Differential treatment planning for young adult chronic patients

An assessment of 110 young adult chronic patients on six variables related to their social interactions indicates that social behavior may be an important indicator of treatment needs. The assessment delineated four treatment profiles--subgroups of patients who share a common cluster of social behaviors and who require distinct treatment approaches. This paper describes the four treatment profiles by outlining each subgroup's salient characteristics and modal patient and the treatment approaches that are most and least appropriate for its members. The authors suggest that outpatient programs may need to accommodate the characterologic and personality variables of young chronic patients to make treatment tolerable and comfortable for them, rather than deny them admission because they do not demonstrate responsible, appropriate, and independent behavior.     

Beyond deinstitutionalization: a new ideology for the postinstitutional era

The emergence of the young adult chronic patient, and the attendant perception that deinstitutionalization has failed, may be viewed as the inevitable result of the success of deinstitutionalization. Deinstitutionalization gave freedom to the mentally ill, but in doing so it left patients free to struggle on their own. The deinstitutionalization ideology failed to predict the difficult clinical reality that most patients do not readily choose the identity of chronic mental patient and are reluctant to make use of available treatment programs. The author presents the key principles of a new postinstitutional ideology that focuses on helping patients attain the best possible adaptation to their illness regardless of the setting in which they are treated. He hopes the ideology will infuse new hope and clinical expertise into work with people with chronic mental illness.     

Substance abuse by young adult chronic patients

Of 41 chronic psychiatric patients between the ages of 19 to 39 seen at a community mental health center, 44 percent were current substance abusers, 29 percent had a history of substance abuse, and only 27 percent had little or no substance abuse history. The three subgroups were similar in diagnosis, gender, and age at first hospitalization. However, the persistent substance abusers had a psychiatric hospitalization rate more than twice as high as the other two groups, and for these patients substance abuse frequently preceded hospitalization. The author recommends that consideration be given to routinely testing all hospitalized young adult chronic patients for drug and alcohol abuse. He also suggests using outside sources to obtain information on substance abuse, since most patients deny abuse. He stresses the need for more data on the physical and psychological effects of abused substances on the young mental patient.     

Juvenile and adult problems in 20 forensic psychiatric rapists in Sweden

The purpose of this study was to assess the pattern of background variables of 20 convicted rapists. The sample comprised two distinct forensic psychiatric subgroups undergoing different treatments. Data were extracted from forensic psychiatric files. The study variables were juvenile and adult problems of the offenders, related by previous research to the occurrence of rape. Records of juvenile problems and juvenile psychological disturbances tended to co-occur with adult problems of aggressiveness, alcoholism and extensive criminality. The correlation analysis further supports the notion that psychosocial disturbances have a persistent character: in our sample, different problems in young age are linked to each other as well as to adulthood problems. The results are discussed in the light of empirical research and the need for early and proper individual treatment programmes.     

Juvenile and adult problems in 20 forensic psychiatric rapists in Sweden

The purpose of this study was to assess the pattern of background variables of 20 convicted rapists. The sample comprised two distinct forensic psychiatric subgroups undergoing different treatments. Data were extracted from forensic psychiatric files. The study variables were juvenile and adult problems of the offenders, related by previous research to the occurrence of rape. Records of juvenile problems and juvenile psychological disturbances tended to co-occur with adult problems of aggressiveness, alcoholism and extensive criminality. The correlation analysis further supports the notion that psychosocial disturbances have a persistent character: in our sample, different problems in young age are linked to each other as well as to adulthood problems. The results are discussed in the light of empirical research and the need for early and proper individual treatment programmes.     

Associations between coping and survival time of adult leukemia patients receiving allogeneic bone marrow transplantation: results of a prospective study

BACKGROUND: To investigate associations between coping strategies and length of survival in a sample of 52 adult leukemia patients receiving allogeneic bone marrow transplantation (BMT). METHODS: 52 adult patients, diagnosed with acute (AML) and chronic myeloid leukemia (CML) admitted for allogeneic BMT to a university hospital BMT unit in preparation for a transplantation of genotypically matched HLA donor marrow, were interviewed immediately after informed consent and prior to preparatory treatment for transplantation. Semistructured interviews were conducted and recorded for analysis to assess coping styles and were evaluated by a new content analytic coping measure [Ulm Coping Manual (UCM)]. Patients were a random sample of all eligible patients on the BMT unit between May 1990 and May 1994. RESULTS: Complete audiotaped interviews were rated by blind raters, employing a newly developed content analysis for the identification of patients' coping strategies. Multivariate analysis using a Cox model revealed three pretransplant variables that demonstrated a statistically significant influence on 5-year survival: Stage of Disease at transplant (P < .012), Distraction (P < .007), and Fighting Spirit as coping modalities (P < .013). CONCLUSIONS: The results of this prospective study document the impact of certain psychological variables, notably coping style on survival with BMT. This suggests the necessity of utilizing psychosocial interventions to address stress and anxiety in patients awaiting transplantation in order to reduce anxieties and to employ more effective coping techniques to deal more appropriately with their situation and to enhance Fighting Spirit. The effects on survival of such psychosocial interventions need to be tested in a randomized controlled study.     

Who really treats the severely impaired young adult patient? A comparison of treatment settings

To make informed decisions about allocation of resources between state hospitals and community services, it is necessary to have comparable data on patients being served in both kinds of settings. Using a random sample of 611 severely impaired young adult patients with major mental illnesses, a study in Missouri compared those who were treated in state-operated facilities with those treated in private, not-for-profit community mental health centers that received state funds. A major finding was that young adult patients were more likely to be treated in a state-operated facility, and that 89 percent of inpatient admissions of this group were made to state-operated facilities. Compared with patients seen in the centers, those served by state facilities were more likely to have histories of arrests or violence, to be minority-group members, to be poor or unemployed, to have a diagnosis of schizophrenia, and to come from more urbanized areas. Of the 26 percent of the sample defined as chronic patients, 73 percent were treated at state-operated facilities.     

Characteristics of young adults with schizophrenic disorders treated in the community

The authors describe the characteristics of 100 young adults with schizophrenia or schizophrenia-related disorders who are being treated in the community, patients who are at high risk for serious, long-term impairment but have not necessarily developed such impairment yet. In contrast to subjects in some other studies of young adult chronic patients, the patients show great variability in previous levels of functioning, such as employment history, ability to live independently, and drug use. The authors hypothesize that highly individualized assessment and comprehensive treatment provided early in the course of illness can prevent or limit chronic functional disability for many patients; they provide recommendations for such treatment.     

Intensive inpatient treatment of young adult chronic patients

Young adults with chronic mental disorders have become a major concern among mental health professionals during the past decade. Many of these patients require frequent hospitalizations, are noncompliant with treatment, experience behavioral crises that threaten themselves or others, abuse drugs and alcohol, and alienate their families and support systems. The authors describe an intensive inpatient program for young adult chronic patients who have repeatedly failed to respond to community-based and standard state hospital care and appear to need extended institutional care. The program, which integrates psychiatric and rehabilitation strategies, has succeeded in increasing the amount of time these patients remain in the community. Although the goal for such patients remains a community-based treatment program, the value of an extended period of active inpatient treatment for some patients may be overlooked in current planning for them.     

DNA damage in rats after treatment with methylphenidate

BACKGROUND: Methylphenidate (MPH) is a widely prescribed psychostimulant for the treatment of attention-deficit hyperactivity disorder (ADHD). Recently, some studies have addressed the genotoxic potential of the MPH, but the results have been contradictory. Hence, the present study aimed to investigate the index of cerebral and peripheral DNA damage in young and adult rats after acute and chronic MPH exposure. METHODS: We used (1) single cell gel electrophoresis (Comet assay) to measure early DNA damage in hippocampus, striatum and total blood, and (2) micronucleus test in total blood samples. RESULTS: Our results showed that MPH increased the peripheral index of early DNA damage in young and adult rats, which was more pronounced with chronic treatment and in the striatum compared to the hippocampus. Neither acute nor chronic MPH treatment increased micronucleus frequency in young or in adult rats. Peripheral DNA damage was positively correlated with striatal DNA damage. CONCLUSION: These results suggest that MPH may induce central and peripheral early DNA damage, but this early damage may be repaired.     

Childhood psychiatric disorders and young adult crime: a prospective, population-based study

OBJECTIVE: While psychopathology is common in criminal populations, knowing more about what kinds of psychiatric disorders precede criminal behavior could be helpful in delineating at-risk children. The authors determined rates of juvenile psychiatric disorders in a sample of young adult offenders and then tested which childhood disorders best predicted young adult criminal status. METHOD: A representative sample of 1,420 children ages 9, 11, and 13 at intake were followed annually through age 16 for psychiatric disorders. Criminal offense status in young adulthood (ages 16 to 21) was ascertained through court records. RESULTS: Thirty-one percent of the sample had one or more adult criminal charges. Overall, 51.4% of male young adult offenders and 43.6% of female offenders had a child psychiatric history. The population-attributable risk of criminality from childhood disorders was 20.6% for young adult female participants and 15.3% for male participants. Childhood psychiatric profiles predicted all levels of criminality. Severe/violent offenses were predicted by comorbid diagnostic groups that included both emotional and behavioral disorders. CONCLUSIONS: The authors found that children with specific patterns of psychopathology with and without conduct disorder were at risk of later criminality. Effective identification and treatment of children with such patterns may reduce later crime.     

Headlock: psychotherapy of a patient with multiple neurological and psychiatric problems.

Psychodynamic psychiatrists seldom engage in psychotherapy with brain-injured patients because psychodynamic treatment typically depends on the patient's highly developed verbal skills, reflectiveness, tolerance of frustration, and capacity for abstract thinking and generalization--characteristics impaired by brain injury. The author describes the difficult but successful extended treatment of a young adult patient with preexisting attention-deficit hyperactivity disorder and personality disorders who had also abused alcohol and drugs and had suffered severe brain trauma. Treatment was characterized by a lengthy developmental process, the success of which depended on several factors, particularly the maintenance of the therapeutic alliance.     

Randomized, double-blind, placebo-controlled trial of fluoxetine treatment for elderly patients with dysthymic disorder.

OBJECTIVE: The authors compared the efficacy and side effects of fluoxetine and placebo in elderly outpatients with dysthymic disorder. METHODS: Patients were randomly assigned to fluoxetine (20 mg-60 mg/day) or placebo for 12 weeks in a double-blind trial. RESULTS: Of 90 randomized patients, 71 completed the trial. In the intent-to-treat sample, random regression analyses of the Hamilton Rating Scale for Depression (Ham-D; 24-item) and Cornell Dysthymia Rating Scale (CDRS) scores at each visit produced significant time x treatment group interactions favoring the fluoxetine group. Analysis of percentage change in Ham-D scores yielded no effect for treatment group, but a similar analysis of percentage change in CDRS scores yielded a main effect for treatment group, favoring fluoxetine over placebo. In the intent-to-treat sample, response rates were 27.3% for fluoxetine and 19.6% for placebo. In the completer sample, response rates were 37.5% for fluoxetine and 23.1% for placebo. CONCLUSION: Fluoxetine had limited efficacy in elderly dysthymic patients. The clinical features of elderly dysthymic patients are typically distinct from those of dysthymic disorder in young adults, and the findings suggest that treatments effective for young adult dysthymic patients may not be as useful in elderly dysthymic patients. Further research is needed to identify efficacious treatments for elderly patients with dysthymic disorder, and investigative tools such as electronic/computerized brain scans and neuropsychological testing may help identify the factors that moderate antidepressant treatment response and resistance.     

Description of study population and analysis of factors influencing adherence in the observational Italian study "Evaluation of Pharmacotherapy Adherence in Bipolar Disorder" (EPHAR)

Background: In patients with bipolar disorder, medication is effective in preventing relapses. Unfortunately, adherence to treatment in bipolar disorder, as in other chronic or recurrent conditions, is not optimal. Estimates of nonadherence to prescribed treatment range from 30% to 60% in epidemiological studies, and are at around 30% in clinical trials. Adherence to treatment is a potent predictor of effectiveness, both in clinical trials and cohort studies, therefore is a very relevant area of investigation. This study will try to show a picture of the real life care where adherence is influenced by a wide range of variables. Methods: Prospective, observational, multicenter study in 650 adult patients with bipolar disorder, who had to initiate or change their treatment regimen, observed for 1 year. Adherence was measured by the Simplified Medication Adherence Questionnaire (SMAQ). Additional variables: Symptom severity, Montgomery‐Åsberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), Clinical Global Impression–Bipolar Disorder (CGI‐BD), the Drug Attitude Inventory score (DAI‐30), and quality of life (EuroQoL 5 Dimensions). The variables were recorded every 3 months for the next year. Results: Most subjects were out‐patients (77.1%), female (58.8%), aged 31–50 years (50.1%) and overweight (41.8%) or obese (28.7%); 67.4% had type I bipolar disorder and 66.8% had depressive or mixed symptoms. Adherence was 39.9% at baseline (and increased up to 67.0% at completion. The main predictors of nonadherence were alcohol consumption, severe bipolar symptoms, young age at time of first treatment, negative attitude towards treatment. Conclusions: The patient population of this observational trial was representative of the patients changing their therapy for bipolar disorder seen in clinical practice in Italy. Lack of adherence to pharmacotherapy for bipolar disorder is a serious issue, which is more likely to arise in alcohol users and patients with severe symptoms, negative attitude towards medication and/or initiation of treatment early in life. The findings could lead to a more adequate approach of adherence in patients with bipolar disorders.     

Influence of child and adolescent psychiatric disorders on young adult personality disorder.

OBJECTIVE: This study examines associations between childhood psychopathology and young adult personality disorder in a random sample of 551 youths, who were 9 to 16 years old at first assessment. METHOD: Subjects were evaluated for DSM-III-R psychiatric disorders. Information was obtained prospectively from youths and their mothers at three points over 10 years. The predictive effects of prior axis I disorders and adolescent axis II personality disorder clusters A, B, and C on young adult personality disorder were examined in logistic regression analyses. RESULTS: The odds of young adult personality disorder increased given an adolescent personality disorder in the same cluster. Prior disruptive disorders, anxiety disorders, and major depression all significantly increased the odds of young adult personality disorder independent of an adolescent personality disorder. In addition, comorbidity of axis I and axis II disorders heightened the odds of young adult personality disorder relative to the odds of a disorder on a single axis. CONCLUSIONS: Assessment of personality pathology before late adolescence may be warranted. Childhood or adolescent axis I disorders may set in motion a chain of maladaptive behaviors and environmental responses that foster more persistent psychopathology over time. Identification and treatment of childhood disorder may help to reduce that risk.     

Symptoms of anxiety and depression in patients undergoing chronic haemodialysis

Symptoms of anxiety and depression in a sample of 82 patients undergoing chronic haemodialysis were assessed using the Symptoms of Anxiety and Depression Scale. Mean anxiety and depression scores, were found to be significantly higher than those of normal subjects. The frequency of personal disturbance and personal illness were also higher in the patient sample. Examination of the effects of demographic, illness and treatment variables on the questionnaire scores and categories revealed that women had higher anxiety scores than men, and that they were more frequently personally disturbed and personally ill; the effects of other variables were not significant. Factor analysis of the symptoms measured by the scale revealed four factors: anxiety, suicidal ideation, mood intensity, and ruminative anxiety.     

Cholestatic jaundice induced by duloxetine in a patient with major depressive disorder

Duloxetine is a balanced and potent serotonin and noradrenaline reuptake inhibitor (SNRI) and has adverse effects that are commonly associated with such drugs, including nausea, dry mouth, constipation, insomnia, and dizziness. Recently, duloxetine-induced liver injury has also been observed in patients with preexisting liver disease or chronic alcohol use. We investigated the effects of duloxetine in a healthy young adult with major depressive disorder (MDD) but no risk factors, and found that his total bilirubin level increased to 3.3 mg/dL and he developed jaundice after 5 months of duloxetine treatment. Discontinuation of duloxetine treatment saw his total bilirubin level decrease to 1.8 mg/dL. Thus, the administration of duloxetine might induce liver injury in a patient with MDD. However, the limitations of this single case report must be acknowledged. Although the cause of hepatic dysfunction in this case remains to be elucidated, clinicians should monitor liver function carefully after duloxetine treatment. Further investigations with a larger sample are needed.