings of energy and fatigue as an important outcome variable. A greater understanding of the effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue will be reached when more true experiments are conducted thereby avoiding the primary limitation of the literature reviewed; that is, the frequent use of non-experimental research designs.

A comparison of quality-of-life in schizophrenia and affective disorder patients in a Nigerian tertiary hospital

This study determined the degree of satisfaction with various aspects of life in patients with affective disorders and schizophrenia in a Nigerian tertiary hospital. We compared quality-of-life (QOL) at onset-of-illness (first episode) with QOL at time of study and identified sociodemographic and clinical variables that may predict QOL. All consenting patients with ICD-10 compatible diagnosis of schizophrenia (n = 100) and affective disorders (n = 35) receiving treatment in the study center during the study period were interviewed. The WHOQOL-Bref was used to assess respondents' subjective QOL, and a data-collection sheet assessed objective domains of QOL. Respondents with schizophrenia and affective disorders had a good outcome in terms of objective QOL scores. In both groups, however, the subjective ratings were poor as the illness progresses. We conclude that in Nigerian hospital cases, patients with schizophrenia andaffective disorders have a good outcome in terms of objective QOL scores, which are not in consonance with their subjective ratings. Marital status and employment status are predictive of QOL.

Reductions in postdischarge suicide after deinstitutionalization and decentralization: a nationwide register study in Finland

OBJECTIVE

This study analyzed trends in suicides occurring after a psychiatric hospitalization during more than a decade of significant structural changes in mental health services in Finland-that is, deinstitutionalization, downsizing of inpatient care, and decentralization.

METHODS

Retrospective register data on completed suicides and psychiatric inpatient treatments were collected for the periods 1985-1991 and 1995-2001, representing service provision before and after significant structural changes. The data were used to produce an estimate for a change in postdischarge suicide risk.

RESULTS

In both periods, a fifth of suicide victims had been psychiatrically hospitalized within the preceding year. Among persons hospitalized, the risk of suicide was greater in 1985-1991 than in 1995-2001 for both one week after discharge (risk ratio [RR]=1.50, 95% confidence interval [CI]=1.38-1.62) and one year after discharge (RR=1.25, CI=1.19-1.30). When types of disorders were analyzed separately, the relative risk of suicide one year postdischarge for those hospitalized in the earlier period was greater for patients with schizophrenia (RR=1.26, CI=1.17-1.36) and patients with affective disorders (RR=1.60, CI=1.48-1.73). In parallel with general development of inpatient psychiatric services, in 1995-2001 the inpatient treatment periods preceding suicides were significantly shorter (a mean+/-SD of 45+/-340 days in 1995-2001, compared with a mean of 98+/-558 days in 1985-1991), the number of individual patients treated in the hospital for schizophrenia spectrum disorders was lower (26% compared with 36%), and the number treated for affective disorders was higher (45% compared with 35%).

CONCLUSIONS

The restructuring and downsizing of mental health services was not associated with any increase in suicides immediately (one week) or one year postdischarge. Instead, the risk of these suicides decreased significantly between the two time periods among several diagnostic categories. Although the role of psychiatric hospitalization in general may have changed over time, patients who are hospitalized now may be less suicidal after discharge. Our results indicate, in terms of postdischarge suicides, that the downsizing of psychiatric hospitals has been a success. However, there is still a substantial need for better recognition of suicidal risk among psychiatric patients.

Pharmacological issues in the management of people with mental illness and problems with alcohol and illicit drug misuse

BACKGROUND

While there is plentiful information on the pharmacological management of detoxification from alcohol and on withdrawal from or maintenance of opiates for people with a principal problem of substance misuse or dependency, the pharmacological management of substance misusers presenting with a mental illness can be more complicated. Mental health and substance misuse services tend to be separate, but there is now a drive to increase effective overlap between them by equipping mental health clinicians with the skills and confidence to manage substance misuse disorders in conjunction with major mental illness.

AIMS

This paper aims to highlight, for a multi-professional readership, some of the prescribing options and precautions to consider when psychotropic medicines are prescribed for treatment of a mental illness in someone who may continue to use illicit substances or alcohol. It also considers interactions with the completely licit substances, nicotine and caffeine. With recent legislation prohibiting smoking in public places people are likely to reduce or stop smoking, which can have a substantial effect on the levels of medication in their blood.

The application of mindfulness-based cognitive interventions in the treatment of co-occurring addictive and mood disorders

This article reviews the theory, clinical application, and empirical findings on mindfulness-based cognitive therapy (MBCT) for mental health and addictive disorders. Expanding upon the research demonstrating the efficacy of cognitive-behavioral therapy (CBT) for addiction, this article develops and explores the rationale for combining mindfulness-based interventions with evidence-based CBTs in treating addictive disorders, with an emphasis on substance use disorders with co-occurring mood disorders. This article proposes that deficits in affect--regulation related to the behavioral and emotional effects of neurobiological changes that occur with long-term substance abuse--pose a unique set of challenges in early recovery. Prolonged use of addictive substances impairs the brain pathways that mediate certain affect regulation functions. These functions involve attention and inhibitory control, the saliency of and response to addictive versus natural reward stimuli, and the ability to detach or maintain perspective in response to strong emotional states. In treating this affective dysregulation, which can contribute to the vulnerability to relapse in the early stages of recovery, the affect-regulation-specific focus of MBCT adds a valuable element to augment CBT for addiction. Summarizing magnetic resonance imaging and positron emission tomography findings on the effects of MBCT and the neurobiology of drug addiction, this article outlines directions for further research on potential benefits of MBCT for the recovering individual. Finally, this article describes a structured protocol, developed at the Mount Sinai School of Medicine in New York City, which combines CBT with mindfulness-based intervention, for the treatment of affect-regulation issues specific to co-occurring addictive and mood disorders.

Psychopathology among cannabis-dependent treatment seekers and association with later substance abuse treatment

We determined the proportion of psychiatric treatments for disorders not due to substance use among a cohort of subjects (n = 3,114) seeking treatment for cannabis dependence. Data were retrieved from Danish treatment registers. Cases were compared with a representative sample, which was randomly selected from the general population according to age and gender (n = 15,570). Cannabis users were followed, and reentry into substance abuse treatment was used as an outcome deploying Cox regression analysis. The proportion of treatment for all psychiatric disorders was much higher among cases than among controls: schizophrenia (odds ratio [OR] = 7.9; 95% confidence interval [95% CI] = 6.1-10.2), bipolar disorders (OR = 4.9; 95% CI = 2.8-8.5), other affective disorders (OR = 7.6; 95% CI = 6.1-9.5), and personality disorders (OR = 17.3; 95% CI = 14.5-20.5). All in all, 40.7% of cases, compared with 5.2% of controls, had received psychiatric treatment (OR = 12.5; 95% CI = 11.3-13.8). A history of psychiatric treatment was associated with increased rates of reentry into substance abuse treatment, in general (OR = 1.35; 95% CI = 1.20-1.53), specifically for cannabis (OR = 1.26; 95% CI = 1.07-1.48) and opioid (OR = 1.56; 95% CI = 1.23-1.99) dependence. This is the first study to show that the proportion of psychiatric treatment is much elevated among subjects seeking treatment for cannabis dependence, and that a history of psychiatric problems is associated with higher rates of reentry into substance abuse treatment.

Impaired psychological recovery in the elderly after the Niigata-Chuetsu Earthquake in Japan:a population-based study

BACKGROUND

An earthquake measuring 6.8 on the Richter scale struck the Niigata-Chuetsu region of Japan at 5.56 P.M. on the 23rd of October, 2004. The earthquake was followed by sustained occurrence of numerous aftershocks, which delayed reconstruction of community lifelines. Even one year after the earthquake, 9,160 people were living in temporary housing. Such a devastating earthquake and life after the earthquake in an unfamiliar environment should cause psychological distress, especially among the elderly.

METHODS

Psychological distress was measured using the 12-item General Health Questionnaire (GHQ-12) in 2,083 subjects (69% response rate) who were living in transient housing five months after the earthquake. GHQ-12 was scored using the original method, Likert scoring and corrected method. The subjects were asked to assess their psychological status before the earthquake, their psychological status at the most stressful time after the earthquake and their psychological status at five months after the earthquake. Exploratory and confirmatory factor analysis was used to reveal the factor structure of GHQ12. Multiple regression analysis was performed to analyze the relationship between various background factors and GHQ-12 score and its subscale.

RESULTS

GHQ-12 scores were significantly elevated at the most stressful time and they were significantly high even at five months after the earthquake. Factor analysis revealed that a model consisting of two factors (social dysfunction and dysphoria) using corrected GHQ scoring showed a high level of goodness-of-fit. Multiple regression analysis revealed that age of subjects affected GHQ-12 scores. GHQ-12 score as well as its factor 'social dysfunction' scale were increased with increasing age of subjects at five months after the earthquake.

CONCLUSION

Impaired psychological recovery was observed even at five months after the Niigata-Chuetsu Earthquake in the elderly. The elderly were more affected by matters relating to coping with daily problems.

Suicide among older psychiatric inpatients: an evidence-based study of a high-risk group

OBJECTIVE

Older adults have elevated suicide rates, especially in the presence of a psychiatric disorder, yet not much is known about predictors for suicide within this high-risk group. The current study examines the characteristics associated with suicide among older adults who are admitted to a psychiatric hospital.

METHOD

All persons aged 60 and older living in Denmark who were hospitalized with psychiatric disorders during 1990-2000 were included in the study. Using a case-control design and logistic regression analysis, the authors calculated the suicide risk associated with specific patient characteristics.

RESULTS

Affective disorders were found to be associated with an almost twofold higher risk of suicide among psychiatric inpatients than other types of disorders (95% confidence interval [CI]: 1.5-2.6). Patients with dementia had a significantly lower risk ratio of 0.2 (95% CI: 0.1-0.3). In combination with other types of disorder, affective disorders were found to modify an increased risk of suicide. First versus later admission for depression was a better predictor for suicide than age at first hospitalization for depression (before or after age 60 years). More than half of suicides occurred either within the first week of admission or discharge (chi(2) [1] = 27.70, p <0.001) compared with the distribution of patient days.

CONCLUSIONS

Our findings underline the important role of affective disorder in combination with other types of disorders. Assessment of suicide risk among older psychiatric inpatients should take current or previous episodes of affective illness into consideration and pay special heed to the time shortly after admission and discharge.

Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities

BACKGROUND

The Mental Health Service for People with Learning Disabilities (MHSPLD) is a service development in keeping with UK government policy that promotes cross agency working and access to mainstream mental health services for people with intellectual disabilities. We aimed to show whether the service model brought about improvements in people's mental state and level of functioning.

METHODS

Community and inpatient groups were compared across three time points using a range of clinical outcome measures that assessed psychiatric symptoms, risk, needs and level of functioning.

RESULTS

Inpatients and community groups had similar mental health problems, but inpatients had higher unmet needs and lower functioning, and were at greater risk. There were significant improvements across the range of outcome measures in both groups.

CONCLUSIONS

Working with mainstream mental health services and across health and social service boundaries delivers effective mental health care for people with intellectual disabilities.

Mood disorders: cardiovascular and diabetes comorbidity

PURPOSE OF REVIEW

Depression is often associated with medical comorbidity. New research quantifies patterns of mood disorder in illnesses such as cardiovascular disease and diabetes, evaluates the prognostic significance of mood symptoms, and seeks to identify common mechanisms for both mood and medical disease. This review provides recent findings on comorbidity, summarizes mechanistic hypotheses, and outlines developments in treatment and services.

RECENT FINDINGS

Depression occurs in up to one-quarter of patients with cardiovascular disease and diabetes. Depressed patients with heart disease have poorer medical outcomes including increased risk of reinfarction and all-cause mortality. Patients with diabetes and depression have poorer glycemic control, more diabetes symptoms, and greater all-cause mortality. Depression is associated with both biological (hypothalamic-pituitary-adrenal axis dysregulation) and psychosocial processes (adherence, poorer diet, and exercise) that may mediate adverse medical outcomes. Antidepressant treatments are effective in treating depression in medically ill patients, but their impact on medical outcomes remains to be quantified.

SUMMARY

Depression, cardiovascular disease, and diabetes are among the most common chronic illnesses affecting an aging population. Depression is treatable in patients with medical illnesses, and collaborative care models can yield better detection and depression treatment in primary care settings in which most patients with depression are seen.

Effectiveness of the Coping With Depression (CWD) course for older adults provided by the community-based mental health care system in the Netherlands: a randomized controlled field trial

BACKGROUND

The Dutch version of the Coping With Depression (CWD) course for older adults has been implemented in the prevention arm of the community-based mental health care system in the Netherlands. The study group included older adults with subclinical depression as well as those with a major depressive disorder; all were enrolled into the course by mental health care professionals. The effectiveness (immediate and long-term) of the course for this heterogeneous population was studied in an effectiveness trial.

METHOD

Participants were self-referred, responding to media announcements. A total of 119 participants aged 55-85 years (69% female), with subclinical depression and major depression, were randomized to either the CWD course (N = 61) or the waiting list (N = 58).

RESULTS

Nine participants dropped out of the course. According to a diagnostic interview based on the DSM-IV, 39% had a major depressive disorder (MDD), 69% had had a previous MDD, and 45% had an anxiety disorder. Older adults in the intervention group showed a significant decrease in depression symptoms. Gains were maintained over 14 months. In the intervention condition 83% had a pre-treatment score > or = 16 on the Center for Epidemiologic Studies Depression Scale (CES-D); at post-treatment 62% still scored > or = 16.

CONCLUSIONS

The course was beneficial for participants with mild or severe depression, and treatment acceptability was high. It should be fitted into a stepped-care protocol that varies intervention intensity according to clinical needs, using the post-treatment level of functioning as an indication for the next step.

Alcohol abuse partly mediates the association between coronary heart disease and affective or psychotic disorders: a follow-up study in Sweden

OBJECTIVE

To analyse whether hospitalization for affective or psychotic disorders predicts coronary heart disease (CHD) after accounting for occupation, region and alcohol-related disorders.

METHOD

National registers were used to identify all individuals in Sweden aged 25-64 years at first hospitalization for affective or psychotic disorders and aged 25-79 years at first hospitalization for CHD between 1987 and 2001. Standardized incidence ratios (SIRs) were calculated.

RESULTS

The association between CHD and affective or psychotic disorders was strongest in the youngest age groups. The overall SIRs varied between 1.39 and 1.68. They were strongly attenuated but remained significant after adjustment for hospitalization because of alcohol-related disorders, especially among women.

CONCLUSION

Hospitalization because of affective or psychotic disorders predicts CHD. These associations are partly mediated by alcohol abuse. Clinicians and decision makers should be aware of the increased risk of CHD in these patient groups.

Pathophysiologic aspects of major depression following traumatic brain injury

Mood disorders, particularly major depression, are the most frequent complication of traumatic brain injury. Major depression is present in about 40% of patients hospitalization for a traumatic brain injury. Anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts are frequently associated with major depression, and their coexistence constitutes a marker of a more disabling clinical course. The complex interactions of genetic, developmental, and psychosocial factors determine patients' vulnerability to developing affective disturbances following a traumatic brain injury. Symptoms of depression cluster into the domains of low mood and distorted self-attitude, lack of motivation and anhedonia, subjective cognitive complaints, and hyperactive and disinhibited behavior. It is reasonable to assume that these symptomatic clusters have specific underlying mechanisms that need to be integrated in a comprehensive pathophysiologic model.

Effects of horticultural therapy on mood and heart rate in patients participating in an inpatient cardiopulmonary rehabilitation program

PURPOSE

To assess the effects of horticultural therapy (HT) on mood state and heart rate (HR) in patients participating in an inpatient cardiac rehabilitation program.

METHODS

Cardiac rehabilitation inpatients (n = 107) participated in the study. The HT group consisted of 59 subjects (34 males, 25 females). The control group, which participated in patient education classes (PECs), consisted of 48 subjects (31 males, 17 females). Both HT sessions and PEC are components of the inpatient rehabilitation program. Each group was evaluated before and after a class in their respective modality. Evaluation consisted of the completion of a Profile of Mood States (POMS) inventory, and an HR obtained by pulse oximetry.

RESULTS

Changes in the POMS total mood disturbance (TMD) score and HR between preintervention and postintervention were compared between groups. There was no presession difference in either TMD score (16 +/- 3.6 and 19.0 +/- 3.2, PEC and HT, respectively) or HR (73.5 +/- 2.5 and 79 +/- 1.8, PEC and HT, respectively). Immediately following the intervention, the HT TMD was significantly reduced (post-TMD = 1.6 +/- 3.2, P < .001), while PEC TMD was not significantly changed (TMD = 17.0 +/- 28.5). After intervention, HR fell in HT by 4 +/- 9.6 bpm (P < .001) but was unchanged in PEC.

CONCLUSION

These findings indicate that HT improves mood state, suggesting that it may be a useful tool in reducing stress. Therefore, to the extent that stress contributes to coronary heart disease, these findings support the role of HT as an effective component of cardiac rehabilitation.

The impact of psychiatric comorbidity on general hospital length of stay

Medical inpatients often suffer from comorbid psychiatric illness, which has been shown in previous studies to be associated with longer hospital stays. The present analysis used a large representative dataset to examine the impact of patient demographic and clinical characteristics on the relationship between psychiatric comorbidity and hospital length of stay. Analyses showed the existence of a psychiatric comorbidity predicted longer hospital stays for medical inpatients. However, in comparison to previous research, this effect was attenuated in this sample. Patients with mental disorders who were elderly, on Medicare, and those with schizophrenia or mood disorders were especially at risk for slightly longer lengths of stay.

Does additional care provided by a consumer self-help group improve psychiatric outcome? A study in an Italian community-based psychiatric service

This study compares the two-year clinical and social outcome, the use of services and the direct costs of patients of the South-Verona Community Psychiatric Service who were members of a self-help group, with those who were not. Use of services and costs in the two years before the baseline were compared with those occurring two years after the baseline. Self-help subjects decreased their use of hospital stay as to number of admissions and days in hospital, with a reduction of costs; they were more satisfied as to work/education while non self-help matches presented an increase of unmet needs. Clinical and social outcome showed no significant difference. The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome.

The Role of Self-Discrepancy Theory in Understanding Post–Traumatic Brain Injury Affective Disorders

This pilot study examined the utility of self-discrepancy theory (SDT) in explaining post-traumatic brain injury (TBI) depression and anxiety. The SDT model was expanded to include the discrepancy between the postinjury self and the preinjury self. Study participants were 21 individuals with mild to severe TBI residing in the community, who completed the Selves Interview, the Selves Adjective Checklist, the Beck Depression Inventory-II and the Beck Anxiety Inventory. Strong correlations were found between affective distress and self-discrepancies, as measured by the checklist. Scores on the interview were not related to affective distress. The findings suggest that further research is merited to examine the utility of the SDT in addressing issues of post-TBI depression and anxiety.

Three-year follow-up of a family support service cohort of children with behavioural problems and their parents

Abstract Background The aim of this study was to establish the medium-term (three-year) psychosocial outcome of children with behavioural problems and their parents, who had received an intervention from a family support service. Methods Forty families were traced at the three-year follow-up and agreed to participate. Pre- and post-intervention and follow-up measures were the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the Strengths and Difficulties Questionnaire (SDQ). Results The primary HoNOSCA outcome items (i.e. those initially targeted by the parenting intervention) of aggression/antisocial behaviour and family relationships were not found to have changed significantly from the baseline (but had not sustained the sort-term improvement following the intervention). Deterioration was found in other HoNOSCA items such as overactivity, self-harm, scholastic/language skills, emotional, and poor school attendance. When we compared pre-intervention with follow-up SDQ scores, there was no significant change on any scales, i.e. these had returned to the level reported at the time of the original referral to the family support service. Conclusions Following the intervention from a family support service, children and families reported a significant improvement in most outcome measures, predominantly child behaviour and family relationships. However, these improvements were either not sustained or there were additional difficulties at three-year follow-up. These could be related to various external and developmental factors. This lack of sustainable treatment effects for children with behavioural problems is consistent with previous research findings on parenting programmes.

Patients with affective disorders admitted to maximum secure care (1999--2003)

The State Hospital, Carstairs, is a special secure psychiatric facility for Scotland and Northern Ireland. This study describes the background, illness and offence (where appropriate) characteristics of 25 patients admitted between 1999 and 2003 with a diagnosis of any affective disorder. Patients were, on average, 37 years old and had a lengthy history of psychiatric contact. Patients with an affective disorder were more likely to be admitted under civil proceedings, following a transfer from hospital, as opposed to being admitted under criminal procedure. Sixty per cent were discharged to prison, court or local hospitals within one year of their admission to special secure care. Significant violence during an episode of mania or hypomania (even in the presence of psychotic symptoms) appears rare. Recurrent unipolar depression resistant to first and second line treatments in women, and lithium withdrawal mania in male bipolar patients were the most common clinical problems. Treatments aimed at reducing co-morbid substance misuse, and improving compliance with mood stabilisers, appear important in managing this patient group.