How Well are We Helping Problem Gamblers? An Update to the Evidence Base Supporting Problem Gambling Treatment

Evidence based medicine developed to link clinical practice and policy decisions to evidence, so that effective treatments are maximized and ineffective treatments minimized. The objective was to evaluate current status of problem gambling treatment evidence base. The method was literature review of problem gambling treatment articles published from 2003 through 2006. The evidence base for gambling treatment remains limited. No treatment, either psychosocial or pharmacologic fulfills the current standards for efficacy. Articles published in this time period provide more support for the efficacy and effectiveness of cognitive behavioral treatment and use of opioid antagonists. The current evidence base is not sufficient to support the goal of community evidence based treatment. Three types of studies are needed: replication studies of the possibly efficacious treatments by independent investigators, effectiveness studies of the possibly efficacious treatments with community populations and clinicians, and outcome studies of community treatment programs to serve as benchmarks.     

Factors that Predict Treatment Outcomes in a Community Treatment Agency for Problem Gamblers

The study reported on factors that were associated with treatment outcomes of problem gamblers in an Australian outpatient treatment agency. Data were collected over a 2-1/2 year period by therapists using semi-structured interviews and monitoring clients’ treatment progress on the 488 clients during treatment. Results showed that gross personal income, problem gambling behaviors (i.e., preoccupation, tolerance to gambling, withdrawal symptoms and gambling to escape), excessive behaviors, intrapersonal difficulties and abuse issues significantly predicted resolution of gambling correlates and/or methods of treatment cessation. Implications for these findings and directions for future research were also discussed.     

Gender differences in the associations between past-year gambling problems and psychiatric disorders

Background Psychiatric disorders frequently co-occur with pathological gambling. The extent to which co-occurence extends to subsyndromal levels of gambling or differs between women and men is incompletely understood. Aim To examine whether the association between psychiatric disorders and past-year gambling problems is stronger in women than men. Methods Data from the national epidemiological survey of alcoholism and related disorders (NESARC) (n = 43,093) were analyzed. Results Increasing severity of past-year gambling problems was associated with increasing odds of most past-year Axis I and lifetime Axis II disorders, regardless of gender. Associations between gambling problems and major depression, dysthymia, panic disorder, and nicotine dependence were statistically stronger in women than in men. Conclusions A severity-related association exists between past-year gambling problems and psychiatric disorders. The stronger associations in women suggest that gambling research, prevention and treatment efforts consider gender differences.     

Are the Effects of Gambling Treatment Overestimated?

Background Studies of clinical trials across the field of healthcare found use of designs that overestimate treatment effects. Objective review clinical trial designs used to develop gambling treatment evidence base for suitability to assess cause and effect and to accurately assess treatment effects. Methods literature review, grading of evidence, proportions and confidence limits Results The majority of published studies on gambling treatment are methodologically unsuited to determine treatment effects. Suitable (randomized and controlled) trails often use designs that can overestimate treatment effects. Attrition in published studies of gambling treatment is substantial, ranging from 11 to 83%. If attrition is not included in the analysis, overestimation of treatment effects may be similar in magnitude. Conclusions The current evidence may overestimate gambling treatment effects. The inclusion of intention to treat analysis, careful blinding, more equivalent control groups and measures of adherence to treatment would improve problem gambling treatment clinical trial design.     

Measuring Treatment Outcome in a Child and Adolescent Partial Hospitalization Program

Mental health practitioners are increasingly being called upon to evaluate the effectiveness of the treatment they provide. The partial hospitalization component of the mental health industry has also felt this call for outcome research. This article presents the results of assessments of treatment outcome at a child and adolescent partial hospitalization program. The research design was an effectiveness study, a type of clinical outcome evaluation. Subjects were evaluated at admission and discharge, using the Revised Behavior Problem Checklist. The article is intended both to demonstrate the effectiveness of a partial hospitalization program and to provide an example of program evaluation that is easy and inexpensive to administer.     

Psychometric Properties of the Dual-Disorder Treatment Fidelity Scale: Inter-Rater Reliability and Concurrent Validity

Psychometric properties of the Dual-Disorder Treatment Fidelity Scale (Mueser et al. Integrated treatment for dual disorders: A guide to effective practice, 2003) were evaluated. Reliability was assessed through measures of inter-rater agreement, and validity was assessed through a concurrent known groups validation procedure. Two raters assessed three community mental health center (CMHC) and three specialized dual diagnosis (DDE) programs for fidelity; inter-rater agreement was good. Total fidelity scores did not distinguish between CMHC and DDE program types; however, a cluster analysis revealed concurrent validity based on the item level ratings. Conclusions drawn from item level ratings appear valid; the validity of conclusions based on total scores remains unsupported.     

The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review

Abstract

Objective: To review systematically the eating disorder literature in order to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder. Methods: Six relevant databases were searched for studies in which interpersonal problems prior to treatment were examined in relation to treatment outcome in patients diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS). Results: Thirteen studies were identified (containing 764 AN, 707 BN and 48 EDNOS). The majority of studies indicated that interpersonal problems at the start of therapy were associated with a detrimental treatment outcome. Conclusions: Individuals with a binge/purge-type of eating disorder may be particularly vulnerable to interpersonal issues and these issues may lead to poorer treatment recovery by reducing the individual's ability to engage in the treatment process on a functional level. The clinical and research implications are discussed.     

DSM-III-R personality disorders in outpatients with non-bipolar depression: The frequency in a sample of Japanese and the relationship to the 4-month outcome under adequate antidepressant therapy

Summary We investigated the frequency of personality disorders (PDs) and the relationship between the pressence of PD and the 4-month outcome of depression under adequate antidepressant therapy in a Japanese sample of 96 outpatients with non-bipolar major depression. The diagnosis of PD was made using a structured interiew method (the Structured Clinical Interview for DSM-III-R Personality Disorders) and after severe depressive symptoms were reduced. Any one kind of PD was found in 54.2% of the saple. The most frequent was avidant (34–4%), obsessived-compulsive (22.9%), narcisstic (18.8%), and dependent (16.7%) PDs. The frequencies of these PDs in our study except narcisstic PD, were about the same as those reported in previous studies with a matched setting for the PD diagnosis. Compared with patients without PD, a worse outcome was found in patients with PD, especially patients with multiple PDs from multiple PD clussters. There was no evidence that a specific PD or PD cluster especially worsens the outcome of depression.     

Schizophrenia, Co-occurring Substance use Disorders and Quality of Care: The Differential Effect of a Managed Behavioral Health Care Carve-out

This study explores the differential effect of a managed behavioral health Carve-Out (CO) on outpatient treatment quality for persons with schizophrenia (SCHZ) alone and co-occurring substance use disorders (SUD) (SCHZ+SUD). We used claims data from a state Medicaid program and employed a retrospective, quasi-experimental design with logit and difference in difference formula regression models. The results show the CO was associated with greater changes in treatment quality for the SCHZ population, compared to the SCHZ+SUD population. Most pronounced across both populations were decrements in receiving the psychosocial treatments for enrollees in the CO arrangement.An earlier version of this analysis was presented on June 24, 2004 at the Co-occurring Conditions Conference sponsored by NIMH, NIDA, NIAAA, AHRQ, HRSA AND SAMHSA.     

精神分裂症病程与结局十二年随访

目的了解我国精神分裂症长期结局。方法按世界卫生组织提供的方法及评定工具，于１９９４年对１９８２年调查的８个地区的８９例精神分裂症患者进行随访。结果直接随访的５８例在症状总体功能和社会缺陷总体功能评定中，分别有２８例（４８％）为结局好及较好者。结论近半数的患者为结局好或较好，可能与近年来普遍使用精神药物有关；同时，仅４０％的患者接受常规治疗，提示精神分裂症患者的社区康复工作仍有待加强。     

抑郁症首次发病患者治疗前后认知功能的研究

目的研究抑郁症首次发病(以下简称首发)患者治疗前后的认知功能改变及其相关影响因素。方法对80例符合国际疾病分类第10版诊断标准的抑郁症首发患者(患者组),给予文拉法辛缓释剂(40例,75~300MG/D)或盐酸氟西汀胶囊(40例,20~40MG/D)治疗,共12周。于治疗基线和治疗末评定17项汉密尔顿抑郁量表(HAMD17)、韦氏记忆量表、韦氏成人智力量表、威斯康星卡片分类测验,并与41名健康志愿者(对照组)比较。结果(1)治疗后患者组的神经心理学测验成绩较治疗前均有明显提高(P<0·05或P<0·01)。(2)患者组记忆商数改变与睡眠障碍分改变呈负相关(R=-0·26,P=0·021),短时记忆分改变与HAMD17总分改变、睡眠障碍分改变呈负相关(R=-0·27和-0·34,P=0·017和0·002),语言智商改变与阻滞分改变呈负相关(R=-0·24,P=0·034)。(3)痊愈组(HAMD17总分≤7分)患者的长时记忆分[(41·96±3·77)分]低于对照组[(44·05±5·06)分],症状残留组(HAMD17总分>7分)的记忆商数(107·52±18·12)、长时记忆分[(40·89±5·06)分]、短时记忆分[(60·74±12·58)分]低于对照组[分别为(121·90±11·26)、(44·05±5·06)分和(71·41±8·51)分;P<0·05和P<0·01]。(4)治疗后仍有14例(18%)患者的记忆商数低于正常值范围下界(均数-1·96倍标准差),多于对照组[1例(2%);P<0·05]。结论抑郁症首发患者治疗后认知功能明显提高,认知障碍改善与临床症状缓解存在相关性,治疗后仍有少部分患者的记忆功能未恢复到正常水平。     

Objective Measure of Treatment Outcome in Epilepsy

Summary: Treatment outcome in epilepsy is too often a vague, ill-defined subjective measure. Based on a proposal of Shoffer and Temkin (1987) of "time to kth seizure" as a measure of seizure frequency, we devised the formula: % improvement = 100 - [time to X seizure (i*) * 100]/ [time to X seizure (f*)]. This formula provides an objective measure of treatment outcome and should prove useful in clinical settings and research. We offer examples of practical applications of the formula.     

Quality of Care Measures for the Treatment of Bipolar Disorder

The staff of the American Psychiatric Assocition (APA), the American Psychiatric Institute for Research and Education (APIRE), and a national panel of experts in bipolar disorder and practice guideline development have collaborated to generate a set of quality of care indicators for the pharmacologic and psychosocial treatment of bipolar disorder. The indicators were derived from APA’s evidence-based Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2002 (1) and the Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder, 2000 (2) These quality indicators can be used for quality monitoring, benchmarking, and quality improvement efforts across health plans, systems of care, and health care providers to improve quality and outcomes of care for patients with bipolar disorder.     

尤瑞克林治疗急性脑梗死患者临床疗效及安全性观察

目的 探讨尤瑞克林治疗急性脑梗死的临床疗效及安全性。 方法 急性脑梗死患者200例分为对照组和治疗组,每组各100例,两组予相同的基础治疗,但治疗组加用尤瑞克林0．15PNA单位静脉滴注,每日1次,连用7～14d,同时使用抗血小板药物或抗凝药物进行病因治疗及神经康复治疗,于治疗前后评定患者神经功能缺损程度、日常生活活动能力、伤残或严重程度,并记录不良反应事件。 结果 治疗后两组患者的神经功能缺损、日常生活活动能力、伤残或严重程度评分均有改善,与治疗前相比差异具有统计学意义（P相似文献   

Factors Associated with the Severity of Gambling Problems in a Community Gambling Treatment Agency

Factors (demographics, gambling behaviors and comorbid problems) that may be related to the severity of gambling problems were investigated among 440 problem gamblers seeking treatment in an Australian outpatient treatment agency. The participants were divided into sub-threshold pathological gamblers (SPGs; N = 104) and pathological gamblers (PGs; N = 336) using Diagnostic Statistical Manual (DSM) IV diagnosis of pathological gambling. SPGs were more likely to be separated/divorced, while PGs were more likely to be single. PGs tended to be younger than SPGs. Participation in lottery games was the only form of gambling that could distinguish between the two severity groups. No significant differences were found in participation in more than one gambling session per week and average amount spent per session on various gambling activities between the two groups. PGs were more likely to report financial, relationship, employment, physical, intrapersonal, other excessive behaviors (e.g., substance problems), leisure (e.g., loneliness, boredom) and legal problems than SPGs. Implications and limitations of these findings are discussed.     

奥扎格雷钠治疗进展性脑卒中疗效观察

目的探讨奥扎格雷钠治疗进展性脑卒中的疗效与安全性。方法将90例进展性脑卒中患者随机分为两组,治疗组45例患者应用奥扎格雷钠注射液80 mg溶于0．9%氯化钠溶液250 ml中静滴,早晚各1次,同时加用低分子右旋糖酐500 ml,川芎嗪80 mg,1次/d静滴,连用14 d;对照组45例患者应用低分子右旋糖酐500 ml,川芎嗪80 mg,1次/d静滴,连用14 d。两组患者同时应用低分子肝素钠5000U皮下注射,2次/d,连用7 d。观察两组患者治疗前后神经功能缺损评分,血小板聚集率等指标的变化。结果两组患者疗效间差别有显著性意义(P＜0．05);治疗后两组患者的全血黏度、纤维蛋白原水平、血小板聚集率间差别均有显著性意义(P＜0．05);两组患者的不良反应经对症处理后消失,差别无显著性意义。结论奥扎格雷钠治疗进展性卒脑中安全有效。     

Smiles may go unseen in generalized social anxiety disorder: Evidence from binocular rivalry for reduced visual consciousness of positive facial expressions

Research has demonstrated increased attention to negative social cues and reduced attention to positive social cues in generalized social anxiety disorder (GSAD), but little is known about whether GSAD also involves differences in lower levels of visual processing. This study explored visual experience in GSAD compared to participants with generalized anxiety disorder (GAD) and healthy controls using binocular rivalry. Participants were presented with dissimilar images to each eye, and the two images competed for perceptual dominance. Consistent with the hypothesis that GSAD involves a reduced visual salience for positive social cues, we found that smiling faces were dominant for significantly shorter durations in GSAD compared to GAD and controls. Contrasting with our hypothesis of greater visual salience of negative social cues, we found no difference in negative stimuli salience. These findings are consistent with the broader view that a perceiver's affective state directly influences the content of visual consciousness.     

Interaction of haloperidol plasma level and antipsychotic effect in early phases of acute psychosis treatment

The definition of the best combination of “when” and “how much” of haloperidol dosing during acute psychotic illness still represents a challenge. Randomized controlled trials can hardly account for the high variability of dose × timing of dose increase strategies that can be applied in everyday practice. We conducted an observational study in order to study and evaluate the naturalistic strategies of haloperidol oral administration in a sample of 101 acutely ill psychotic patients. Out of this sample, 82 patients had complete data on PANSS scores and 50 patients had data on the haloperidol plasma levels. In accordance with previous evidence, we found that improvement during the first two weeks of treatment was a significant predictor of response (t = 6.94, p = 2.11E−08). On this note, increasing the haloperidol doses over 6.64 ± 2.08 mg/day on average from the second to the third week of treatment in those patients who did not respond to treatment during the first two weeks of treatment was of no use for further amelioration. This cutoff was associated with treatment efficacy but not with the incidence of side effects. In conclusion a moderate dose of haloperidol is suggested in the first two weeks, in case of non response a dose increase is of no further benefit. This finding could contribute to tailor more individualized treatment and highlights the need for early detection of non-responders.     

The school behaviors of children in three psychiatric treatment settings: An outpatient clinic,a day hospital,and an inpatient hospital

Compares teachers' ratings of the school behaviors of children entering an outpatient clinic, a day psychiatric program, and an inpatient psychiatric hospital. Many of the ratings did not discriminate among the three groups. Children starting outpatient versus day treatment were rated as higher in aggression, anxiety, and hostile withdrawal, and children beginning outpatient and day treatment versus inpatient treatment, were reported as more skilled socially.