The impact of traditional psychiatric services and case management services on the functioning of people with schizophrenia: A cross-national study in Nova Scotia and Texas

The purpose of this study was to determine the impact of traditional psychiatric services with case management services on the functioning of people with schizophrenia. Traditional services were defined as routine clinic services consisting of medication follow-along, psychotherapy, and support services. Case management consisted of activities involved in linking, planning, and monitoring services for the outpatient client who has schizophrenia. The target population was adult schizophrenics who had been receiving outpatient clinic services for a minimum of six months. Structured interviews were conducted using standardized scales (e.g., Quality of Life, Self-Efficacy, and Brief Symptom Inventory) with 78 outpatient client volunteers from two sites: Nova Scotia (Canada) and Texas (USA). The researcher tested for differences in psychiatric symptomatology, recidivism, and quality of life for persons with schizophrenia receiving traditional psychiatric services in Nova Scotia and traditional plus case management services in Texas. Data were collected from the structured interviews and medical records review forms. Types of services were blocked into low and high levels of Intensity (frequency x minutes) and compared to determine the relative contribution of each. Finally, the role of clients' self-efficacy was tested as an intervening variable. Although the findings did not support the hypotheses in the direction anticipated, there were some interesting and useful results. From the Nova Scotia site, clients who received low levels of services were hospitalized less compared to the Texas site. The more psychotic a patient was the higher their involvement in medication follow-along and the more monitoring they received. The more psychotherapy received, the lower the reported satisfaction with social relationships. Of particular interest is the role that self-efficacy played in improved client outcomes. Although self-efficacy scores were related to improved functioning, the mechanism for this still needs to be clarified through subsequent research. ^

Gender disparities in utilization, unmet need and expenditure for mental health care

Objectives: To compare mental health care utilization regarding the source, types, and intensity of mental health services received, unmet need for services, and out of pocket cost among non-institutionalized psychologically distressed women and men. ^ Method: Cross-sectional data for 19,325 non-institutionalized mentally distressed adult respondents to the “The National Survey on Drug Use and Health” (NSDUH), for the years 2006 -2008, representing over twenty-nine millions U.S. adults was analyzed. To assess the relative odds for women compared to men, logistic regression analysis was used for source of service, for types of barriers, for unmet need and cost; zero inflated negative binomial regression for intensity of utilization; and ordinal logistic regression analysis for quantifying out-of-pocket expenditure. ^ Results: Overall, 43% of mentally distressed adults utilized a form of mental health treatment; representing 12.6 million U.S psychologically distressed adults. Females utilized more mental health care compared to males in the previous 12 months (OR: 1. 70; 95% CI: 1.54, 1.83). Similarly, females were 54% more likely to get help for psychological distress in an outpatient setting and females were associated with an increased probability of using medication for mental distress (OR: 1.72; 95% CI: 1.63, 1.98). Women were 1.25 times likelier to visit a mental health center (specialty care) than men. ^ Females were positively associated with unmet needs (OR: 1.50; 95% CI: 1.29, 1.75) after taking into account predisposing, enabling, and need (PEN) characteristics. Women with perceived unmet needs were 23% (OR: 0.77; 95% CI: 0.59, 0.99) less likely than men to report societal accommodation (stigma) as a barrier to mental health care. At any given cutoff point, women were 1.74 times likelier to be in the higher payment categories for inpatient out of pocket cost when other variables in the model are held constant. Conclusions: Women utilize more specialty mental healthcare, report more unmet need, and pay more inpatient out of pocket costs than men. These gender disparities exist even after controlling for predisposing, enabling, and need variables. Creating policies that not only provide mental health care access but also de-stigmatize mental illness will bring us one step closer to eliminating gender disparities in mental health care.^

End -of -life planning and decision -making: Implications for adults with mental retardation

This research focused on the topic of end-of-life planning and decision-making for adults affected by mental retardation. Adults with mental retardation have unique challenges in this regard, including difficulty communicating their wishes without assistance and diminished decision-making skills. The primary research objective was to identify factors that can affect opportunities for adults with mental retardation in community-based services settings (and their advocates) to be involved in planning and deciding about their own end-of-life experience. ^ A descriptive qualitative inquiry was designed to explore issues related to death and dying, and the notion of end-of-life planning, from the perspective of adults with mental retardation who receive publicly-funded community services ("clients") and family members of individuals who receive such services. Study participants were recruited from a single mental retardation service provider in a large urban setting (the "Agency"). Sixteen clients and 14 families of Agency clients took part. Client data collection was accomplished through face-to-face interviews, focus group meetings, and record reviews; family members were involved in a face-to-face interview only. ^ An initial coding scheme was developed based upon literature and policy reviews, and themes related to the research questions. Analysis involved extracting data from transcripts and records and placing it into appropriate thematic categories, building support for each theme with the accumulated data. Coding themes were modified to accommodate new data when it challenged existing themes. ^ Findings suggest that adults with mental retardation do have the requisite knowledge, interest, and ability to participate in decisions about their end-of-life experience and handling of affairs. Siblings are overwhelmingly the chosen future surrogates and they (or their children) will likely be the end-of-life advocates for their brothers and sisters affected by mental retardation. Findings further point to a need for increased awareness, accurate information, and improved communication about end-of-life issues, both in general and particular to adults affected by mental retardation. Also suggested by the findings is a need to focus on creating accommodations and adaptations that can best uncover a person's authentic views on life and death and related end-of-life preferences. Practical implications and suggestions for further research are also discussed. ^

How does family intervention improve the outcome of people with schizophrenia?

Background: There is strong evidence of the efficacy of family psychosocial interventions for schizophrenia, but evidence of the role played by the attitudes of relatives in the therapeutic process is lacking. Method: To study the effect of a family intervention on family attitudes and to analyse their mediating role in the therapeutic process 50 patients with schizophrenia and their key relatives undergoing a trial on the efficacy of a family psychosocial intervention were studied by means of the Affective Style Coding System, the Scale of Empathy, and the Relational Control Coding System. Specific statistical methods were used to determine the nature of the relationship of the relatives’ attitudes to the outcome of family intervention. Results: Family psychosocial intervention was associated with a reduction in relatives’ guilt induction and dominance and an improvement in empathy. Empathy and lack of dominance were identified as independent mediators of the effect of family psychosocial intervention. The change in empathy and dominance during the first 9 months of the intervention predicted the outcome in the following 15 months. Conclusion: Relatives’ empathy and lack of dominance are mediators of the beneficial effect of family psychosocial intervention on patient’s outcome.

Coping with AIDS : psychological and social considerations in helping people with HTLV-III infection.

Mode of access: Internet.

Child welfare and juvenile justice : federal agencies could play a stronger role in helping states reduce the number of children placed solely to obtain mental health services : report to congressional requesters /

"GAO-03-397."

Mental health recovery and occupational therapy in Australia and New Zealand

Every individual with mental illness has the right to be safe and cared for. Most people will receive the love and care from their families and friends, but they will also expect mental-health professionals, occupational therapists and the community to work together to provide the necessary services to support their recovery from mental illness. This article highlights the development of the recovery approach for people with mental illness in Australia and New Zealand. The implications of recovery concepts for occupational therapy, in the areas of individualized approach, participation of service users and carers, person-centred assessment and intervention, intersectoral links and mental-health promotion, are discussed. There are a number of key areas requiring further research and debate, notably the most effective means of implementing and evaluating recovery-focused interventions.

Telepaediatrics and diabetic retinopathy screening of young people with diabetes in Queensland

We have examined the feasibility of a telemedicine-enabled screening service for children and adolescents with diabetes in Queensland. There are approximately 1400 young people with diabetes in Queensland and only about two-thirds of them are screened in accordance with international guidelines. A regional retinal screening service was established using a non-mydriatic digital retinal camera. Seven centres volunteered to participate in the study. During a five-month pilot trial, 83 of the young people with diabetes who attend these centres underwent digital retinal screening (3.7%). Retinal images were sent via email to a paediatric ophthalmologist for review and results were returned via email. A copy of each participant's results was forwarded by mail to the referring diabetes doctor and the participant and family. The majority of the image files (96%) were rated as excellent or good. Only one participant was identified as having an abnormal result. Participants and their families expressed satisfaction with the digital retinal screening process.

Addressing internet training issues for people with Parkinson's disease

The Internet enables access to information, services, support and participation in leisure opportunities. Some populations, including people with disabilities, lack access to these opportunities through the Internet. Barriers may include finances, physical access, lack of resources and inaccessible websites. Limited access to Internet training is an additional barrier for people with communication impairments. People with Parkinson's disease (PD) may have difficulty accessing usual Internet training due to high-level language, cognitive and physical limitations. Aphasia-friendly Internet training materials were trialed with this population to investigate if participants could learn to use the Internet and would benefit from Internet training. The tutors' experience was also investigated using qualitative measures. Seven people with PD were matched with volunteer tutors. These pairs met for six Internet training lessons using training materials available as a free download from: http://dexter.shrs.uq.edu.au/cdaru/aphasiagroups/. Pre and post-test Internet skills assessments and attitudinal questionnaires were conducted. Significant differences between pre and post-test scores were found. Participants reached varying levels of independence on Internet tasks. Favorable outcomes were reported by participants, and tutors reported a positive experience. Further investigation is recommended to determine the efficacy of this approach compared with other training avenues and with other communication-impaired populations. Practical and theoretical implications for speech pathology practice are discussed.

Validity of accelerometry for measurement of activity in people with brain injury

Purpose: To evaluate the validity of a uniaxial accelerometer (MTI Actigraph) for measuring physical activity in people with acquired brain injury (ABI) using portable indirect calorimetry (Cosmed K4b(2)) as a criterion measure. Methods: Fourteen people with ABI and related gait pattern impairment (age 32 +/- 8 yr) wore an MTI Actigraph that measured activity (counts(.)min-(1)) and a Cosmed K4b(2) that measured oxygen consumption (mL(.)kg(-1.)min(-1)) during four activities: quiet sitting (QS) and comfortable paced (CP), brisk paced (BP), and fast paced (FP) walking. MET levels were predicted from Actigraph counts using a published equation and compared with Cosmed measures. Predicted METs for each of the 56 activity bouts (14 participants X 4 bouts) were classified (light, moderate, vigorous, or very vigorous intensity) and compared with Cosmed-based classifications. Results: Repeated-measures ANOVA indicated that walking condition intensities were significantly different (P < 0.05) and the Actigraph detected the differences. Overall correlation between measured and predicted METs was positive, moderate, and significant (r = 0.74). Mean predicted METs were not significantly different from measured for CP and BP, but for FP walking, predicted METs were significantly less than measured (P < 0.05). The Actigraph correctly classified intensity for 76.8% of all activity bouts and 91.5% of light- and moderate-intensity bouts. Conclusions: Actigraph counts provide a valid index of activity across the intensities investigated in this study. For light to moderate activity, Actigraph-based estimates of METs are acceptable for group-level analysis and are a valid means of classifying activity intensity. The Actigraph significantly underestimated higher intensity activity, although, in practice, this limitation will have minimal impact on activity measurement of most community-dwelling people with ABI.

Population pharmacokinetics and association between A77 1726 plasma concentrations and disease activity measures following administration of leflunomide to people with rheumatoid arthritis

Aims To investigate the concentration-effect relationship and pharmacokinetics of leflunomide in patients with rheumatoid arthritis (RA). Methods Data were collected from 23 RA patients on leflunomide therapy (as sole disease modifying antirheumatic drug (DMARD)) for at least 3 months. Main measures were A77 1726 (active metabolite of leflunomide) plasma concentrations and disease activity measures including pain, duration/intensity of morning stiffness, and SF-36 survey. A population estimate was sought for apparent clearance (CL/F ) and volume of distribution was fixed (0.155 l kg(-1)). Factors screened for influence on CL/F were weight, age, gender and estimated creatinine clearance. Results Significantly higher A77 1726 concentrations were seen in patients with less swollen joints and with higher SF-36 mental summary scores than in those with measures indicating more active disease (P < 0.05); concentration-effect trends were seen with five other disease activity measures. Statistical analysis of all disease activity measures showed that mean A77 1726 concentrations in groups with greater control of disease activity were significantly higher than those in whom the measures indicated less desirable control (P < 0.05). There was large between subject variability in the dose-concentration relationship. A steady-state infusion model best described the pharmacokinetic data. Inclusion of age as a covariate decreased interindividual variability (P < 0.01), but this would not be clinically important in terms of dosage changes. Final parameter estimate (% CV interindividual variability) for CL/F was 0.0184 l h(-1) (50%) (95% CI 0.0146, 0.0222). Residual (unexplained) variability (% CV) was 8.5%. Conclusions This study of leflunomide in patients using the drug clinically indicated a concentration-effect relationship. From our data, a plasma A77 1726 concentration of 50 mg l(-1) is more likely to indicate someone with less active disease than is a concentration around 30 mg l(-1). The marked variability in pharmacokinetics suggests a place for individualized dosing of leflunomide in RA therapy.