Effects of a smoking ban on a general hospital psychiatric service

After a private general hospital announced plans to ban smoking inside the hospital, the authors initiated a study on the psychiatric units to identify anticipated and actual patient-related problems associated with the ban and to assess staff and patient attitudes toward the ban. Data were obtained through pre- and post-ban surveys of medical and nursing staff and predischarge interviews with patients. The findings showed that staff anticipated more smoking-related problems than actually occurred and that patients who smoked were able to reduce their tobacco use during their hospital stay. No evidence was found to suggest that hospitalized psychiatric patients are less capable of cutting down on smoking than the general population.     

A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine

Cormac I, Brown A, Creasey S, Ferriter M, Huckstep B. A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine. Objective: To investigate the effect of a complete smoking ban on a group of psychiatric inpatients maintained on the antipsychotic medication clozapine. Method: Retrospective data on clozapine dose and plasma levels were collected from a three month period before and a six month period after the introduction of the smoking ban. Results: Before the ban only 4.2% of patients who smoked had a plasma clozapine level ≥1000 μg/l but after the ban this increased to 41.7% of the sample within the six month period following the ban despite dose reductions. Conclusion: Abrupt cessation of smoking is associated with a potentially serious risk of toxicity in patients taking clozapine. Plasma clozapine levels must be monitored closely and adjustments made in dosage, if necessary, for at least six months after cessation.     

Ethical, legal, and psychodynamic considerations in intervention of a possible cult member

A 17-year-old boy is brought involuntarily by his parents for admission to an adolescent unit after running away from home to join a cult. The adolescent is admitted to the hospital for a multidisciplinary assessment. Follow-up 6 months after discharge shows the family to have continued in family therapy with the patient remaining at home with no additional contact with the cult. The case raises important ethical and dynamic issues about whom the child psychiatrist serves--the parents, the adolescent, or society. Discussion by an ethicist, lawyer, and child and adolescent psychoanalyst follows the case presentation.     

Negative effects of a smoking ban on an inpatient psychiatry service

Although many psychiatric inpatient units have banned smoking, the authors suggest that problems associated with implementation of no-smoking policies in these settings have been underreported. Over a two-year period after implementation of a smoking ban on inpatient units at a Veterans Affairs medical center, an estimated 20 to 25 percent of patients who smoked had difficulty adjusting to the ban, and some patients experienced major disruption in their treatment. Four cases illustrating problems in treating highly disturbed, nicotine-dependent patients are presented. The authors recommend that inpatient settings where smoking is banned should accommodate patients who cannot tolerate abrupt smoking cessation by providing smoking areas or allowing off-unit smoking breaks.     

Parent and child acceptability and staff evaluation of K-SADS-PL

Background Standardised diagnostic interviews are used increasingly in child and adolescent psychiatry; yet little is known about the attitudes towards such interviews among parents, children and staff members. In this study, we have aimed to assess (1) the K-SADS-PL’s acceptability to parents and children (2) the usefulness of the interview as perceived by the staff. Methods Following the implementation of a semi-structured diagnostic interview in the standard assessment, parents, children, and staff were asked to fill in, anonymously, a brief questionnaire enquiring about their impression of the interview. Results Parental satisfaction with the parent interview was very high. Parental satisfaction with the child interview was high as well, although a small group of children were reported to be more sad/hyperactive or difficult immediately after the interview. However, these were found among the younger children only, and mainly children with conduct problems. Most children found that the interview was a good or fairly good way to talk about how they felt, but more than half the children found the interview boring to some extent, and a few felt worse after the interview than they did before. The staff found the interview to be useful in most cases, primarily for diagnostic purposes. Conclusions Semi-structured diagnostic interviews are well accepted by parents and children, and have good face validity among staff members. To young children with many conduct difficulties the interview may seem overwhelming, and future work should focus on ways of making diagnostic interviews more engaging for children.     

Effects of a Complete Smoking Ban on Inpatients at an Intermediate to Long-Term Psychiatric Facility

The majority of research on reactions to smoking bans in psychiatric facilities focuses on staff feedback in acute inpatient settings. The purpose of this pilot study was to assess inpatient attitudes about a complete smoking ban in an intermediate to long-term psychiatric facility. One hundred inpatients were surveyed via questionnaire. Inpatients reported changes in smoking and improvements in health as a result of the ban, despite evidence of non-compliant smoking at the facility. There was evidence that inpatients perceived others’ attitudes about the ban to be worse than reality. The findings from this pilot study suggest that consequences of smoking bans in psychiatric facilities are not as negative as some perceive. Smoking bans in intermediate to long-term settings may result in improvements in health among both smoking and non-smoking patients.     

Goal directed informal sessions: their impact on an adolescent unit

Goal Directed Informal Sessions ( GDIS ) were utilized on an inpatient adolescent unit in an attempt to facilitate communication between adolescents and their parents, to neutralize partially the almost universal fantasy that adolescents know more than their respective parents on any given topic, and to maximize the impact of the therapeutic milieu in other ways. The vehicle for the GDIS was discussions of various aspects of human sexuality. Thirty-four adolescents (average age 14.8), their parents, and staff were asked to respond to a questionnaire relating to human sexuality prior to the onset of GDIS . Adolescents speculated that their parents would perform least well. The average test scores for the adolescents, their parents, and staff respectively were: 65 percent, 79 percent and 81 percent. There was no significant difference between the scores of staff and parents. The difference between adolescents' scores and those of the parents and staff was significant (p less than 0.05). Framework for the GDIS is outlined, and illustrative vignettes are offered. Based on one year's experience, GDIS are recommended for other adolescent facilities.     

Expressed Emotion Moderates the Effects of Family-Focused Treatment for Bipolar Adolescents

ObjectiveFamily interventions have been found to be effective in pediatric bipolar disorder (BD). This study examined the moderating effects of parental expressed emotion (EE) on the 2-year symptomatic outcomes of adolescent BD patients assigned to family-focused therapy for adolescents (FFT-A) or a brief psychoeducational treatment (enhanced care [EC]).MethodA referred sample of 58 adolescents (mean age 14.5 ± 1.6 years, range 13-17 years) with BD I, II, or not otherwise specified was randomly allocated after a mood episode to FFT-A or EC, both with protocol pharmacotherapy. Levels of EE (criticism, hostility, or emotional overinvolvement) in parents were assessed through structured interviews. Adolescents and parents in FFT-A underwent 21 sessions in 9 months of psychoeducation, communication training, and problem-solving skills training, whereas adolescents and parents in EC underwent 3 psychoeducation sessions. Independent “blind” evaluators assessed adolescents' depressive and manic symptoms every 3 to 6 months for 2 years.ResultsParents rated high in EE described their families as lower in cohesion and adaptability than parents rated low in EE. Adolescents in high-EE families showed greater reductions in depressive and manic symptoms in FFT-A than in EC. Differential effects of FFT-A were not found among adolescents in low-EE families. The results could not be attributed to differences in medication regimens.ConclusionsParental EE moderates the impact of family intervention on the symptomatic trajectory of adolescent BD. Assessing EE before family interventions may help determine which patients are most likely to benefit from treatment. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(6):643-651.     

Consumer satisfaction at a child and adolescent state psychiatric hospital

OBJECTIVE: This study examined satisfaction with services among patients in a child psychiatric hospital and their parents, and assessed the relationship between consumer satisfaction and the perception of improvement in the problem that led to hospitalization. METHODS: A consumer satisfaction survey developed by the investigators was administered to three sampling waves of child and adolescent psychiatric inpatients (N=157) and their parents or guardians (N=111). Ninety-five percent of patients contacted and 97 percent of their parents or guardians agreed to participate in the study. The survey provided data about the children's and parents' satisfaction with inpatient care and their perceptions of the children's clinical improvement. RESULTS: Most parents and children reported high satisfaction with patient care. Twenty-eight percent of children and 21 percent of parents reported some form of abuse by the staff during the hospital stay. Those who reported abusive behavior were significantly less satisfied with the hospital experience than those who did not report abuse. The participants' perception of clinical improvement was only weakly related to their satisfaction. CONCLUSIONS: Most child psychiatric patients and their parents will participate in consumer satisfaction surveys about inpatient care. Consumers are critical of a hospital if specific prompts in the survey are provided. An unexpectedly high level of consumer-reported abuse was found. Consumer-perceived clinical improvement was only weakly related to satisfaction.     

Explaining educational differences in adolescent substance use and early sexual debut: the role of parents and peers

Previous studies from a wide variety of European countries have demonstrated that low educated adolescents engage more frequently in health risk behaviors compared to high educated adolescents. The present study investigates the mediating roles of parental knowledge and time spent with peers in this relationship. Data were retrieved from a nationally representative sample of 12- to 16-year old Dutch adolescents (N=5422). Risk behaviors were measured by adolescents' report of daily smoking, binge drinking and cannabis use in the previous month, and sexual debut before age 17. Low educated adolescents indicated that their parents had less knowledge on their whereabouts and reported spending more time with peers than high educated adolescents. Both factors mediated the relationship with health risk behaviors. These results hint to parenting practices and adolescent peer relations as points of reference for prevention and intervention work aiming to reduce educational inequalities in adolescent health risk behaviors.     

Staff expressed emotion and causal attributions for client problems on a low security unit: an exploratory study

This is an exploratory study that sought to investigate a number of measures of staff-patient relationships on a continuing care, low security inpatient facility for patients with severe mental illness. Twenty staff members were assessed for expressed emotion (EE) using the Camberwell Family Interview (CFI) in regard to a client for whom they were a designated key worker. Their spontaneous attributions for the patient's problems were also assessed, along with self-report staff and patient ratings of their expressed and perceived feelings and thoughts about their staff or patient counterpart. The study found that although none of the staff were rated as fulfilling criteria for high EE, there was evidence of some variability in the quality of staff-patient relationships as assessed from the subjective self-report scales of staff and patients. Patients seemed to be sensitive to staff feelings for them: patient ratings of perceived feelings and thoughts from staff were significantly correlated with staff expressed feelings both from the CFI EE ratings and the direct self-report staff measures. Staff tended to view the behaviors of patients they felt less positively disposed toward as more controllable, and this association between less benign explanations of behavior and a more critical attitude is consistent with the attribution research for familial caregivers. The more negatively perceived patient group was found to be more likely to have behavioral disturbances in the 7 months after the relationship ratings were made. This article discusses measurement issues in the assessment of formal caregiver-patient relationships in the light of this and previous studies.     

Smoking cessation services in U.S. methadone maintenance facilities

OBJECTIVES: Most patients in drug treatment smoke cigarettes. This study established the prevalence and types of nicotine dependence services offered in methadone and other opioid treatment clinics in the United States. METHODS: A cross-sectional survey was conducted of all outpatient methadone maintenance clinics in the United States. One person in a leadership position from each clinic was surveyed. The 20-minute survey was collected by phone, fax, or mail, according to responder preference. RESULTS: Fifty-nine percent of the clinics (408 of 697 clinics) responded. The sample was very similar to all outpatient methadone maintenance clinics in the United States in size, region, and ownership. In the 30 days before the survey, respondents reported that their clinics provided the following services to at least one patient: 73 percent provided brief advice to quit, 18 percent offered individual or group smoking cessation counseling, and 12 percent prescribed nicotine replacement therapy. However, the services were provided to very few patients. Clinics with written guidelines that required them to address smoking were much more likely to provide services than those without guidelines. Private for-profit clinics were significantly less likely than public or private nonprofit clinics to treat nicotine dependence. Most respondents (77 percent) reported that their staff were interested in receiving training in nicotine dependence treatment, and more than half (56 percent) had at least one staff member ("champion") with a strong interest in treating nicotine dependence. CONCLUSIONS: A vast majority of methadone patients smoke; yet in the 30 days before the survey only one out of three facilities provided counseling to any patients and only one out of ten prescribed nicotine replacement therapy to any patients. A dual strategy of requiring clinics to provide comprehensive nicotine dependence services and training staff to provide these services may provide the incentive and support necessary for the widespread adoption of treatment for nicotine dependence in methadone facilities.     

Health-related quality of life and self-perceived competence of children assessed before and up to two years after epilepsy surgery

PURPOSE: To measure outcome of epilepsy surgery in terms of health-related quality of life (HrQoL) and self-perceived competence of children and adolescents. METHODS: Prospective longitudinal follow-up study of 21 patients (aged 6.2 to 16.8 years). Frequency and severity of seizures and epilepsy-related restrictions, HrQoL, and self-perceived competence were rated before and 6, 12, and 24 months after epilepsy surgery. Data were analysed nonparametrically and using analysis of variance for repeated measures. RESULTS: Group-wise, seizure parameters had almost normalized 6 months after surgery (p<0.001) and remained so. Two years after surgery, 15 (72%) patients were free of seizures. At the first postsurgical assessment, parents and children evaluated the frequency of activities as improved and that of seizures as diminished (p<0.05). Parents evaluated their children as having positive emotions more frequently (p<0.05). Children started to feel better about seizure variables in the second year after surgery. Two years after surgery, children perceived themselves as being socially more competent and having greater self-worth (p=0.05). In the adolescent group, several aspects of self-perceived competence improved shortly after surgery (p<0.05), whereas 2 years after surgery, athletic competence and romance had improved (p<0.05). CONCLUSIONS: In children and adolescents, epilepsy surgery sets the stage for improvement in HrQoL and in competence to participate in social and societal domains. Most improvement occurs in the first 6 months after surgery.     

Does smoking cessation improve mental health?

There is a possibility that cessation of smoking improves mental health, but there are no studies that have demonstrated this. A cohort study was performed for 1 year in 18 males who spontaneously stopped smoking (cessation group) and 173 who continued to smoke (smoking group). The mental health state was evaluated using the Japanese version of the 30-item General Health Questionnaire (GHQ-30) before the cessation of smoking and 6 months and 1 year after smoking cessation. Changes in the GHQ score were compared between the cessation and smoking groups. In order to control the effects of confounding factors, multiple regression analyses were performed using the GHQ score after 6 months and 1 year as dependent variables. The GHQ score in the cessation group significantly decreased 6 months and 1 year after smoking cessation (P < 0.04 and 0.01, respectively, by paired t-test). In the smoking group, the GHQ score slightly decreased. Repeated measure analysis of variance revealed that the decrease in the GHQ score in the cessation group was significantly larger than in the smoking group. Multiple regression analysis revealed significant effects of smoking cessation on mental health after controlling for other confounding factors. It can be concluded that smoking cessation may improve mental health.     

Prevalence of and Factors Related to Tobacco Ban Implementation in Substance Use Disorder Treatment Programs

This study examined the prevalence of and factors (psychological climate for change and staff attributes) related to indoor and outdoor tobacco bans for patients, employees, and visitors in U.S. substance use disorder treatment programs. Data were collected from a random sample of 1,026 program administrators. Almost all programs banned tobacco use indoors and around one third banned tobacco use outdoors. When there was no tobacco ban, the majority of programs restricted smoking to designated indoor and/or outdoor areas. Further, all psychological climate for change factors (perceived program support, perceived tobacco culture, and tobacco ban beliefs) but none of the staff attributes (percentage licensed/certified clinicians, percentage clinicians with master’s degrees, total staff with education in health-related field) were significantly related to the implementation of comprehensive tobacco bans (both indoors and outdoors).     

Natalizumab vs interferon beta 1a in relapsing-remitting multiple sclerosis: a head-to-head retrospective study

Background – No head‐to‐head study has been performed yet to assess whether natalizumab is more effective than classical immunomodulators in multiple sclerosis (MS). Aim – To retrospectively compare the efficacy of natalizumab vs IFN beta 1a SC (44 μg; Rebif^®) on clinical and radiological findings in two matched cohorts of patients with MS. Patients and methods – We retrospectively enrolled two cohorts of 42 patients (F/M: 35/7) with relapsing‐remitting multiple sclerosis treated with natalizumab or IFN beta 1a for at least 12 consecutive months. Outcome measures were annualized relapse rate (ARR), changes in expanded disability status scale (EDSS) score, and number of contrast‐enhancing lesions (CELs) at magnetic resonance imaging (MRI). Results – In both groups, the ARR in the 12 months of treatment was lower than in the 12 months before therapy (0.24 vs 1.50 in natalizumab‐treated group, P < 0.0000; 0.55 vs 1.10 in IFN beta 1a‐treated group, P = 0.0006), being the effect of natalizumab significantly stronger (P = 0.0125). EDSS reduction was significantly different between the two groups in favor of natalizumab (P = 0.0018). The frequency and number of CELs per patient were decreased in both groups. In the second year, the treatment affected ARR and EDSS progression in the two groups of patients similarly to the first year, whereas number of CELs decreased more significantly in natalizumab group (P = 0.008). Conclusions – After 12 and 24 months of therapy, natalizumab was more effective than IFN beta 1a SC on both disease activity and disability progression. Prospective head‐to‐head studies would be helpful to further evaluate the differences observed in the MRI outcomes.     

Drug compliance of children and adolescents with epilepsy.

BACKGROUND: Compliance behavior depends on the specific clinical situation, the nature of the illness, and the treatment program. The aim of this study was to determine the rate of drug compliance in families caring for a child or adolescent with epilepsy and to describe some associated factors. METHODS: All the patients with epilepsy under 18 years of age who were attending the Motahary Clinic of Shiraz for a six-month period and their families were interviewed. RESULTS: The total number of participants was 181 patients. Drug compliance was satisfactory in 72.4% of the patients. Etiology of epilepsy, mono-therapy versus poly-therapy, duration of the disease, age of the patient, accompanying disease, parental smoking, parental education and living in urban versus rural areas did not significantly influence the drug compliance but maternal age was significantly higher in patients with poor compliance. Also, patients with positive family history of epilepsy had more noncompliance. Moreover, family size had a significant effect on drug compliance. Finally, patients using phenobarbital were more complaint than other patients. CONCLUSIONS: In this study, drug compliance was satisfactory in almost three-fourths of the patients with epilepsy. There was no significant association between noncompliance and the cause of epilepsy, duration of the disease, socio-economic status (parental smoking, living place, education) and number of drugs used to treat the illness. But paying attention to medication education for patients and parents, decreasing the complexity of the treatment regimen and younger possibly more motivated mothers in a small family, increased the drug compliance.     

A decrease in plasminogen activator inhibitor-1 activity after successful percutaneous transluminal coronary angioplasty is associated with a significantly reduced risk for coronary restenosis.

To determine a possible relation of changes in plasma levels of plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (t-PA) to the development of coronary restenosis after successful coronary angioplasty (PTCA), we followed 104 patients with a low grade residual stenosis after PTCA (less than 30%) for a period of 12 months. PAI-1 plasma levels (functional activity) and t-PA antigen were determined 1 day before PTCA and 3 days, 3 months and 6 months thereafter. Thirty-four patients (32.69%) developed angiographically proven coronary restenosis (group A) within a time range of 4-48 weeks (median 12.5 weeks) after PTCA while the remaining patients (group B) had neither clinical signs nor angiographic evidence of restenosis after 6 months. No significant differences could be demonstrated in t-PA antigen or PAI-1 activity (plasma levels between the two groups of patients the day before PTCA). During the whole observation period t-PA plasma levels were not significantly different between the two groups; however, PAI-1 plasma levels were significantly higher at 3 months and 6 months after PTCA in patients of group A (p less than 0.005). When the pattern of PAI-1 plasma levels over time (increase or decrease between two consecutive time points of blood collection) was used to discriminate between the two study groups only 3.5-18% of patients with a decrease in PAI-1 developed coronary restenosis within the following observation period in contrast to 25-58% of patients with an increase in PAI-1 plasma levels (p less than 0.05 to p less than 0.0005).     

Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit

OBJECTIVE: Aggression is common in children and adolescents admitted to psychiatric inpatient units. Few interventions for reducing aggressive behaviors have been identified. This study aimed to evaluate the impact of a milieu-based behavioral management program on the frequency of aggressive behaviors in a child and adolescent mental health inpatient unit. METHOD: The behavioral management program incorporated individualized patient management plans, early detection and prevention, staff training, reinforcement of appropriate behaviors, and intervention using the least restrictive option. Outcomes were assessed for 6 months before and after program introduction, and included episodes of aggressive behavior, injuries, use of physical restraint, seclusion, p.r.n. sedation, use of security services, and staffing factors. RESULTS: Implementation of behavioral management led to a significant reduction in the episodes of aggressive behavior (p < .05) and other unwanted outcomes including injuries (p < .05), use of physical restraint (p < .001), and duration of seclusion (p < .001). These outcomes were achieved without reducing the number of admissions, changing the types of patients admitted, increasing staff costs, or increasing the use of p.r.n. medications. CONCLUSIONS: Aggressive behaviors in child and adolescent psychiatric inpatient units can be reduced by implementing a broad-based behavioral management program. These findings highlight the importance of organizational approaches to behavior and risk management.     

自体骨髓间充质干细胞移植治疗脑出血32例：是否安全、可行及有效？

背景：大量动物实验证实骨髓间充质干细胞在适宜条件下能够定向分化为神经细胞,但目前其应用于临床治疗神经系统损伤性疾病的报道较少。 目的：观察自体骨髓间充质干细胞移植治疗脑出血的近期疗效。 方法：以2007-11/2009-01聊城市脑科医院神经外科收治的32例脑出血患者作为治疗组,根据患者一般状况及血肿量大小,分别行钻孔引流或开颅血肿清除,均留置血肿腔引流管,退至血肿腔边缘,通过引流管注射自体骨髓间充质干细胞悬液3.5 mL。选择同期入院但未行干细胞移植的40例患者作为对照组。分别于移植前和移植后6个月进行神经功能缺损程度评定(NIHSS评分)和日常生活活动能力评定(Barthel指数),行颅脑MRI、血生化指标、肿瘤标记物检查,监测干细胞移植的安全性。 结果与结论：移植前两组患者NIHSS评分及Barthel指数基本相似。与对照组比较,移植后6个月治疗组NIHSS评分显著降低(P < 0.01),Barthel指数显著升高(P < 0.01)。与移植前比较,治疗组在移植后6个月NIHSS评分显著降低(P < 0.01),Barthel指数显著升高(P < 0.01)。治疗组2例患者在移植后出现一过性发热,予对症处理后症状缓解。移植后6个月随访,除1例患者因肺癌导致肿瘤标记物CA-153升高外,颅脑MRI及血生化指标均未出现明显异常,说明自体骨髓间充质干细胞移植治疗脑出血是安全可行的,且在近期内疗效确定,远期疗效尚待进一步观察。