Does naltrexone treatment lead to depression? Findings from a randomized controlled trial in subjects with opioid dependence

OBJECTIVE: Dysphoria and depression have been cited as side effects of the opioid antagonist naltrexone. We aimed to assess whether depressive symptoms are a clinically relevant side effect in a population receiving naltrexone as a treatment for opioid dependence. METHODS: We carried out a randomized controlled, open-label trial comparing rapid opiate detoxification under anesthesia and naltrexone treatment with continued methadone maintenance at the Alcohol and Drug Service, Royal Brisbane and Women's Hospital, Brisbane, Australia. The study subjects were patients stabilized on methadone maintenance treatment for heroin dependence who wished to transfer to naltrexone treatment. The Beck Depression Inventory, State-Trait Anxiety Inventory and Opiate Treatment Index subscales for heroin use and social functioning were used at baseline and follow-up assessments at 1, 2, 3 and 6 months. RESULTS: Forty-two participants were allocated to receive naltrexone treatment, whereas 38 continued methadone maintenance as the control condition. Participants who received naltrexone did not exhibit worsening of depressive symptoms. In participants attending all follow-up assessments, there was a trend for those receiving naltrexone to exhibit an improvement in depression over time compared with the control group. Participants who were adherent to naltrexone treatment exhibited fewer depressive symptoms than those who were nonadherent. CONCLUSIONS: These results suggest that depression need not be considered a common adverse effect of naltrexone treatment or a treatment contraindication and that engaging with or adhering to naltrexone treatment may be associated with fewer depressive symptoms.     

Can staff training reduce behavioural problems in residential care for the elderly mentally ill?

The effect of a brief in-service training programme on the psychosocial management of behavioural disturbance in residential care is described. Although the incidence of problematic behaviour did not change 3 months after training, staff in the experimental homes reported a significant improvement in their management of problematic behaviour, as compared to the control home. However, these effects were not maintained a year later. The importance of post-training supervision and the sociocultural context of the home in the maintenance of psychosocial intervention in residential settings is discussed. © 1998 John Wiley & Sons, Ltd.     

Florida's outpatient commitment law: a lesson in failed reform?

An involuntary outpatient commitment law became effective in Florida in January 2005. However, only 71 orders for outpatient commitment have been issued in three years, even though during that period 41,997 adults had two or more 72-hour involuntary emergency examinations under Florida's civil commitment law. This column describes the criteria for outpatient commitment in the Florida statute and discusses possible reasons for its low rate of use, including additional statutory criteria that make filing a petition for outpatient commitment difficult, lack of community treatment resources, and lack of enforcement mechanisms.     

Can individuals with Williams syndrome interpret mental states from moving faces?

The Williams syndrome (WS) social phenotype is characterised by a high level of social engagement, heightened empathy and prolonged attention to people's faces. These behaviours appear in contradiction to research reporting problems recognising and interpreting basic emotions and more complex mental states from other people. The current task involved dynamic (moving) face stimuli of an actor depicting complex mental states (e.g., worried, disinterested). Cues from the eye and mouth regions were systematically frozen and kept neutrally expressive to help identify the source of mental state information in typical development and WS. Eighteen individuals with WS (aged 8-23 years) and matched groups of typically developing participants were most accurate inferring mental states from whole dynamic faces. In this condition individuals with WS performed at a level predicted by chronological age. When face parts (eyes or mouth) were frozen and neutrally expressive, individuals with WS showed the greatest decrement in performance when the eye region was uninformative. We propose that using moving whole face stimuli individuals with WS can infer mental states and the eye region plays a particularly important role in performance.     

Can receipt of a regular postcard reduce suicide‐related behaviour in young help seekers? A randomized controlled trial

Aim: Suicide attempt, ideation and deliberate self‐harm are common among adolescents. Limited evidence exists regarding interventions that can reduce risk; however, research indicates that maintaining contact with at‐risk adults following discharge from services via letter or postcard can reduce risk. The aim of the study was to test a postcard intervention among people aged 15–24 who presented to mental health services but were not accepted, yet were at risk of suicide. Methods: A randomized controlled trial of 3 years in duration was used. The intervention consisted of 12 postcards sent once a month for 12 months following presentation to the service. Key outcomes of interest were reduced rates of suicide attempt, suicidal ideation and deliberate self‐harm, assessed at 12 and 18 months. Results: Participants reported that they liked receiving the postcard and that they used the strategies recommended. However, no significant effect of the postcard intervention was found on suicide risk, although participants in both groups improved on measures of mental health over the course of the study. Conclusions: There remains a need for further research into youth‐friendly interventions for young people at risk of suicide.     

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).     

Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial

OBJECTIVE: The use of interactive videoconferencing to provide psychiatric services to geographically remote regions, often referred to as telepsychiatry, has gained wide acceptance. However, it is not known whether clinical outcomes of telepsychiatry are as good as those achieved through face-to-face contact. This study compared a variety of clinical outcomes after psychiatric consultation and, where needed, brief follow-up for outpatients referred to a psychiatric clinic in Canada who were randomly assigned to be examined face to face or by telepsychiatry.METHODS: A total of 495 patients in Ontario, Canada, referred by their family physician for psychiatric consultation were randomly assigned to be examined face to face (N=254) or by telepsychiatry (N=241). The treating psychiatrists had the option of providing monthly follow-up appointments for up to four months. The study tested the equivalence of the two forms of service delivery on a variety of outcome measures. RESULTS: Psychiatric consultation and follow-up delivered by telepsychiatry produced clinical outcomes that were equivalent to those achieved when the service was provided face to face. Patients in the two groups expressed similar levels of satisfaction with service. An analysis limited to the cost of providing the clinical service indicated that telepsychiatry was at least 10% less expensive per patient than service provided face to face. CONCLUSIONS: Psychiatric consultation and short-term follow-up can be as effective when delivered by telepsychiatry as when provided face to face. These findings do not necessarily mean that other types of mental health services, for example, various types of psychotherapy, are as effective when provided by telepsychiatry.     

How does Housing First catalyze recovery?: Qualitative findings from a Canadian multi-site randomized controlled trial

Qualitative narrative interviews were conducted with 195 participants with histories of homelessness and mental illness at baseline and at an 18-month follow-up. Participants were randomly assigned at baseline to Housing First (HF; n = 119) or treatment as usual (TAU; n = 76) in five Canadian cities. Changes in consumers’ narratives over time were examined for 13 life domains (e.g., housing stability, typical day, social relationships). HF participants showed superior housing stability that led to three important transitions in their recovery journeys: (1) the transition from street to home (e.g., greater control over one’s environment, becoming unstuck), (2) the transition from home to community (e.g., pursuing relationships, participating in the community), and (3) the transition from the present to the future (e.g., developing autonomy and hope). In spite of the gains experienced by many HF participants and some TAU participants, there was a subgroup of HF participants and many more TAU participants who experienced considerable difficulty making positive transitions. This research affirms the importance of housing and support for people with mental illness who are homeless but extends previous research by elucidating how HF enables participants to navigate important transitions in their recovery journeys. Once housing stability is achieved, other services (e.g., supported employment, education, and socialization) are needed to accelerate the transitions that participants strive to make in their lives.     

Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months

BACKGROUND AND PURPOSE: We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke. METHODS: This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed. RESULTS: Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points). CONCLUSIONS: A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers.     

Psychotherapy for personality disorders: Short-term day hospital psychotherapy versus outpatient individual therapy – a randomized controlled study

This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N = 114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of patients for the next few years, the results of which may have implications for resource allocation and the organization of mental health services for patients with personality disorders.     

Can an illness perception intervention reduce illness anxiety in spouses of myocardial infarction patients? A randomized controlled trial

Objective

To investigate whether a brief in-hospital illness perception intervention for myocardial infarction (MI) patients and their spouses could change spouses' illness perceptions and reduce spouses' anxiety about the illness.

Methods

Fifty-seven spouses participated in a randomized controlled trial of an illness perception intervention for MI patients. Spouses of patients randomized to the intervention attended one half-hour patient-and-spouse session with a psychologist in addition to standard care. Spouses completed measures of illness perceptions, expectations, and illness anxiety at admission and at 1 week following discharge, and spouses' illness worry was rated by the patients at 3 months. The main outcome for spouses was differences in anxiety between intervention and control groups.

Results

One week following discharge, spouses in the intervention group had higher illness understanding, lower concern, stronger causal attributions to hereditary factors, and fewer questions about their partner's heart condition compared to the control group. Intervention group spouses reported more positive expectations about the ability of the patient's heart to recover, and lower perceived likelihood of another MI. They had lower anxiety about the patient doing physical activity and about the patient's medications, and lower distress about the patient's symptoms. Spouses in the intervention group were rated as less worried about the illness at 3 months.

Conclusion

Spouses of patients represent a new target for illness perception interventions and these results demonstrate that a brief illness perception intervention can change illness perceptions and reduce anxiety about the illness in spouses of MI patients.     

Home or hospital for stroke Rehabilitation? Results of a randomized controlled trial : II: cost minimization analysis at 6 months

BACKGROUND AND PURPOSE: The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke. METHODS: A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization. RESULTS: The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient's level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver. CONCLUSIONS: The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective.     

Does occasional cannabis use impact anxiety and depression treatment outcomes?: results from a randomized effectiveness trial

This study investigated the extent to which occasional cannabis use moderated anxiety and depression outcomes in the Collaborative Care for Anxiety and Panic (CCAP) study, a combined cognitive-behavioral therapy (CBT) and pharmacotherapy randomized effectiveness trial. Participants were 232 adults from six university-based primary care outpatient clinics in three West Coast cities randomized to receive either the CCAP intervention or the usual care condition. Results showed significant (P<.01) evidence of an interaction between treatment group (CCAP vs. usual care) and cannabis use status (monthly vs. less than monthly) for depressive symptoms, but not for panic disorder or social phobia symptoms (all P>.05). Monthly cannabis users' depressive symptoms improved in the CCAP intervention just as much as those who used cannabis less than monthly, whereas monthly users receiving usual care had significantly more depressive symptoms than those using less than monthly. A combined CBT and medication treatment intervention may be a promising approach for the treatment of depression among occasional cannabis users.