New directions for psychiatric rehabilitation in the USA

American researchers have led the world in developing, evaluating, and disseminating evidence-based psychiatric rehabilitation practices for people with serious mental illness. Paradoxically, however, the USA lags behind most industrialized nations in providing access to high-quality mental health and psychiatric services. This essay examines several evidence-based practices developed in the USA, the spread of these practices, the barriers to ensuring availability to people who could benefit from these services, and some promising directions for overcoming the barriers. Factors influencing the growth and sustainment of effective client-centred practices include the availability of adequate and stable funding, committed leadership, and the influence of vested interests. Two strategies for promoting the spread and sustainment of well-implemented evidence-based practices are the adoption of fidelity scales and learning communities.

Psychiatric rehabilitation in Europe

To describe the core elements of modern psychiatric rehabilitation. Based on selected examples we describe the discussion about values in mental health care with focus on Europe. We present outcome data from studies, which have tried to implement care structures based on this value discussion. In the second half of the 20th century, mental health care in all European and other high-income countries changed conceptually and structurally. Deinstitutionalisation reduced the number of psychiatric beds and transferred priority to outpatient care and community-based services, but community mental health programs developed differently across and within these countries. High-income countries in Europe continued to invest in costly traditional services that were neither evidence-based nor person-centered by emphasising inpatient services, sheltered group homes and sheltered workshops. We argue that evidence-based, person-centred, recovery-oriented psychiatric rehabilitation offers a parsimonious solution to developing a consensus plan for community-based care in Europe. The challenges to scaling up effective psychiatric rehabilitation services in high-income countries are not primarily a lack of resources, but rather a lack of political will and inefficient use and dysfunctional allocation of resources.

Dynamics of subatmospheric pressure in the pulmonary interstitial fluid

Systems analyses are presented for several aspects of pulmonary fluid dynamics, especially those related to (1) transport of fluid between the pulmonary interstitial spaces and the alveoli, (2) the possibility of a mechanism for concentrating protein in the lymph vessels, and (3) the effects of very high resistance to fluid flow in the alveolar septal wall. The analysis of fluid transport between the interstitial space and the alveoli, assuming that there is no active secretory or active absorptive process, shows that the interstitial fluid pressure in the normal lung cannot be more positive than the fluid pressure in the alveoli. Since the surface tension of this fluid causes it to have a subatmospheric pressure, the calculated maximum pressure for interstitial fluid in the normal lung is about -2 mmHg (-0.266 kPa). At any pressure more positive than this the alveoli will fill with fluid. The systems analyses for concentrating protein in the pulmonary lymphatics and for the effects of high resistance to fluid flow in the alveolar septal wall offer possible explanations for very negative pressures of pulmonary interstitial fluid, even though calculations of the interstitial fluid pressure based on the assumption that the colloid osmotic pressure of pulmonary interstitial fluid is equal to the osmotic pressure of pulmonary lymph give estimated pressures of pulmonary interstitial fluid approaching 0 mmHg.

Edemagenic gain and interstitial fluid volume regulation

Under physiological conditions, interstitial fluid volume is tightly regulated by balancing microvascular filtration and lymphatic return to the central venous circulation. Even though microvascular filtration and lymphatic return are governed by conservation of mass, their interaction can result in exceedingly complex behavior. Without making simplifying assumptions, investigators must solve the fluid balance equations numerically, which limits the generality of the results. We thus made critical simplifying assumptions to develop a simple solution to the standard fluid balance equations that is expressed as an algebraic formula. Using a classical approach to describe systems with negative feedback, we formulated our solution as a "gain" relating the change in interstitial fluid volume to a change in effective microvascular driving pressure. The resulting "edemagenic gain" is a function of microvascular filtration coefficient (K(f)), effective lymphatic resistance (R(L)), and interstitial compliance (C). This formulation suggests two types of gain: "multivariate" dependent on C, R(L), and K(f), and "compliance-dominated" approximately equal to C. The latter forms a basis of a novel method to estimate C without measuring interstitial fluid pressure. Data from ovine experiments illustrate how edemagenic gain is altered with pulmonary edema induced by venous hypertension, histamine, and endotoxin. Reformulation of the classical equations governing fluid balance in terms of edemagenic gain thus yields new insight into the factors affecting an organ's susceptibility to edema.

Evolving U.S. service model for patients with severe mental illness and co-occurring substance use disorder

Co-occurring severe mental illness and substance use disorder has been recognized as a common problem in the U.S. since the early 1980s (1-3). For these individuals with co-occurring disorders, research demonstrates the effectiveness of various forms of combining, blending, or integrating mental health and substance abuse treatments (4). The evolving U.S. service model for integrated dual disorders treatment emphasizes several key elements: implementation, leadership, training, engagement, assessment, counseling for all patients, ancillary treatments for those with multiple needs, secondary treatments for patients who are nonresponders, and quality assurance regarding process and outcomes.

Pulmonary edema and elevated left atrial pressure: four hours and beyond

Cardiogenic pulmonary edema is caused by the increase in left atrial pressure when the left heart fails. The increased pressure causes rapid fluid accumulation within the lung interstitial spaces. However, over the following days to weeks, additional fluid may accumulate due to the deposition of excess lung connective tissue.

Policy implications for implementing evidence-based practices

The authors describe the policy and administrative-practice implications of implementing evidence-based services, particularly in public-sector settings. They review the observations of the contributors to the evidence-based practices series published throughout 2001 in Psychiatric Services. Quality and accountability have become the watchwords of health and mental health services; evidence-based practices are a means to both ends. If the objective of accountable, high-quality services is to be achieved by implementing evidence-based practices, the right incentives must be put in place, and systemic barriers must be overcome. The authors use the framework from the U.S. Surgeon General's 1999 report on mental health to describe eight courses of action for addressing the gap between science and practice: continue to build the science base; overcome stigma; improve public awareness of effective treatments; ensure the supply of mental health services and providers; ensure delivery of state-of-the-art treatments; tailor treatment to age, sex, race, and culture; facilitate entry into treatment; and reduce financial barriers to treatment.

Developing effective treatments for posttraumatic disorders among people with severe mental illness

OBJECTIVE

The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms.

METHODS

The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities.

RESULTS AND CONCLUSIONS

Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.

Requirements for multidisciplinary teamwork in psychiatric rehabilitation

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.

Managing comorbid schizophrenia and substance abuse

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.

Reliability of instruments in a cooperative, multisite study: employment intervention demonstration program

Reliability of well-known instruments was examined in 202 people with severe mental illness participating in a multisite vocational study. We examined interrater reliability of the Positive and Negative Syndrome Scale (PANSS) and the internal consistency and test-retest reliability of the PANSS, the Rosenberg Self-Esteem Scale, the Medical Outcomes Study Short Form-36 (SF-36), and the Quality of Life Interview. Most scales had good levels of reliability, with intraclass correlation coefficients (ICCs) and coefficient alphas above .70. However, the SF-36 scales were generally less stable over time, particularly Social Functioning (ICC = .55). Test-retest reliability was lower among less educated respondents and among ethnic minorities. We recommend close monitoring of psychometric issues in future multisite studies.

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.

Moving assertive community treatment into standard practice

This article describes the assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness and discusses issues pertaining to implementation of the model. The assertive community treatment model has been the subject of more than 25 randomized controlled trials. Research has shown that this type of program is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care. Despite evidence of the efficacy of assertive community treatment, it is not uniformly available to the individuals who might benefit from it.

Fidelity of supported employment programs and employment outcomes

This study attempted to identify critical components of a supported employment program that were strongly correlated with competitive employment outcomes in a state mental health system. Researchers used a supported employment fidelity scale to rate programs at ten community mental health centers in Vermont. The staff at the centers concurrently assessed competitive employment outcomes for 2,639 clients who had been diagnosed as having severe and persistent mental illness. Higher competitive employment rates were strongly correlated with overall program fidelity and with two program components, namely, providing services in the community as opposed to providing them in the clinic and using full-time employment specialists as opposed to staff with mixed roles.

A comparison of long-term and short-term residential treatment programs for dual diagnosis patients

The authors compared measures of process and six-month outcomes for 45 individuals who were treated in a long-term residential treatment program for patients with dual diagnoses with measures for 39 individuals who were treated in a short-term program. They also compared outcomes for individuals within each group. Those who received long-term treatment experienced improvements between entry into the program and six-month follow-up, and they were more likely to have engaged in treatment than individuals in the short-term group. At follow-up, individuals in the long-term residential treatment group were more likely to have maintained abstinence and less likely to have experienced homelessness than those in the short-term group.

Implementing dual diagnosis services for clients with severe mental illness

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Implementing supported employment as an evidence-based practice

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.

Social patterns of substance use among people with dual diagnoses

An ethnography, part of the larger New Hampshire Dual Diagnosis Study, discovered in a small subsample (n = 16) that clients participated in 1 (or sometimes 2) of 4 distinct and different social patterns of substance-use. These 4 patterns, (1) "the lone user," (2) "the small, closed social clique," (3) "the large, open user syndicate," and (4) the "entrepreneurial drug provider," manifest important social functions of such substance-use. These social functions need to be taken into account as case managers attempt to persuade clients to abstain from using substances, because changing one's substance-use immediately affects one's participation in these user networks. Case managers can understand the social pressures toward certain patterns of substance-use by attending to the social patterning of that use. Many social functions provided by these social patterns must be continued by other means if clients, once persuaded to attempt abstinence, are to be effectively supported in their sobriety.

Rural and urban differences in patients with a dual diagnosis

OBJECTIVES

To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas.

METHODS

Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life.

RESULTS

Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness.

CONCLUSIONS

Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.

Converting day treatment centers to supported employment programs in Rhode Island

OBJECTIVE

The purpose of the study was to compare vocational and nonvocational outcomes of clients of two community mental health centers that underwent conversion from day treatment programs to supported employment programs with outcomes of clients of a center that delayed conversion until after the study was completed.

METHODS

As part of a statewide effort in Rhode Island to convert day treatment programs to supported employment programs, the authors assessed 127 day treatment clients with severe mental illness in three community mental health centers. Two of the centers converted to supported employment, and one continued its rehabilitative day program. Participants were assessed prospectively for 30 to 36 months, with special attention to vocational and social outcomes.

RESULTS

Former day treatment clients in the converted centers attained higher rates of competitive employment than those in the comparison group (44.2 percent and 56.7 percent versus 19.5 percent). Other employment outcomes also improved, and hospitalization rates and overall social functioning were unchanged.

CONCLUSIONS

This study supports findings of previous studies suggesting that replacing rehabilitative day treatment programs with supported employment programs yields improvements in employment outcomes without adverse effects.

The effects of clozapine on alcohol and drug use disorders among patients with schizophrenia

Several case studies indicate that clozapine use is associated with reductions in the use of nicotine, alcohol, or illicit drugs. Although not designed to assess clozapine, this study explored a posteriori the effects of clozapine on alcohol and drug use disorders among schizophrenia patients. Among 151 patients with schizophrenia or schizoaffective disorder and co-occurring substance use disorder who were studied in a dual-disorder treatment program, 36 received clozapine during the study for standard clinical indications. All participants were assessed prospectively at baseline and every 6 months over 3 years for psychiatric symptoms and substance use. Alcohol-abusing patients taking clozapine experienced significant reductions in severity of alcohol abuse and days of alcohol use while on clozapine. For example, they averaged 54.1 drinking days during 6-month intervals while off clozapine and 12.5 drinking days while on clozapine. They also improved more than patients who did not receive clozapine. At the end of the study, 79.0 percent of the patients on clozapine were in remission from alcohol use disorder for 6 months or longer, while only 33.7 percent of those not taking clozapine were remitted. Findings related to other drugs in relation to clozapine were also positive but less clear because of the small number of patients with drug use disorders. This study was limited by the naturalistic design and the lack of prospective, standardized measures of clozapine use. The use of clozapine by patients with co-occurring substance disorders deserves further study in randomized clinical trials.

Psychosocial approaches to dual diagnosis

Recent research elucidates many aspects of the problem of co-occurring substance use disorder (SUD) in patients with severe mental illness, which is often termed dual diagnosis. This paper provides a brief overview of current research on the epidemiology, adverse consequences, and phenomenology of dual diagnosis, followed by a more extensive review of current approaches to services, assessment, and treatment. Accumulating evidence shows that comorbid SUD is quite common among individuals with severe mental illness and that these individuals suffer serious adverse consequences of SUD. The research further suggests that traditional, separate services for individuals with dual disorders are ineffective, and that integrated treatment programs, which combine mental health and substance abuse interventions, offer more promise. In addition to a comprehensive integration of services, successful programs include assessment, assertive case management, motivational interventions for patients who do not recognize the need for substance abuse treatment, behavioral interventions for those who are trying to attain or maintain abstinence, family interventions, housing, rehabilitation, and psychopharmacology. Further research is needed on the organization and financing of dual-diagnosis services and on specific components of the integrated treatment model, such as group treatments, family interventions, and housing approaches.

Implementing evidence-based practices in routine mental health service settings

The authors describe the rationale for implementing evidence-based practices in routine mental health service settings. Evidence-based practices are interventions for which there is scientific evidence consistently showing that they improve client outcomes. Despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research shows that routine mental health programs do not provide evidence-based practices to the great majority of their clients with these illnesses. The authors define the differences between evidence-based practices and related concepts, such as guidelines and algorithms. They discuss common concerns about the use of evidence-based practices, such as whether ethical values have a role in shaping such practices and how to deal with clinical situations for which no scientific evidence exists.

Implementing evidence-based practices for persons with severe mental illnesses

Extensive empirical research, summarized in several reviews and codified in practice guidelines, recommendations, and algorithms, demonstrates that several pharmacological and psychosocial interventions are effective in improving the lives of persons with severe mental illnesses. Yet the practices validated by research are not widely offered in routine mental health practice settings. As part of an effort to promote the implementation of evidence-based practice, the authors summarize perspectives on how best to change and sustain effective practice from the research literature and from the experiences of administrators, clinicians, family advocates, and services researchers. They describe an implementation plan for evidence-based practices based on the use of toolkits to promote the consistent delivery of such practices. The toolkits will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Special materials will address the concerns of mental health authorities (funders), administrators of provider organizations, clinicians, and consumers and their families.

Ethnographic findings from the Washington, D.C., Vocational Services Study

Based on a 20-month period of participant observations and interviews of persons receiving services, employment specialists and clinicians, this ethnographic substudy identified and documented dilemmas encountered during implementation of an assertive, manualized supported employment program, Individual Placement and Support (IPS), situated in a Washington, D.C., community mental health organization that previously focused on clinical interventions but lacked vocational services. Those receiving services, primarily African Americans, had extensive histories of homelessness and dual diagnosis, and minimal work experiences. Real-world issues centered on conflicting expectations and priorities, diverse perceptions of the role of work, and difficulties in integrating vocational rehabilitation with clinical treatment.

[Integrated treatment for severe mental illness and substance abuse: Effective components of programs for persons with co-occurring disorders.]

Traditional approaches to treating clients with co-occurring disorders based sequential or parallel mental health and substance abuse treatments have failed, leading to the development of integrated treatment programs. In this article we define integrated treatment for clients with co-occurring disorders, and identify the core components of effective integrated programs, including: assertive outreach, comprehensiveness, shared decision-making, harm-reduction, long-term commitment, and stage-wise (motivation-based) treatment. The concept of stages of treatment is described to illustrate the different motivational states through which clients progress as they recover from substance abuse: engagement, persuasion, active treatment, and relapse prevention. The stages of treatment have clinical utility for guiding clinicians in identifying appropriate treatment goals matched to clients' motivational states, and selecting interventions based on these goals. By recognizing each client's current stage of treatment, clinicians can optimize outcomes by selecting interventions that are appropriate to the client's current motivational state or stage of treatment, and minimize clients dropping out from treatment. Effective integrated treatment programs for clients with co-occurring disorders differ in the specific services they provide, but share common elements in their philosophy and values. Research documents the beneficial effects of these programs, which bodes well for the long-term prognosis of clients with co-occurring disorders.

An ethnographic study of the longitudinal course of substance abuse among people with severe mental illness

A two-year ethnography conducted among 16 dually diagnosed clients yielded two longitudinal findings. First, four "positive quality of life" factors were strongly correlated with clients' efforts to cease using addictive substances: (1) regular engagement in an enjoyable activity; (2) decent, stable housing; (3) a loving relationship with someone sober who accepts the person's mental illness; and (4) a positive, valued relationship with a mental health professional. Second, the study revealed that five "negative background factors" in participants' childhood homes were predictive of long-term continuation of substance use: (1) substance abuse in childhood home, (2) childhood household in dire poverty, (3) "non-functional" household members, (4) reporting of abuse imputed to care-givers, and (5) serious mental illness in household. The implications of these findings for treatment are discussed.

Evidence-based treatment of schizophrenia

People with schizophrenia can be helped greatly with pharmacologic and psychosocial interventions that are known to be effective. Several interventions are now supported by research: use of medications following specific guidelines, training in illness self-management, case management based on principles of assertive community treatment, family psychoeducation, supported employment, and integrated substance abuse treatment. However, few patients actually receive these evidence-based interventions because they are not provided in routine mental health settings. Therefore, implementing effective treatments in mental health treatment programs is a critical challenge for the field. We review the six areas of evidence-based treatment of schizophrenia, as well as knowledge regarding implementation of mental health programs in routine practice settings.

Self-esteem as an outcome measure in studies of vocational rehabilitation for adults with severe mental illness

OBJECTIVE

Self-esteem is widely used as an outcome variable in studies of psychiatric rehabilitation, based on the assumption that improved functional status leads to higher self-esteem. Little is known, however, about the determinants of self-esteem among adults with severe mental illness. The utility of a popular measure of global self-esteem-the Rosenberg Self-Esteem Scale-as an outcome measure was examined in this population.

METHODS

A total of 143 participants enrolled in a study of vocational rehabilitation were assessed at baseline and six, 12, and 18 months later using measures of self-esteem, symptoms, life satisfaction, work status, housing status, and total income.

RESULTS

Scores on the Rosenberg Self-Esteem Scale did not vary with work status or other functional outcomes but instead were strongly related to measures of life satisfaction and affective symptoms.

CONCLUSIONS

The hypothesis that working leads to improved self-esteem for people with severe mental illness was not supported. For this population, self-esteem, as measured by the Rosenberg Self-Esteem Scale, appears to be a relatively stable trait that reflects general life satisfaction and affective symptoms rather than objective functional status.

A randomized clinical trial of supported employment for inner-city patients with severe mental disorders

BACKGROUND

This experiment evaluated the effectiveness of 2 approaches to vocational services for persons with severe mental disorders: (1) individual placement and support (IPS), in which employment specialists within the mental health center help patients to obtain competitive jobs and provide ongoing support, and (2) enhanced vocational rehabilitation (EVR), in which stepwise vocational services are delivered by rehabilitation agencies.

METHODS

One hundred fifty-two unemployed, inner-city patients with severe mental disorders who expressed interest in competitive employment were randomly assigned to IPS or EVR and followed up for 18 months. Following diagnostic assessment, participants were assessed with standardized measures of work, income, self-esteem, quality of life, symptoms, and hospitalization at baseline and at 6-, 12-, and 18-month follow-up evaluations. Employment was tracked monthly and job satisfaction every 2 months.

RESULTS

During the 18-month study, participants in the IPS program were more likely to become competitively employed (60.8% vs 9.2%) and to work at least 20 hours per week in a competitive job (45.9% vs 5.3%), whereas EVR participants had a higher rate of participation in sheltered employment (71.1% vs 10.8%). Total earnings, job satisfaction, and nonvocational outcomes were similarly improved for both groups.

CONCLUSION

The IPS model of supported employment is more effective than standard, stepwise EVR approaches for achieving competitive employment, even for inner-city patients with poor work histories and multiple problems.

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study

OBJECTIVE

The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs.

METHODS

Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years.

RESULTS

Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction.

CONCLUSIONS

Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success.

Measuring resource use in economic evaluations: determining the social costs of mental illness

Concern over costs associated with mental disorders has led to an increase in the number of economic evaluations of treatment interventions; unfortunately, methods for measuring resource use have not kept pace with this concern. Although it is well-known that a significant proportion of the costs associated with mental illness are for resources other than treatment, program evaluators and researchers often count only treatment costs in cost-effectiveness comparisons. Further, existing methods for measuring resource use are plagued by faulty assumptions about resource use, poor validity and reliability, and difficulties quantifying resource use. The authors discuss these problems and suggest five ways of improving measurement of nontreatment resources: clarifying assumptions, using multiple data sources, flexible data collection strategies, methods for improving the accuracy of recall, and an episodic approach to measurement.

HIV risk factors among people with severe mental illness in urban and rural areas

No studies have reported HIV risk behavior in rural populations with severe mental illness. A total of 84 rural patients with severe mental illness in New Hampshire and 158 urban patients in Baltimore were interviewed about their HIV risk behavior in the past six months using the Risk Assessment Battery, a 38-item structured clinical interview. Rates of sexual and drug risk behavior among rural patients were significantly lower than among urban patients. Regression analyses showed that urban setting, younger age, never having been married, and a bisexual or gay orientation significantly predicted higher HIV risk scores. The differences in risk behaviors may reflect urban-rural differences in drug availability and sexual practices.

Conduct disorder, antisocial personality disorder and substance use disorders in schizophrenia and major affective disorders

OBJECTIVE

To examine the relationships between childhood conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (substance abuse or substance dependence) in psychiatric patients with severe mental illness.

METHOD

Substance use-related problems on screening instruments, lifetime and recent prevalence of substance use disorders, and family history of substance use disorder were evaluated in four groups of 293 patients with mainly schizophrenia-spectrum and major affective disorders: No ASPD/CD, CD Only, Adult ASPD Only, Full ASPD.

RESULTS

Full ASPD was strongly related to all measures of substance use problems and disorders, as well as fathers' history of substance use disorder. The odds ratios for Full ASPD and substance use disorders ranged between 3.96 (lifetime cannabis use disorder) to 11.35 (recent cocaine use disorder). To a lesser extent, patients with CD Only or Adult ASPD Only were also at increased risk for having substance use disorders compared to the No ASPD/CD patients.

CONCLUSIONS

Childhood CD and adult ASPD represent significant risk factors for substance use disorders in patients with schizophrenia-spectrum and major affective disorders. Considering other research indicating that CD and ASPD have a higher prevalence in patients with severe mental illness, the present findings suggest that CD and ASPD could reflect a common factor that independently increases patients' vulnerability to both psychiatric and substance use disorders.

Research on the individual placement and support model of supported employment

This paper reviews research on the Individual Placement and Support (IPS) model of supported employment for people with severe mental illness. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disabilities to find and maintain competitive employment than rehabilitative day programs or than traditional, stepwise approaches to vocational rehabilitation. There is no evidence that the rapid-job-search, high-expectations approach of IPS produces untoward side effects. IPS positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. The cost of IPS is similar to the costs of other vocational services, and cost reductions may occur when IPS displaces traditional day treatment programs. Future research should be directed at efforts to enhance job tenure and long-term vocational careers.

Review of integrated mental health and substance abuse treatment for patients with dual disorders

Patients with severe mental disorders such as schizophrenia and co-occurring substance use disorders traditionally received treatments for their two disorders from two different sets of clinicians in parallel treatment systems. Dissatisfaction with this clinical tradition led to the development of integrated treatment models in which the same clinicians or teams of clinicians provide substance abuse treatment and mental health treatment in a coordinated fashion. We reviewed 36 research studies on the effectiveness of integrated treatment for dually diagnosed patients. Studies of adding dual-disorders groups to traditional services, studies of intensive integrated treatments in controlled settings, and studies of demonstration projects have thus far yielded disappointing results. On the other hand, 10 recent studies of comprehensive, integrated outpatient treatment programs provide encouraging evidence of the programs' potential to engage dually diagnosed patients in services and to help them reduce substance abuse and attain remission. Outcomes related to hospital use, psychiatric symptoms, and other domains are less consistent. Several program features appear to be associated with effectiveness: assertive outreach, case management, and a longitudinal, stage-wise, motivational approach to substance abuse treatment. Given the magnitude and severity of the problem of dual disorders, more controlled research on integrated treatment is needed.

Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders

OBJECTIVE

To determine the cost-effectiveness of Assertive Community Treatment (ACT) in comparison to Standard Case Management (SCM) for persons with severe mental illness and substance use disorders.

DATA SOURCES AND STUDY SETTING

Original data on the effectiveness and social costs of ACT and SCM that were collected between 1989 and 1995. Seven community mental health centers in New Hampshire provided both types of treatment.

STUDY DESIGN

Persons with schizophrenia, schizoaffective disorder, or bipolar disorder and a concurrent substance use disorder were randomly assigned to ACT or SCM and followed for three years. The primary variables assessed were substance use, psychiatric symptoms, functioning, quality of life, and social costs.

DATA COLLECTION METHODS

Effectiveness data were obtained from interviews at six-month intervals with persons enrolled in treatment and with their service providers. Social cost and service utilization data came from client reports; interviews with informal caregivers; provider information systems and Medicaid claims; law enforcement agencies; courts; and community service providers.

PRINCIPAL FINDINGS

Participants in both groups showed significant reductions in substance use over time. Focusing on quality of life and substance use outcomes, ACT and SCM were not significantly different in cost-effectiveness over the entire three-year study period. Longitudinal analyses showed that SCM tended to be more efficient during the first two years but that ACT was significantly more efficient than SCM during the final year of the study.

CONCLUSIONS

In an adequately funded system, ACT is not more cost-effective than SCM. However, ACT efficiency appears to improve over time.

Gender differences in homeless persons with schizophrenia and substance abuse

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.

Dual diagnosis: a review of etiological theories

The etiology of the high prevalence of substance use disorders in patients with severe mental illness (schizophrenia or bipolar disorder) is unclear. We review the evidence of different theories of increased comorbidity, organized according to four general models: common factor models, secondary substance use disorder models, secondary psychiatric disorder models, and bidirectional models. Among common factor models, evidence suggests that antisocial personality disorder accounts for some increased comorbidity. Among secondary substance use disorder models, there is support for the supersensitivity model, which posits that biological vulnerability of psychiatric disorders results in sensitivity to small amounts of alcohol and drugs, leading to substance use disorders. There is minimal support for the self-medication model, but the accumulation of multiple risk factors related to mental illness, including dysphoria, may increase the risk of substance use disorder. Secondary psychiatric disorder models remain to be convincingly demonstrated. Bidirectional models have not been systematically examined. Further clarification of etiologic factors, including the identification of subtypes of dual diagnosis, may have implications for developing more effective prevention efforts and treatment.

A research induction group for clients entering a mental health research project: a replication study

Through education and discussion, the research induction group introduces mental health clients to participation in a research study. The purpose is to help clients to understand fully the clinical and research procedures involved in the study so that they can make a truly informed decision about whether or not to participate. This study replicated a previous study in showing that the research induction group resulted in informed decision-making, high rates of participation in the clinical services and in the research, and high rates of satisfaction with both vocational services and research procedures.

Lymphatic drainage reduces intestinal edema and fluid loss

Lymphatic vessels are important in removing excess fluid from the intestine and transporting the fluid to veins in the neck. However, in some diseases, neck vein pressure is increased and the high pressure may slow lymph flow. This study was to test the hypothesis that lymphatic clearance of fluid from the intestine may be increased by draining the lymphatics. Inflatable cuffs were used to increase neck vein pressure and portal venous pressure in anesthetized sheep. The lymphatic vessel from one segment of small intestine was cannulated and drained. The lymphatic vessel to a control segment of intestine was left intact. After 90 min. we found significantly less fluid in the lumen of the drained vs. control segments (7.4 +/- 3.1 (SD) ml vs 11.5 +/- 4.7 ml per gram dry tissue, respectively). Also we found significantly less tissue fluid in the drained vs control segments (5.3 +/- 0.3 ml/g vs 6.0 +/- 0.4 ml/g). The findings support the hypothesis that external diversion of lymph in the presence of an elevated central venous pressure reduces edema formation.