Specialist service use following psychiatric emergency presentation: an 18-month follow-up study

The aim of the present study was to identify the subsequent use of specialist psychiatric services by a group of 170 individuals referred as psychiatric emergencies. Hospital and community mental health team (CMHT) records and databases were used to identify specialist contact in an 18-month follow-up period. Out of the total of 170 people, 169 were traced. The majority (60.9%) had had some specialist psychiatric contact in the follow-up period. Those with severe mental health problems formed a minority of presenters, but were heavy users of services. Coverage by CMHT services was insufficient to prevent crisis in many cases. Improved access to broader community services is needed for those with life crises. This study suggests some important gaps in coverage by wider mental health services, which the current mental health agenda goes some way towards addressing.     

Perfectionism in anorexia nervosa: a 6-24-month follow-up study

OBJECTIVE: This study examined the relationship between perfectionism and outcome in anorexia nervosa (AN). METHOD: Seventy-three patients received inpatient treatment for AN. Participants completed the Eating Disorder Inventory (EDI) at admission to (n = 55), at discharge (n = 27), and at a median of 15.9 months (n = 49) after inpatient treatment. At follow-up, participants also completed the Multidimensional Perfectionism Scale (MPS) and their scores were compared with those of healthy controls. RESULTS: EDI Perfectionism was associated with illness status. A lower EDI Perfectionism score at admission was associated with a better response to treatment, which was subsequently associated with better outcome at follow-up. Both the good and poor outcome groups had significantly higher MPS total perfectionism scores than healthy controls. DISCUSSION: The EDI measures an aspect of perfectionism that is sensitive to illness status, whereas the MPS is less dependent on clinical state and may reflect a common personality trait that persists with remission of disease.     

Improving follow-up after an abnormal pap smear: results from a quasi-experimental intervention study

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.     

Risk factors for alcohol dependence: a case-control study

Several possible risk factors for ICD-10 alcohol dependence were studied by comparing cases (117 men, 188 women) with controls (248 men, 300 women). Logistic regression analyses showed that parental alcohol problems and high trait anxiety were significantly related to high occurrence of alcohol dependence in both men and women. In women, high antisocial behaviour, high impulsivity, and high externality were also related to high occurrence of alcohol dependence. High facial flushing and high stimulation when intoxicated were related to low occurrence of alcohol dependence in both men and women. In men, this was also the case for high social support. Several interactions were observed. In contrast to earlier studies, there was no significant association between alcohol dependence and left-handedness.     

An evaluation of an abstinence-only sex education curriculum: an 18-month follow-up

The article examines the results from an 18-month follow-up evaluation of an abstinence education curriculum series. Participants were students from 15 school districts recruited to participate in the project. The intervention was the Sex Can Wait curriculum series, consisting of upper elementary, middle school, and high school components. The 5-week curriculum was implemented by teachers who had participated in a special teacher training workshop. Both intervention and comparison students were surveyed before and after the curriculum intervention and at 18-month follow-up. Results indicated short-term effects as follows. Upper elementary intervention students indicated higher level of knowledge, more hopefulness for the future, and greater self-efficacy than did the comparison group. Middle school intervention students did not differ from comparison students. High school intervention students reported lower participation rates than the comparison group students in sexual intercourse (ever and last month), a more positive attitude toward abstinence and a greater intent to remain abstinent. Long-term (18 month) benefits were noted as follows: upper elementary intervention students had greater knowledge and were less likely than comparison students to report participation in sexual intercourse in the last month. Middle school intervention students were less likely than comparison students to report participation in sexual intercourse ever and sexual intercourse in the last month. High school intervention students evidenced greater knowledge and greater intent to remain abstinent than did comparison students. Results indicate that the program did have some positive benefits that should be considered by those interested in abstinence education programming.     

Naltrexone versus acamprosate: one year follow-up of alcohol dependence treatment

Naltrexone and acamprosate reduce relapse in alcohol dependence. They have not yet been compared in a published trial. The aim of this study was to compare the efficacy of these compounds in conditions similar to those in routine clinical practice. Random allocation to a year of treatment with naltrexone (50 mg/day) or acamprosate (1665-1998 mg/day) was made in 157 recently detoxified alcohol-dependent men with moderate dependence (evaluated using the Addictions Severity Index and Severity of Alcohol Dependence Scale). All were patients whom a member of the family would accompany regularly to appointments. Alcohol consumption, craving and adverse events were recorded weekly for the first 3 months, and then bi-weekly, by the treating psychiatrist who was not blinded. At 3-monthly intervals, investigators who were blinded to the treatment documented patients' alcohol consumption based on patients' accounts, information given by the psychiatrists when necessary, and reports from patients' families. Serum gamma-glutamyltransferase (GGT) was also measured. Efforts were made to sustain the blindness of the investigators. The same investigator did not assess the same patient twice. The integrity of the blindness was not checked. There was no difference between treatments in mean time to first drink (naltrexone 44 days, acamprosate 39 days) but the time to first relapse (five or more drinks in a day) was 63 days (naltrexone) versus 42 days (acamprosate) (P = 0.02). At the end of 1 year, 41% receiving naltrexone and 17% receiving acamprosate had not relapsed (P = 0.0009). The cumulative number of days of abstinence was significantly greater, and the number of drinks consumed at one time and severity of craving were significantly less, in the naltrexone group compared to the acamprosate group, as was the percentage of heavy drinking days (P = 0.038). More patients in the acamprosate than the naltrexone group were commenced on disulfiram during the study. Naltrexone patients attended significantly more group therapy sessions, though this could not explain their better outcome. There were non-significant trends for the naltrexone group to comply better with medication, to stay in the study longer, and to show greater improvement over baseline in serum GGT.     

Effects of short duration stress management training on self-perceived depression, anxiety and stress in male automotive assembly workers: a quasi-experimental study

To examine the effects of short duration stress management training (SMT) on self-perceived depression, anxiety and stress in male automotive assembly workers, 118 male automotive workers from Pekan, Pahang (n = 60, mean age = 40.0 years, SD = 6.67) and Kota Bharu, Kelantan (n = 58, mean age = 38.1 years, SD = 5.86) were assigned to experimental and control group, respectively. A SMT program consisting of aerobic exercise, stress management manual, video session, lecture, question and answer session, and pamphlet and poster session were conducted in the experimental group. A validated short-form Malay version of the Depression Anxiety Stress Scales (DASS-21) were self-administered before and after the intervention program in the experimental and control group and their time and group interaction effects were examined using the repeated measure ANOVA test. Results indicated that the mean (SD) scores for DASS-Depression (p = 0.036) and DASS-Anxiety (p = 0.011) were significantly decreased, respectively, after the intervention program in the experimental group as compared to the control group (significant time-group interaction effects). No similar effect was observed for the mean (SD) scores for DASS-Stress (p = 0.104). However, the mean (SD) scores for subscales of DASS-Depression (Dysphoria, p = 0.01), DASS-Anxiety (Subjective Anxiety, p = 0.007, Situational Anxiety, p = 0.048), and DASS-Stress (Nervous Arousal, p = 0.018, Easily Upset, p = 0.047) showed significant time and group interaction effects. These findings suggest that short duration SMT is effective in reducing some aspects of self-perceived depression, anxiety and stress in male automotive workers.     

Childhood attention deficit/hyperactivity disorder and alcohol dependence: a 1-year follow-up

AIMS: To investigate the onset and outcome of alcohol dependence in subjects with childhood attention deficit/hyperactivity disorder (ADHD) in a Turkish sample. METHODS: Among patients being treated for alcohol dependence, 15 had a history of childhood ADHD [ADHD (+)] and 45 did not [ADHD (-)]. ADHD history was assessed according to DSM-IV criteria by a child and adolescent psychiatrist who interviewed the subjects and their close relatives. Severity of dependence was measured by the Michigan Alcoholism Screening Test. Subjects were followed up for 1 year for the assessment of relapse. RESULTS: The age of onset for alcohol drinking, alcohol abuse and alcohol dependence were significantly lower in the ADHD (+) group than in the ADHD (-) group. Comorbid substance use was more prevalent in the ADHD (+) group. The study found no significant difference in the severity of alcohol dependence between ADHD (+) and ADHD (-) groups. During follow-up, 80% of the ADHD (+) subjects relapsed, compared with 55.6% in the ADHD (-) group. Relapse occurred on average 2.74 months earlier in the ADHD (+) group than in the ADHD (-) group. CONCLUSIONS: As found in other countries, alcohol dependence in Turkish subjects with childhood ADHD starts early and is relatively resistant to treatment. Early diagnosis and treatment of ADHD might help prevent alcohol- and substance-related disorders.     

Impact of a mentoring program on psychosocial wellbeing of youth in Rwanda: Results of a quasi-experimental study

Addressing the psychosocial needs of vulnerable children and youth is viewed increasingly as a priority of humanitarian programs, particularly in Africa, where the scale of the problem necessitates community-based solutions. This quasi-experimental study tested a model of adult mentorship and support to improve psychosocial outcomes among youth-headed households in a rural area of Rwanda. Two rounds of data were collected from youth who served as heads of their households. Following the baseline survey in 2004 (n?=?692), an adult mentorship program was implemented among half the sample. A follow-up survey was conducted after 18 months of intervention exposure (n?=?593). Through regular home visits, mentors developed a stable, caring relationship with youth in their community living without an adult caregiver. Each mentor was assigned 2–3 youth-headed households located within their own community to visit at least once a month for 2–3 hours in the home. Over an 18-month period, 156 trained adult mentors (60% male, 40% female) visited and supported 441 households. Multivariable analyses explored linkages between exposure to the intervention and four key psychosocial outcomes: perceptions of adult support, marginalization, grief and symptoms of depression. Over time, youth with a mentor reported a significant increase in perceptions of available adult support and decreases in marginalization. While grief in the comparison group grew significantly over time, grief levels in the intervention group remained stable, suggesting that the mentorship program may have mitigated grief among youth in the intervention areas. Intervention respondents also reported a slight, but significant, decrease in depressive symptoms. Findings suggest that the mentoring program enhanced available support and community connectedness among youth in this study. However, program impact on emotional wellbeing was more modest. More intensive interventions may be needed to reduce grief symptoms and for those with high levels of depressive symptoms.     

Acamprosate and relapse prevention in the treatment of alcohol dependence: a placebo-controlled study

The objective of this study was to compare acamprosate with placebo in the treatment of alcohol-dependent patients during a 6-month post-detoxification treatment and a 3-month medication-free follow-up. Patients (n = 330) were detoxified and randomized to treatment with acamprosate (1998 mg/day) or placebo within an out-patient programme including medical counselling, psychotherapy and self-help groups. The main outcome criterion was drinking behaviour as assessed by: abstinence/relapse ratio, cumulative abstinence duration (CAD) and the period of continued abstinence. Anxiety, depression and craving were also monitored. Intention to treat (ITT) statistical principles were followed. Twenty-five per cent of patients dropped out over the first 6 months. At the end of the treatment period, the abstinence rate was 57.9% for acamprosate and 45.2% for placebo (P = 0.03). The CAD was 110+/-77 days for acamprosate and 89+/-77 days for placebo (P = 0.016). Patients on acamprosate had a higher continuous abstinence rate and experienced less severe relapses. No differential effect was noted for anxiety, depression or craving. Treatment remained positive, but not significant, 3 months after termination of study medication. No significant difference in adverse events was noted between treatment groups. Acamprosate treatment over 180 days was consistently more effective than placebo to maintain abstinence and to diminish relapse severity.     

Comorbidity of alcohol dependence and personality disorders: a comparative study

AIMS: To describe the frequency and profile of personality disorders related to alcohol dependence, and to compare them with non-addictive disorders and with normal population. METHODS: In this cross-sectional clinical-epidemiological study, using the International Personality Disorder Examination and the Millon Clinical Multiaxial Inventory-II for personality disorders, 158 consecutively recruited alcohol-dependent patients attending a psychiatric outpatient clinic were compared with 120 consecutively recruited psychiatric patients with non-addictive disorders, and 103 subjects from the general population chosen to match the patient samples for age, gender and socioeconomic level. RESULTS: Of the alcohol-dependent patients, 44.3%, and of the general clinical sample, 21.7% (vs 6.8% of the normative sample) showed at least one personality disorder. Obsessive-compulsive personality disorders were most prevalent (12%), followed by antisocial, paranoid and dependent personality disorders (7% each). Most of them showed only one personality disorder.     

Competencies for health management practice: a practitioner's perspective

The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed.     

Long-term follow-up of a 10-month programme in curriculum development for medical educators: a cohort study

Context  There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long-term impact of a longitudinal programme in curriculum development.
Methods  We surveyed eight cohorts of participants ( n  =   64) and non-participants ( n  =   64) from 1988 to 1996 at baseline and at 6–13 years after completion of a 10-month, one half-day per week programme offered annually, which included a mentored CD project, workshops on CD steps, a final paper and a presentation.
Results  Fifty-eight participants (91%) and 50 non-participants (78%) returned completed follow-up surveys. In analyses, controlling for background characteristics and baseline self-rated proficiencies, participants were more likely than non-participants at follow-up to report having developed and implemented curricula in the past 5 years (65.5% versus 43.7%; odds ratio [OR] 2.41, 95% confidence interval [CI] 1.03–5.66), to report having performed needs assessment when planning a curriculum (86.1% versus 58.8%; OR 5.59, 95% CI 1.20–25.92), and to rate themselves highly in developing (OR 3.57, 95% CI 1.36–9.39), implementing (OR 3.04, 95% CI 1.16–7.93) and evaluating (OR 2.74, 95% CI 1.10–6.84) curricula. At follow-up, 86.2% of participants reported that the CD programme had made a moderate or great impact on their professional careers. Responses to an open-ended question on the impact confirmed continued involvement in CD work, confidence in CD skills, application of CD skills and knowledge beyond CD, improved time management, and lasting relationships formed because of the programme.
Conclusions  Our results suggest that a longitudinal faculty development programme that engages and supports faculty in real CD work can have long-lasting impact.     

Comorbid phobic disorders do not influence outcome of alcohol dependence treatment. Results of a naturalistic follow-up study

AIMS: Despite claims that comorbid anxiety disorders tend to lead to a poor outcome in the treatment of alcohol dependence, the few studies on this topic show conflicting results. OBJECTIVE: To test whether the outcome of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder is worse than that of similar patients without a comorbid phobic disorder. METHODS: The probabilities of starting to drink again and of relapsing into regular heavy drinking in (i) a group of 81 alcohol-dependent patients with comorbid social phobia or agoraphobia were compared with those in (ii) a group of 88 alcohol-dependent patients without anxiety disorders in a naturalistic follow-up using Cox regression analysis. RESULTS: Adjusted for initial group differences, the hazard ratio for the association of phobic disorders with resumption of drinking was 1.05 (95% CI, 0.85-1.30, P = 0.66) and the adjusted hazard ratio for the association of phobic disorders with a relapse into regular heavy drinking was 1.02 (95% CI, 0.78-1.33, P = 0.89). CONCLUSION: The findings of this study do not confirm the idea that alcohol-dependent patients who have undergone alcohol-dependence treatment are at greater risk of a relapse if they have a comorbid anxiety disorder. No differences were found in abstinence duration or time to relapse into regular heavy drinking between patients with and without comorbid phobic disorders.     

The psychosocial work environment and alcohol dependence: a prospective study

Aims: To examine whether a stressful psychosocial work environment predicts alcohol dependence.

Methods: Alcohol dependence of participants in the Whitehall II occupational cohort of London based civil servants (1985–88) was measured in 1991–93 using the CAGE questionnaire. The psychosocial work environment was measured by self report questions on the job demand-support-control model and on the model of effort-reward imbalance. Potential mediators including physical illness and poor mental health (GHQ) were measured at follow up in 1989.

Results: Effort-reward imbalance at work was associated with alcohol dependence in men after adjustment for employment grade and other baseline factors related to alcohol dependence. Although effort-reward imbalance predicted future longstanding illness, poor mental health and negative aspects of close relationships, the association between effort-reward imbalance and alcohol dependence in men was only partially mediated through these health and social support measures. In women, low decision latitude was related to alcohol dependence to some extent, but alcohol dependence among women was more prevalent in higher occupational grades. Men with high job demands or with low work social supports had a slightly reduced risk of alcohol dependence. No association was found between objectively assessed demands, job control, and alcohol dependence in either men or women.

Conclusion: A stressful psychosocial work environment in terms of effort-reward imbalance was found to be a risk factor for alcohol dependence in men. In view of the public health importance of alcohol dependence in working populations these findings call for more emphasis on psychosocial factors in occupational health research and prevention.

     

Folate and vitamin B12 in relation to lactation: a 9-month postpartum follow-up study

OBJECTIVE: To investigate the relation between lactation and markers of folate and vitamin B12 (B12) deficiency in women with and without vitamin supplementation. DESIGN: A 9-month follow-up study. Subjects and methods: Blood samples from 91 women, who gave birth to a single healthy child, were collected 3 weeks, 4 and 9 months postpartum and analysed for circulating level of homocysteine (tHcy), methylmalonic acid (MMA), folate and B12. The participants were categorized as exclusively, partly or not breast-feeding dependent on the degree of lactation 4 months postpartum. During follow-up, lifestyle factors were recorded by structured interviews. RESULTS: Among 72 exclusively breast-feeding women, the median (10-90% percentile) tHcy was 5.8 (3.1-8.3) micromol/l 3 weeks postpartum, 6.1 (4.1-10.3) micromol/l 4 months postpartum and 5.3 (3.6-8.7) micromol/I 9 months postpartum. At 9 months postpartum, none of the women breast-fed exclusively. No significant change occurred in the concentration of B12 and folate. Exclusively breast-feeding women without vitamin supplementation had higher median tHcy than supplemented exclusively breast-feeding women 4 and 9 months postpartum (7.0 vs 5.4 micromol/l (P < 0.001) and 5.8 vs 4.5 micromol/l (P = 0.003), respectively). Six women had increased (>15 micromol/l) tHcy; four of these were unsupplemented and exclusively breast-feeding. CONCLUSION: We found no overall indication of depletion of the folate and B12 stores during the lactation period in this population. However, folate-supplemented women had lower tHcy and higher folate levels, suggesting a beneficial effect of supplementation with folate throughout lactation.     

Validity of self-reports of knee-straining activities at work: a field study with 6-month follow-up

Objectives

To measure short-term and long-term validity of self-reported duration of kneeling and squatting at work and to examine the possibility of differential misclassification due to knee complaints.

Methods

Work-related kneeling and squatting were analysed for 190 male subjects (mean age, 35.0 and SD, 11.5) in field by both measurements and questionnaires. Posture capturing was performed with an ambulatory measuring system (CUELA). Immediately after the measurement (t ₀), each participant was asked to estimate frequency and duration of five specific knee postures taken during the measurement period. After 6 months (t ₁), the survey was repeated (n = 125). Health status of all subjects was recorded by Nordic questionnaire. Statistical analysis was performed by using nonparametric tests, correlations, and Bland–Altman plots.

Results

At both time points, subjects were able to recall the occurrence of knee postures rather well (100.0–57.6 % agreement) but many of them failed in quantifying their knee load. We found poor-to-moderate correlations between measurements and self-reports for all examined postures in both surveys (0.23 < ρ < 0.63). The durations of knee postures were both over- and underestimated but overestimations predominated (t _0, 74.7 % and t _1, 87.2 % overestimations). High-exposed subjects seemed to misjudge their exposure to a greater extent than low-exposed ones, while knee complaints seemed to have no impact on the assessment behaviour.

Conclusions

As our study showed, self-reported knee loading may deviate widely from measured exposure. These limitations of self-reporting emphasise the arguments in favour of using objective data whenever possible, for example by complementing self-reported occurrence of knee postures with quantitative measurement data.     

Changes in self-reported and parent-reported health-related quality of life in overweight children and adolescents participating in an outpatient training: findings from a 12-month follow-up study

Background

Health-related quality of life (HRQoL) was found to improve in participants of weight management interventions. However, information on moderately overweight youth as well as on maintaining HRQoL improvements following treatment is sparse. We studied the HRQoL of 74 overweight, but not obese participants (32.4% male, mean age?=?11.61?±?1.70 SD) of a comprehensive and effective six-month outpatient training at four time-points up to 12 months after end of treatment.

Methods

HRQoL was measured by self-report and proxy-report versions of the generic German KINDL-R, including six sub domains, and an obesity-specific additional module. Changes in original and z-standardized scores were analyzed by (2×4) doubly multivariate analysis of variance. This was done separately for self- and proxy-reported HRQoL, taking into account further socio-demographic background variables and social desirability. Additionally, correlations between changes in HRQoL scores and changes in zBMI were examined.

Results

There were significant multivariate time effects for self-reported and proxy-reported HRQoL and a significant time-gender interaction in self-reports revealed (p?<?.05). Improvements in weight-specific HRQoL were evident during treatment (partial η²?=?0.14-0.19). Generic HRQoL further increased after end of treatment. The largest effects were found on the dimension self-esteem (partial η²?=?0.08-0.09 for proxy- and self-reported z-scores, respectively). Correlations with changes in weight were gender-specific, and weight reduction was only associated with HRQoL improvements in girls.

Conclusions

Positive effects of outpatient training on generic and weight-specific HRQoL of moderately overweight (not obese) children and adolescents could be demonstrated. Improvements in HRQoL were not consistently bound to weight reduction. While changes in weight-specific HRQoL were more immediate, generic HRQoL further increased after treatment ended. An extended follow-up may therefore be needed to scrutinize HRQoL improvements due to weight management.

Trial registration

clinicaltrials.gov NCT00422916