A research network to evaluate assertive community treatment: introduction

Association of metabolic syndrome and inflammation with neurocognition in patients with schizophrenia

The aim of this study is to assess the relationships of metabolic syndrome (MetS) and inflammation with neurocognition in schizophrenia. In this cross-sectional study, we included patients with diagnosis of schizophrenia according to the DSM-IV-TR criteria. We collected socio-demographic information, clinical characteristics, anthropometric measurements, blood tests, and neurocognition measures. A multivariate analysis using multiple linear regressions was performed to determine variables that are potentially associated with neurocognition. The analyses were repeated using MetS as a dichotomised variable (< and ≥ 3 MetS criteria), a continuous variable (number of MetS criteria present), and for each component of MetS. One hundred and sixty-eight outpatients participated in our study. The prevalence of MetS was 27.4%. An association was found between the number of MetS criteria present and cognitive impairment. Among the different components of MetS, hypertriglycerides and abdominal obesity were the only factors associated with cognitive impairment. Other factors, such as smoking and alcohol dependence or abuse, also revealed a significant relationship, whereas inflammation was not associated with cognitive impairment. In conclusion, our findings suggest that MetS, alcohol use and non-smoking status are associated with cognitive impairment. These findings may support complementary therapeutic approaches in cognitive remediation that lessen the severity of cognitive impairment in schizophrenia.

Are cardiovascular risk factors associated with verbal learning and memory impairment in patients with schizophrenia? A cross-sectional study

Objective. The aim of this study is to assess the relationships of cardiovascular risk factors with verbal learning and memory in patients with schizophrenia. Methods and Design. cross-sectional study. Inclusion Criteria. Diagnosis of schizophrenia according to the DSM-IV-TR criteria. Data Collection. Sociodemographic information, clinical characteristics, anthropometric measurements, blood tests, and episodic memory using the California Verbal Learning Test (CVLT). Analysis. A multivariate analysis using multiple linear regressions was performed to determine variables that are potentially associated with verbal learning and memory. Results. One hundred and sixty-eight outpatients participated in our study. An association was found between the metabolic syndrome (MetS) and memory impairment on measures of verbal learning, and short- and long-term memory. Among the different components of MeTS, hypertriglycerides, abdominal obesity, and low HDL cholesterol were the only factors associated with memory impairment. Alcohol dependence or abuse was associated with a higher rate of forgetting. Conclusion. Our findings suggest that MetS and alcohol use may be linked with memory impairment in schizophrenia. These findings provide important insights into the interdependencies of cardiovascular risk factors and cognitive disorders and support novel strategies for treating and preventing cognitive disorders in patients with schizophrenia.

Annotation: childhood-onset schizophrenia: clinical and treatment issues

BACKGROUND

In the past 10 years, there has been increased research on childhood-onset schizophrenia and clear advances have been achieved.

METHOD

This annotation reviews the recent clinical and treatment literature on childhood-onset schizophrenia.

RESULTS

There is now strong evidence that the syndrome of childhood-onset schizophrenia exists and there are several similarities between childhood- and later-onset schizophrenia. Schizophrenia in youth can be reliably diagnosed using the same criteria employed with adults, and childhood-onset schizophrenia is predictive of schizophrenia or schizophrenia spectrum disorders in adulthood. Data is accumulating to guide pharmacological treatment strategies, and practice parameters have been developed to guide clinical care.

CONCLUSIONS

Despite significant advances, there remains an urgent need for additional research on treatment and service delivery strategies. Promising work with adults highlights the importance of attending to psychosocial as well as pharmacologic treatment strategies, and the potential value of preventive interventions.

Subjective quality of life in the evaluation of programs for people with serious and persistent mental illness

Despite the widespread application of the concept of quality of life in mental health evaluation, it has been observed that subjective quality of life measures do not reliably capture changes expected to result from intervention efforts. Moreover, because the domains selected to assess subjective life quality are typically generated by investigators or health professionals, the validity of subjective quality of life measures has also been questioned. Although it represents a conceptual shift from investigator-generated domains to client-elicited domains, it is suggested that a client-elicited approach to measuring subjective quality of life may provide fruitful avenues for resolving some of the conceptual and practical issues associated with understanding and measuring the impact of community-based programs on clients with serious mental illness. Accordingly, while acknowledging the utility of assessing the objective circumstances of people's lives, this paper suggests that client-elicited subjective quality of life domains have the potential to resolve the failure of existing measures to register meaningful change. Unlike previous general reviews of quality of life that have emphasized measurement issues, the present review considers some of the fundamental barriers to our ability to adequately understand and document the experiences of people adjusting to community living with a psychiatric disability.

Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness

Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel and used a structured process to identify 37 final competencies. Panel members agreed that these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.

Pentavalent treatment: preliminary effects on state hospital utilization

The purpose of this exploratory study was to determine if a low-cost alternative to assertive community treatment (ACT) programs could achieve results comparable to those previously reported by high-fidelity ACT programs with regard to state hospital utilization by patients with long-term, treatment-refractory serious mental illness and high rates of hospital recidivism. A sample of 30 patients was exposed to a low- cost alternative to ACT for a 12-month period. A quasi-experimental research design was used to compare state hospital utilization by the treatment group and a matched comparison group. The treatment group exhibited significantly less state hospital utilization than the comparison group and had an 88% reduction in state hospital utilization in comparison to its 10-year baseline. Low cost alternatives to ACT programs may be as effective as high-fidelity programs in reducing state hospital utilization and may be more easily adaptable to the current structure, operation, and financial constraints of community mental health centers.

The state hospital and the community: an essential continuum for persons with severe and persistent mental illness

Assertive Community Treatment and related approaches will have a defining impact on state hospitals, now and in the future.

State-of-the-art challenges for mental health services research

BACKGROUND: Research-based, state-of-the-art services for people with serious mental disorders would consist of demonstrably effective treatments, organized synergistically, and financed in ways that create incentives to provide such treatment. While research exists in these domains of treatment, organization and financing, this research base contains significant gaps, and what is known frequently neither informs policy making nor enters practice. REVIEW: The NIMH services-research portfolio has identified successful patient-level and system-level interventions for people with serious mental disorders, but much of this research has yet to make its way into practice. Similarly, while we have made progress in asking "what is good care?", we have much less information about the answers to "what constitutes an adequate try?". Writing a prescription for an efficacious medication does not constitute an adequate trial of that medication. Similarly, offering people boring psychosocial rehabilitation programs does not constitute an adequate try of promoting recovery via rehabilitation services, but what does? Defining what constitutes an adequate try can be a way of allocating scarce resources or it can be a polite way of defining when a system gets to give up on someone. As state governments move to contract with managed care entities for services for Medicaid beneficiaries, one of the great contracting challenges is defining and monitoring the provision of what constitutes an adequate try. DISCUSSION: To obtain better value for our health care expenditures, we need to find ways to get what we know works into practice, whether we are contracting for services or deciding which clinical therapies to pursue. For example, problem-oriented family therapy has been shown to improve clinical outcomes for people with schizophrenia, yet such interventions are rare in practice. We also need to pay more attention to the quality of the clinical care actually being delivered - not what was prescribed, nor what the clinician was trained in, nor what the job description was, but what actually is occurring. Figuring out how to contract for and disseminate efficacious treatments so that they occur and are effective in real-world settings is critically important yet is a largely unexplored area of services research. We need to answer both "what is good care?" and "how do we get it to happen?".