Current Suicidal Ideation among Treatment-Engaged Active Duty Soldiers and Marines

We examined suicidal ideation among 399 active duty Soldiers and Marines engaged in mental health treatment. Using a generalized linear model controlling for demographic and military factors, depression, and positive traumatic brain injury screen, we confirmed our hypothesis that self-report measures of current PTSD symptoms uniquely predicted suicidal ideation. The association between PTSD severity and suicidal ideation was moderated by gender with women at higher risk as PTSD severity increased. Female Soldiers and Marines with high levels of PTSD should receive additional monitoring and intervention. Self-report measures may aid with risk assessment and identify symptom-related distress associated with suicide risk.

Geriatric Patients Improve as Much as Younger Patients from Hospitalization on General Psychiatric Units

OBJECTIVES

To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission.

DESIGN

Cohort study.

SETTING

Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999.

PARTICIPANTS

A total of 5,929 inpatients.

MEASUREMENTS

Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses.

RESULTS

Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients.

CONCLUSION

Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence

A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.

Shorter hospital stays and more rapid improvement among patients with schizophrenia and substance disorders

OBJECTIVE

Length of stay and treatment response of inpatients with acute schizophrenia were examined to determine whether differences existed between those with and without comorbid substance-related problems.

METHODS

The sample comprised 608 patients with a diagnosis of schizophrenia or schizoaffective disorder treated on hospital units with integrated dual diagnosis treatment. They were rated on admission and discharge by a psychiatrist using a structured clinical instrument. Patients with no substance-related problems were compared with those with moderate to severe problems using t tests, chi square tests, and analysis of variance.

RESULTS

When analyses controlled for age, gender, and other clinical variables, dually diagnosed patients were found to have improved markedly faster compared with patients without a dual diagnosis. Their hospital stays were 30 percent shorter on both voluntary and involuntary units. They also showed somewhat greater symptomatic improvement and no increase in 18-month readmission rates. On admission the dual diagnosis group was more likely to be younger, male, and homeless and more likely to be a danger to self and others. Severity of psychosis was the same at admission for the two groups, but the dually diagnosed patients were rated as less psychotic at discharge.

CONCLUSIONS

Dually diagnosed patients with schizophrenia appear to stabilize faster during acute hospitalization than those without a dual diagnosis. The authors hypothesize that substance abuse may temporarily amplify symptoms or that these patients may have a higher prevalence of better-prognosis schizophrenia. The availability of integrated dual-focus inpatient treatment and a well-developed outpatient system may also have helped these patients recover more rapidly.

Relationship between borderline personality disorder and Axis I diagnosis in severity of depression and anxiety

BACKGROUND

This study tested the hypothesis that subjects with borderline personality disorder irrespective of the presence or absence of an Axis I mood or anxiety disorder would exhibit greater severity of depression and anxiety than subjects with either a personality disorder other than borderline personality disorder or no personality disorder.

METHOD

Two hundred eighty-three subjects from an outpatient psychiatry clinic were administered the following assessments: the Structured Clinical Interview for DSM-III-R (SCID) for Axes I and II, the Hamilton Rating Scales for Depression and Anxiety, the Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory. Subjects were categorized into borderline personality disorder, other personality disorder, and no personality disorder categories and into present versus absent categories on Axis I diagnosis of depression and of anxiety. A 2-factor multiple analysis of variance compared personality disorder status and Axis I diagnosis on severity of depression by observer rating and self-report. The analysis was repeated for anxiety.

RESULTS

As hypothesized, significant main effects were found for borderline personality disorder and for both depression and anxiety. Subjects with borderline personality disorder showed greater severity on both depression and anxiety rating scales than did patients with another personality disorder, who showed greater severity than did patients with no personality disorder. Axis I diagnosis was also associated with greater severity on depression or anxiety rating scales. These differences were found for both observer ratings and self-report. An interaction was also found for depression: Subjects with borderline personality disorder but without an Axis I diagnosis of depression rated themselves as more severely depressed on the Beck Depression Inventory than did subjects with another or no personality disorder who also had an Axis I diagnosis of depression.

CONCLUSION

Implications from the study are discussed including the need to assess for borderline personality disorder in research studies of depression and anxiety and to integrate treatments for borderline personality disorder into depression and anxiety treatment to maximize clinical outcomes.

Treatment satisfaction compared with outcome in severe dual disorders

This paper examines patient (N = 75) ratings of treatment satisfaction and outcome for severely mentally ill dually diagnosed outpatients participating in long-term integrated dual focus treatment. In addition, it compares these ratings with case manager ratings of patient outcome over a one year period. Satisfaction ratings ranged from very good to excellent. Combined means of several outcomes ratings indicated that most patients rated themselves as improved. Satisfaction with over-all care and with case management was significantly, though weakly (r = .3 and .31, respectively, p < .05), related to patient ratings of overall outcome. While most patients rated that they had improved, satisfaction with treatment was only weakly related to either patient or case manager rated clinical outcomes. These findings indicate the relatively independent relationship of satisfaction with treatment outcome and caution against over generalizing the meaning of treatment satisfaction measures.

A pilot study comparing severely and persistently mentally ill opiate-addicted patients in dual-diagnosis treatment with patients in methadone maintenance

The authors describe a severely and persistently mentally ill (SPMI) opiate-addicted (OA) patient sample (n = 43) in a dual-diagnosis outpatient treatment program by demographic, clinical, and treatment characteristics and compare these with other dually diagnosed SPMI patients in the same treatment center (n = 297). Also, those SPMI/OA patients with physiological dependence (n = 20) were compared with a matched sample of OA patients in traditional methadone maintenance (n = 20). The authors then present a clinical evaluation of treatment course and outcome for the SPMI/OA patients (n = 43) and discuss implications from these pilot data.

Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders. A comparative study of payee and non-payee participants

The objective of this pilot study is to describe the use of a Social Security representative payee program as a clinical intervention integrated into long-term, dual-disorder treatment of severely mentally ill outpatients with comorbid drug/alcohol disorders. Compared with non-payees, patients selected to be payee participants were more likely to be male, have a diagnosis of schizophrenia, have a history of high inpatient utilization, and have higher current ratings of psychiatric symptoms, substance use, and functional disability. Despite these higher severity ratings, which usually predict poor outpatient compliance and higher rate of adverse outcomes, the payee participants attended about twice the number of outpatient service sessions as non-payees and were no more likely to be currently homeless, hospitalized, or incarcerated. The payee intervention is described, and ethical and research issues are discussed.

Illness severity and treatment services for dually diagnosed severely mentally ill outpatients

This study of a frequently endorsed, but untested, model of outpatient treatment for persons with coexisting severe mental illness and substance use disorders assessed how the amount of treatment services delivered was related to an individual's global severity of illness, whether different modes of treatment were related to different aspects of illness, how noncompliance with treatment was related to the severity of illness and amount of services delivered, and how the diagnosis of schizophrenia/schizoaffective influenced these issues. Participants with high total severity of illness (TSI) received about twice the number of appointments (20.7 vs. 12.3) per month as those with low TSI scores. Higher TSI was also related to a DSM-IV diagnosis of schizophrenia/schizoaffective, being in a lower "phase" of treatment, representative payee benefit management, homelessness, and more hospitalizations. Participants with higher psychiatric symptom severity received significantly more case management and medication services, but not group therapy or day treatment. Severity of substance use condition was significantly related only to case management. This model of treatment was found to be successful in delivering higher levels of treatment services to those needing them.

Development and validation of adolescent-perceived microsystem scales: social support, daily hassles, and involvement

Developed and validated instruments for urban and culturally diverse adolescents to assess their self-reported transactions with family, peer, school, and neighborhood microsystems for the constructs of social support, daily hassles, and involvement. The sample of 998 youth were from schools in three Eastern cities with high percentages of economically disadvantaged youth. Data were collected before and after the transition to junior high school or to senior high school. Blacks constituted 26%, whites 26%, and Latinos 37% of the sample. Factor analyses confirmed and enhanced the hypothesized four-factor microsystem factor structure for support, hassles, and involvement; internal consistency and stability coefficients were consistent with these structures. In general, the microsystem factors were common across gender, ethnicity, and age. However, when group differences did occur on these demographic variables, they tended to validate the salience of microsystem specificity. In contrast to the total scores, the microsystem-specific factors yielded more meaningful and differential information with regard to demographic differences and the mediating processes across a school transition.

Case manager ratings of the clinical status of dually diagnosed outpatients

OBJECTIVE

The researchers' aim was to evaluate the construct validity of a rating scale used by case managers to assess the clinical status of clients in a large outpatient treatment program for persons with severe mental illness and concurrent drug or alcohol problems.

METHODS

A standardized rating scale for assessing clients' levels of four key clinical problems--psychiatric symptoms, substance use, treatment noncompliance, and overall level of dysfunction--was developed for use by case managers. After being trained in use of the instrument, 20 case managers rated 302 clients along these dimensions. Case manager ratings were compared with data on clients' diagnoses and the level of structure they required in their treatment program.

RESULTS

About 42 percent of the clients assessed had schizophrenia, 28 percent had bipolar disorder, 14 percent had major depression, and 11 percent had other psychotic disorders. The case manager ratings were significantly related to clients' diagnosis and the level of structure in their treatment program. The four dimensions were also correlated with each other; strong correlations were found between severity of substance use and noncompliance and between severity of psychiatric disorder and level of dysfunction.

CONCLUSIONS

Ratings by case managers can be used to measure individual progress in treatment as well as the status of the entire client population in a treatment program.