An evaluation of the Cleveland criteria for inpatient treatment of substance abuse.

OBJECTIVE: This study examined the validity of the Cleveland Admission, Discharge, and Transfer Criteria, a comprehensive system for assigning alcohol- and drug-abusing patients to appropriate levels of care. METHOD: The subjects were 143 alcoholic and cocaine-dependent male patients in an intensive Veterans Administration day treatment program for substance abusers. Patients who should have received inpatient treatment according to the Cleveland criteria were compared with those who were properly "matched" to day treatment according to the criteria. The outcome measures were treatment completion, results of urine toxicology screens, and self-reports of substance use and psychosocial functioning. RESULTS: Patients who met the criteria for inpatient care were not more likely to drop out of day hospital treatment, and there was no evidence that they were drinking or using cocaine more frequently during follow-up. Furthermore, they did not appear to be doing worse on any of the other outcome measures, with the exception of psychological status. CONCLUSIONS: The results suggest that for male substance abusers in the lower socioeconomic levels, the Cleveland criteria may not be effective in differentiating patients who can manage well with day hospital treatment and those who require inpatient treatment.     

Methodological and clinical challenges in evaluating treatment outcome of substance-related disorders and comorbidity.

OBJECTIVE: To review the steps required to develop an outcome evaluation package and to report on the 12-month outcome of an integrated day program. METHOD: Based on the identification of salient outcome predictors, standardized instruments were selected. A cohort of 78 patients was assessed at the time of admission to the program, at discharge, and 3, 6, and 12 months afterward. RESULTS: Improvements were sustained over 1 year in all areas including treatment needs, quality of life, and readiness to change. CONCLUSIONS: The gap between the "cultures" of treatment and research must be narrowed. Following evidence of a program's general effectiveness through outcome monitoring, a randomized control design is optimal for specific interventions. The optimal length of follow-up depends on the perceived confounds.     

Longitudinal assessment of psychotherapeutic day hospital treatment for elderly patients with depression

OBJECTIVE: Although previous studies suggested that psychiatric day hospital care is a valuable alternative to inpatient treatment, its effectiveness for elderly patients is disputed. Small number of cases, poor definition of the psychotherapeutic setting, and absence of systematic assessment at different time points may explain the observed discrepancies. We performed an assessment of a psychiatric day hospital treatment combining individual and group psychotherapy in a series of 122 elderly depressed outpatients. METHODS: The Geriatric Depression Scale, Short Form Survey, as well as a Therapeutic Community Assessment Scale and Group Evaluation Scale were repeated at admission, 3, 6, 12 months and discharge. The day hospital program was based on psychotherapeutic treatment combining individual and group settings. All patients presented with major depression or a depressive episode of bipolar disease. Variables included severity of depressive symptoms, quality of life, adhesion to therapeutic community treatment and progress in groups of psychotherapy, art-therapy, and psychomotricity. RESULTS: There was a significant reduction of depressive symptoms, and improvement in mental quality of life across all time points studied. Adhesion to therapeutic community increased from admission to discharge. This was also the case for the progress in group therapy for all three groups used, yet the evolution of this parameter at intermediate time points was highly variable. Neither demographic characteristics, nor pharmacological treatment or presence of stressful life events predicted the clinical improvement. CONCLUSIONS: Psychotherapeutic care program in day hospitals may improve clinical status and quality of life in elderly depressed patients. Copyright (c) 2008 John Wiley & Sons, Ltd.     

The treatment of sedative-hypnotic dependence: evaluating clinical predictors of outcome

BACKGROUND: The objectives of this 6-month prospective study were to evaluate the efficacy of detoxification treatment for sedative-hypnotic dependence, examine the demographic and clinical predictors of outcome, and determine whether anxiety or other psychiatric comorbidity has a negative impact on outcome. METHOD: Eighty-two patients with alcohol or benzodiazepine dependence (DSM-IV diagnostic criteria) were consecutively recruited upon entering treatment and were assessed by clinical and semistructured interviews, the Global Assessment Scale, the Hamilton Rating Scale for Depression, the Beck Depression Inventory, the revised 90-item Symptom Checklist, and urine drug screening. RESULTS: Both alcohol- and benzodiazepine-dependent patients succeeded in reducing their reported use of sedative-hypnotic substances during the follow-up period. However, at 3 months, benzodiazepine-dependent patients fared less well than alcohol-dependent patients in terms of several outcome measures: they reported a lower rate of achieving abstinence, shorter periods of continuous abstinence, and more frequent drug use. At 6 months, the differences in outcome among the drug groups were not maintained. Variables such as sex, drug group, and indicators of psychiatric status had little impact on outcome measures. Benzodiazepine-dependent patients reported significant decreases in their level of anxiety over the follow-up period despite substantial reductions in benzodiazepine use. CONCLUSION: Clinicians may be encouraged regarding the detoxification of patients who have used benzodiazepines at high doses or for long periods of time, or who have comorbid anxiety or other psychiatric disorders.     

Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trial comparing different treatment modalities

Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36 months follow-up of the Ullev?l Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with "ordinary" outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).     

A day hospital program for dual diagnosis patients in a VA Medical Center.

A day hospital program for patients with mental illness and substance abuse problems at a Veterans Affairs medical center uses nonconfrontational group therapy as the primary treatment modality. The goals of the six-to-eight-week program are to reduce substance abuse, improve medication compliance, and reduce the number of hospitalizations. Aftercare is available for patients who complete the program. The authors suggest that patients' ability to relate well to others in group therapy is the primary factor influencing successful outcome. During a 30-month period, 66 percent of the patients admitted to the day hospital program completed it. Three cases illustrating the variable outcomes of patients treated in the program are presented.     

Interjudge Reliability and Agreement About the Patient's Central Issue in Time-Limited Psychotherapy (TLP) and its Relation to TLP Outcome

Abstract

Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36months follow-up of the Ullevål Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with “ordinary” outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).     

Combining day patient treatment with family work in a child psychiatry clinic

Summary The 81 youngsters who began attending a day treatment programme within a 1-year period were assessed using an interval design. The children ranged in age from 18 months to 16 years and attended with similarly aged children for 1 day a week. The treatment programme combined family therapy with the day unit's milieu therapy and specific individual treatment programmes for the child. The results indicate that the combination of a 1 day a week attendance and family therapy had a significant clinical impact upon the problems. The pattern of improvement observed would suggest that the day-unit attendance made a unique contribution to the overall outcome.     

Measuring participation in an evidence-based practice: Illness management and recovery group attendance

Given the important role of treatment attendance as an indicator of program implementation and as a potential moderator of program effectiveness, this study sought to develop useful indicators of attendance for evidence-based practices. The current study examined consumer attendance patterns in a randomized controlled trial comparing illness management and recovery (n=60) to a problem solving control condition (n=58). Associations were examined between consumer clinical indicators, demographics, and level of recovery and indices of attendance. Attendance was poor, but comparable to rates found in many other studies. Four indicators of attendance (percent sessions attended, time enrolled, periods of attendance, and longest period of attendance) were highly inter-related and were more sensitive to baseline differences than a traditional approach of dichotomizing participants into “attenders” and “non-attenders.” Older age, lower hostility, fewer psychotic symptoms, and more education were associated with higher group attendance in both treatment conditions; the client-reported illness management and recovery scale was associated with attendance in the control group. Indicators of attendance were an advancement over dichotomous classification. Strategies to increase attendance are still needed, particularly for younger consumers with greater positive symptoms.     

Young chronic patients and substance abuse

The prevalence of substance abuse was investigated in 100 young chronic patients consecutively admitted to a long-term private psychiatric hospital. Data were obtained from diagnostic research interviews with each subject at admission. Half of the subjects had concurrent diagnoses of psychiatric disorder and substance abuse. One-third of the dual-diagnosis patients began using substances before the onset of a diagnosable psychiatric disorder, and they more often had a diagnosis of schizophrenia. Half of the dual-diagnosis patients abused three or more drugs. Implications of the findings for treatment and community management of dual-diagnosis patients are discussed.     

Residential versus community treatment of personality disorders: a comparative study of three treatment programs

OBJECTIVE: The aim of this study was to compare the effectiveness of three treatment models for personality disorder: 1) a long-term psychoanalytically oriented residential specialist program, 2) a phased "step-down" specialist psychosocial program that included a briefer residential stay and an outpatient component, and 3) a general community psychiatric model. METHOD: One hundred forty-three patients with a personality disorder diagnosis were allocated according to geographical criteria to the three treatment conditions. Outcome was prospectively evaluated at 6, 12, and 24 months through the use of a standardized battery of instruments that included measures of general symptom severity, social adaptation, assessment of mental health functioning, frequency of self-harm and suicide attempts, and rates and duration of hospital readmissions. RESULTS: By 24 months, patients in the step-down condition showed significant improvements on all measures. Patients in the long-term residential model showed significant improvements in symptom severity, social adaptation, and global functioning, while no changes were achieved in self-harm, attempted suicide, and readmission rates. Patients in the general psychiatric group showed no improvement on any variables except self-harm and hospital readmissions. CONCLUSIONS: The results of this study suggest that for personality disorders, a specialist step-down program is more effective than both long-term residential treatment and general psychiatric treatment in the community. Replication is needed that includes a random allocation of patients to conditions to ensure that geographical factors did not account for the observed differences.     

Effectiveness of home rehabilitation program for ischemic stroke upon disability and quality of life: a randomized controlled trial

Background

To develop and examine the effectiveness of individual 6-month home rehabilitation program in ischemic stroke patients upon disability and quality of life at 2 years.

Methods

This is a prospective randomized controlled trial (RCT) in 60 patients with recent ischemic stroke. They were randomly assigned to receive either home rehabilitation program once a month for 6 months with audiovisual materials (intervention group) or usual care (control group). We collected outcome data after discharge from the hospital until 2 years. The Barthel index (BI), the modified Rankin Scale (mRS) and utility index (EQ-5D) were measured for function, disability and quality of life respectively.

Results

At 2 years, the BI was significantly improved in the intervention group more than the control group: 97.2 ± 2.8 vs. 76.4 ± 9.4, p < 0.001. The good outcome, defined as BI 95–100, or mRS 0 or 1. For BI, there were 29 patients (96.7%) in intervention group vs 12 patients (42.9%) in usual care group (95% CI, 42.0, 85.0, p = 0.03). For mRS, there were 28 patients (93.3%) in intervention group vs 9 patients (32.1%) in usual care group (95% CI, 38.2, 87.0, p = 0.02). Number needed to treat for good outcome in mRS was 2.0 (95% CI: 1.0, 1.3). The mean (SD) of utility index in intervention group and control group were 0.9 ± 0.02 and 0.7 ± 0.04 respectively (p = 0.03). There was no significant interaction in baseline characteristics and treatment outcome.

Conclusions

Early home rehabilitation program in the first 6 months period after ischemic stroke leads to more rapid improvement in function, reducing disability and increase quality of life than usual care.     

A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness

CONTEXT: Drug abuse by people with severe mental disorder is a significant public health problem for which there is no empirically validated treatment. OBJECTIVE: To evaluate the efficacy of a new behavioral treatment for drug abuse in this population: Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness (BTSAS). DESIGN: Participants were randomly assigned to 6 months of treatment in either BTSAS or a manualized control condition: Supportive Treatment for Addiction Recovery (STAR). SETTING: Treatment was conducted in community-based outpatient clinics and a Veterans Affairs medical center in Baltimore, Md. PARTICIPANTS: Participants were 129 stabilized outpatients meeting DSM criteria for drug dependence (cocaine, heroin, or cannabis) and serious mental illness: 39.5% met DSM-IV criteria for schizophrenia or schizoaffective disorder; 55.8%, for major affective disorders; and the remainder met criteria for severe and persistent mental illness and other Axis I disorders. INTERVENTIONS: Both treatments were administered by trained health care professionals in small groups, twice a week for 6 months. The BTSAS program is a social learning intervention that includes motivational interviewing, a urinalysis contingency, and social skills training. The control condition, STAR, is a supportive group discussion treatment.Main Outcome Measure The primary outcome measure was urinalysis results from twice-weekly treatment sessions. RESULTS: The BTSAS program was significantly more effective than STAR in percentage of clean urine test results, survival in treatment, and attendance at sessions. The BTSAS program also had significant effects on important community-functioning variables, including hospitalization; money available for living expenses; and quality of life. CONCLUSIONS: The BTSAS program is an efficacious treatment. Further work needs to be done to increase the proportion of eligible patients who are able to become engaged in treatment.     

Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial

OBJECTIVES: To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infarction. METHODS: One hundred and fourteen consecutive patients were randomised to receive the intervention or usual care. Outcome assessment was by self-report questionnaire (the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status), interview at 1 month, and self-report at 3 and 12 months. The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months. RESULTS: Four patients needed to be treated to give an additional patient with improvement in health status at 3 months (number needed to treat [NNT] 4, 95% confidence intervals [CIs] 3 to 12). The intervention group were more confident about returning to activities 1 month after discharge from hospital. Treated patients had fewer further treatment needs. CONCLUSIONS: An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits. A large-scale pragmatic RCT is needed.     

A longitudinal perspective on monitoring outcomes of an innovative program

OBJECTIVES: The use of outcome assessment to evaluate the performance of programs over many years of operation is becoming an increasingly important aspect of health care management. Over a five-year period of program monitoring, this study examined changes in individual client outcomes three months after discharge from a residential work therapy program for veterans with severe substance use disorders. The study also examined the relationship between these outcomes and changing program features, such as staffing, treatment variables, and follow-up rates. METHODS: Data on admissions characteristics, services delivered during treatment, and status at discharges were collected for 3,390 veterans who were treated in 25 sites in the Department of Veterans Affairs' Compensated Work Therapy/Transitional Residence program. Follow-up data were gathered three months after discharge for 1,771 veterans (52.2 percent). Hierarchical linear modeling was used to examine the association between year of discharge, site-level measures of program staffing and follow-up rate, and individual patient-level treatment variables and outcomes. RESULTS: Over the five-year monitoring period, site staff-to-bed ratios and follow-up rates dropped substantially, and veterans attended more Alcoholics Anonymous and Narcotics Anonymous meetings and had more toxicology screens. Higher staff-to-bed ratios were associated with more positive employment outcomes, and higher follow-up rates were associated with poorer outcomes in substance abuse and lower total income. However, no significant outcome trends were observed in clinical follow-up measures after the analyses adjusted for these factors, suggesting that program effectiveness did not deteriorate during a period of program change. CONCLUSIONS: Long-term evaluations of program process and follow-up status can usefully document sustained program effectiveness over many years. Such efforts should enhance their value by examining and adjusting for the impact of factors such as changing staffing levels and follow-up rates.     

Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness

BACKGROUND: This study evaluates the cost and cost-effectiveness of a residential crisis program compared with treatment received in a general hospital psychiatric unit for patients who have serious mental illness in need of hospital-level care and who are willing to accept voluntary treatment. METHODS: Patients in the Montgomery County, Maryland, public mental health system (N = 119) willing to accept voluntary acute care were randomized to the psychiatric ward of a general hospital or a residential crisis program. Unit costs and service utilization data were used to estimate episode and 6-month treatment costs from the perspective of government payors. Episodic symptom reduction and days residing in the community over the 6 months after the episode were chosen to represent effectiveness. RESULTS: Mean (SD) acute treatment episode costs was $3046 ($2124) in the residential crisis program, 44% lower than the $5549 ($3668) episode cost for the general hospital. Total 6-month treatment costs for patients assigned to the 2 programs were $19,941 ($19,282) and $25,737 ($21,835), respectively. Treatment groups did not differ significantly in symptom improvement or community days achieved. Incremental cost-effectiveness ratios indicate that in most cases, the residential crisis program provides near-equivalent effectiveness for significantly less cost. CONCLUSIONS: Residential crisis programs may be a cost-effective approach to providing acute care to patients who have serious mental illness and who are willing to accept voluntary treatment. Where resources are scarce, access to needed acute care might be extended using a mix of hospital, community-based residential crisis, and community support services.     

Efficacy of continuing advocacy in involuntary treatment

OBJECTIVE: The effectiveness of an experimental model of personal advocacy for involuntarily hospitalized psychiatric patients was examined. In the model, a personal advocate represented the needs and best interests of patients throughout the period of involuntary hospital treatment. METHODS: The sample consisted of 105 involuntarily hospitalized psychiatric inpatients in Canberra, Australia. Fifty-three consecutive patients received personal advocacy, which started soon after they entered the hospital and lasted through the commitment process to the time of discharge from involuntary care. The outcome of this group was compared with that of 52 consecutive patients in a control group who received routine rights advocacy from hospital entry through the commitment hearing only. RESULTS: The experimental and control groups were similar in demographic characteristics, diagnosis, and severity of illness. At the start of hospital care, satisfaction with care was similar in both groups; however, it improved significantly in the experimental group while it declined in the control group. Aftercare attendance was significantly better in the experimental group. The experimental subjects' risk of involuntary rehospitalization was less than half the risk of control subjects, and community tenure was significantly increased. Clinical staff reported that the experimental advocacy facilitated management of patients. CONCLUSIONS: Compared with routine rights advocacy, the experimental advocacy based on patients' needs and best interests, which was maintained throughout the patients' involuntary hospitalization, significantly improved patients' and staff members' experience of involuntary treatment. Better compliance with aftercare among patients receiving personal advocacy led to a statistically and economically significant reduction in rehospitalization.     

Development of 2‐hour suicide intervention program among medical residents: First pilot trial

Aim: Suicide is associated not only with primary psychiatric disorders but also with physical disorders. Physicians' education on suicide prevention contributes to reducing suicide. Therefore, medical residents, who contact patients daily and who eventually become primary physicians in each specialty, might be the most appropriate candidates for intervention. In this article, we introduce our newly developed suicide intervention program among medical residents. Methods: We developed a 2‐hour suicide intervention program among medical residents, based on the Mental Health First Aid (MHFA), which had originally been developed for the public. The program contains a 1‐hour lecture and a 1‐hour role‐play session. As the first pilot trial, we conducted the program among 44 first‐year medical residents at a university hospital and evaluated its effectiveness. Changes in confidence, attitudes and behavior toward suicidal people were evaluated using self‐reported questionnaires before, immediately after, and 6 months after the program. Results: Participants' confidence and attitudes significantly improved after the program. The total mean score (standard deviation) of the Suicide Intervention Response Inventory improved from 18.4 (2.0) before the intervention to 19.4 (2.0) immediately after the intervention. However, the effectiveness was limited after 6 months. In the course of 6 months, the participants learned to apply the MHFA principles in their daily clinical practice. Conclusion: Our newly developed brief suicide intervention program demonstrating its effectiveness among medical residents should be modified in order to be more effective in the long term. The next trial with a control group ought to be conducted to evaluate our developed program.     

Specialized inpatient trauma treatment for adults abused as children: a follow-up study

OBJECTIVE: The authors investigated outcome at discharge and at follow-up assessments for adults abused as children who completed a 6-week inpatient program for traumatic stress recovery. METHOD: Participants were assessed at admission, discharge, and 3, 6, and 12 months postdischarge on measures of global symptom severity, posttraumatic stress disorder (PTSD), and disrupted beliefs. Two wait-list comparison groups were also assessed at two points in time for comparison with the discharge and 3-month postdischarge assessments of the treatment group. RESULTS: Relative to admission, the mean scores on all outcome measures for the treatment group were improved at discharge and at 6 and 12 months. Relative to a wait list group, the treatment group was significantly improved at discharge. After 3 months, the scores for the treatment group were not different from those of a wait list group because of deterioration in the treatment group. Age, source of income, and number of axis II disorders were associated with differing patterns of PTSD symptom change over time. Between 32% and 45%, depending on outcome measure, met stringent criteria for clinically significant change at 12 months postdischarge. CONCLUSIONS: At discharge from a specialized inpatient treatment program, adults with a history of abuse during childhood showed improvement relative to a wait list group. Scores tended to deteriorate in the 3 months following discharge but rebounded to discharge levels by 12 months postdischarge. Although many abused adults benefited from specialized inpatient treatment, a substantial proportion did not show clinically significant change 1 year later.     

Cerebral venous thrombosis: an all or nothing disease?: Prognostic factors and long-term outcome

BACKGROUND: There is insufficient data on short- and especially long-term prognosis of cerebral venous thrombosis (CVT). METHODS: In 79 consecutive patients, we analyzed factors for acute death and functional outcome at hospital discharge and after 6 months as well as long-term prognosis >/=12 months. Neurological deficits were graded on the National Institute of Health Stroke Scale (NIHSS), functional outcome on the modified Rankin Scale (mRS). Primary outcome was defined as mRS >/= 3 at 6 months, secondary outcomes were death during hospital treatment and number as well as type of complications during follow-up >/=12 months after hospital discharge. Forty-two patients were recruited prospectively, 37 were identified by chart review. Information on outcome was based on neurological examinations at our outpatient clinic. RESULTS: Factors significantly related to acute death were age, the NIHSS on admission, more than two seizures despite antiepileptic treatment, venous infarct, and hemorrhagic transformation of the venous infarct. Primary outcome after 6 months in 74 patients was excellent with 73% of patients reaching a mRS 0-1, 4% a mRS of 2, and 23% a mRS 3-6, including 12 deaths in the acute stage of illness. Factors significantly related to a mRS >/= 3 at 6 months in a logistic regression analysis were age and items 1a-c of the NIHSS on admission related to consciousness. Fifty-eight surviving patients had a follow-up >/= 12 months (median: 31; mean: 52 +/- 61 months). Most frequent complication on long-term follow-up was epilepsy in nine patients and recurrent venous thrombosis in seven patients. CONCLUSIONS: When the acute stage of illness has been survived, CVT has a good prognosis unlike arterial ischemic stroke.