Pneumonitis after radiotherapy of bronchial carcinoma: incidence and influencing factors

The main purpose of the study was to describe the characteristics of homeless psychiatric patients, and to compare the treatment they are offered to that offered to domiciled patients by the psychiatric services. Another purpose was to analyse the prevalence of homelessness among psychiatric patients before and after the introduction of community mental health centres in Copenhagen. Cross-sectional studies were conducted in two intervention and two control districts before and after introduction of the new treatment modalities. In 1991, 80 of 1008 patients (8%) were homeless. Male sex, young age, living on general welfare, schizophrenia and alcohol or substance abuse were the factors that most markedly differentiated homeless from domiciled patients. Compared with the treatment of domiciled patients, the homeless were more likely to be offered no further treatment after consultation in a psychiatric emergency and, if admitted, they were more likely to be placed in locked wards, given compulsory medication, and medicated with depot neuroleptics. The homeless were also less likely to be offered psychotherapy and consultation with a social worker. Schizophrenia and alcohol or substance abuse characterised the majority of the patients discharged homeless. In the intervention districts, the number of homeless patients in contact with the psychiatric services was found to increase at the same rate as the number of all patients in contact with the psychiatric services. In the control districts, no changes in prevalence of homeless patients or other patients in contact with the psychiatric services occurred. It is concluded that homeless psychiatric patients comprise a difficult patient group, with problems of schizophrenia, substance abuse and lack of motivation for treatment. It is recommended that special efforts be made to create housing facilities that fit the needs of different types of homeless patients, and that the homeless mentally ill are assisted in obtaining and maintaining an acceptable housing situation.     

Utilization of mental health services by women in a male-dominated environment: the VA experience

OBJECTIVE: The study examined whether women in the Veterans Affairs system use mental health services at a lower rate than men because the system is geared to treat a mostly male population. METHODS: Data were obtained on a national cohort of patients utilizing specialty mental health services in the VA during a two-week period in fiscal year 1991 (N = 70,979). Analyses included comparison of the proportion of women among treated veterans with the age-adjusted proportion of women among all veterans, comparison across gender of the likelihood of use of any general psychiatric services or substance abuse care in 1991, comparison of the intensity of services used (inpatient days and outpatient contacts) by service users in 1991, and comparison of the likelihood of receiving care and the intensity of mental health services received two years later. RESULTS: Overall, 3.95 percent of veterans who used VA mental health specialty services were women; 4.02 percent of all veterans were women. No significant differences between genders were found in use of general psychiatric services, either in the likelihood of any use or the intensity of services used. However, women were significantly less likely to receive substance abuse care (16.3 percent of women versus 71.2 percent of men); once receiving care, they used a similar intensity of substance abuse services. CONCLUSIONS: Being a woman does not appear to have a substantial effect on overall access to VA mental health services or use of general psychiatric services; however, women use VA substance abuse treatment services at a lower rate than men.     

Homeless youths and young adults in Los Angeles: prevalence of mental health problems and the relationship between mental health and substance abuse disorders

Although understanding of the subsistence patterns, service utilization, and HIV-risk behaviors of homeless youths and young adults in increasing, relatively little is known about the epidemiology of mental health problems in this group or the relationships between mental health problems and substance use. This study measured symptoms of depression, low self-esteem, ADHD, suicidality, self-injurious behavior (SIB), and drug and alcohol use disorder in a sample of homeless youth and young adults living in Hollywood, CA. Results indicated extremely high prevalences of mental health problems as compared with corresponding rates of mental health problems found among housed youths in previous studies. Prevalence of mental health problems differed by age and ethnicity. African Americans were at lower risk of suicidal thoughts and SIB than were those of other ethnicities. Older respondents and females were at increased risk of depressive symptoms, and younger respondents were at increased risk of SIB. Previous history of sexual abuse and/or assault was associated with increased risk of suicidality and SIB. Risk factors for drug abuse disorders included ethnicity other than African American, homelessness for 1 year or more, suicidality, SIB, depressive symptoms, and low self-esteem. Risk factors for alcohol abuse disorder included male gender, white ethnicity, homelessness for 1 year or more, suicidality, and SIB. Extremely high rates of mental health problems and substance abuse disorders in this sample suggest the need for street-based and nontraditional mental health services targeted toward these youths and young adults.     

Comparability and representativeness of clinical homeless, community homeless, and domiciled clinic samples: Physical and mental health, substance use, and health services utilization.

Evaluating the representativeness of homeless samples is important for generalizing research findings on the homeless and designing interventions targeting their health needs. The present study contrasts homeless and domiciled free-clinic users (216 homeless [132 men, 84 women], 212 domiciled [102 men, 110 women]) and 531 community homeless persons (388 men, 143 women) on latent variables representing substance use, mental and physical health, appearance, life satisfaction, and health services utilization (HSU). Homeless clinic patients equalled the community sample in substance abuse and psychological problems but exceeded the sample in HSU and cleanliness. Homeless clinic users reported more substance abuse, poorer health, greater mental illness and mental HSU, less cleanliness, and lower life satisfaction than domiciled patients. Relationships among the variables are reported, and implications concerning health needs among the homeless are discussed (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health practices and indices of a poor urban population in Indonesia. Part I: Patterns of health service utilization

This first section in a two-part study of health indices and practices among residents living in a Jakarta slum describes the use of public and private primary health care services in relation to socioeconomic and health status. As problems associated with urban poverty rapidly increase in developing countries, it is important to study the ethnic and economic diversity which exists in slums and shanty towns: results of such studies should inform the development of effective strategies for outreach and service delivery. Through a survey of 690 mothers and 593 children, we found that 1) poorer residents were more likely than relatively affluent ones to rely on local government clinics (posyandus) for primary health care; 2) regular posyandu users were more likely than non-users to be fully immunized and to use ORT correctly; 3) delivery in hospital was common among all residents, but especially among the more affluent; and 4) prevalence of contraception was high and not associated with socioeconomic status or type of primary health care service used. Strengthening primary health care services at the government's local health posts could benefit all groups in the community if wealthier residents participated more in the posyandus. Standards of care in the private sector should also be improved.     

Sexual relations in a cold-weather shelter for homeless people

This study was carried out in a cold-weather shelter targeting young people sleeping rough in London. A homeless community mental health team added screening questions to assess sexual and relationship problems. Semistructured interviews were carried out in the shelter with residents not referred to the homeless mental health team. Shelter staff were consulted about their experience of residents' sexual and relationship problems as well as their relationship to substance use.     

Dynamic Recovery: comparative study of therapeutic communities in homeless shelters for men

The Dynamic Recovery Project examined relationships between homelessness, substance abuse, and recovery, and investigated the effectiveness of the therapeutic community (TC) treatment model in helping homeless drug users move toward stable, drug-free living. This project compared two short-term TCs that were situated within pre-existing homeless shelters with a clean and sober dormitory. In a separate condition, peer counselors and staff were provided additional training in TC philosophy and practice to reduce program dropout. Dramatic decreases in drug and alcohol use at follow-up were verified by urinalysis. Length of time in treatment rather than specific program accounted for decreased alcohol and drug use. Important decreases in posttreatment criminality for both treatment programs were documented. The comparison group, starting with low criminality, experienced smaller, nonsignificant decreases unrelated to type of program or time in treatment. Major declines in Beck Depression Scores were evident, but were unrelated to groups or time in treatment. Training had no measurable impact on client retention or outcomes and there were no significant differences between TCs and the comparison group on posttreatment drug use, criminality, or depression. This report documents that short-term therapeutic communities can be successfully implemented in public shelters for homeless men.     

Mental illness and substance use among sheltered homeless persons in lower-density population areas

OBJECTIVE: The prevalence of mental illness and substance abuse in homeless populations has been studied primarily in large urban areas. This study examines a sheltered homeless population in two counties of lower-density population, Dauphin and Cumberland counties in central Pennsylvania, to assess the prevalence of mental illness and substance abuse. METHODS: A total of 81 homeless adults from nine emergency shelters were interviewed using a structured questionnaire. RESULTS: The estimated lifetime prevalence rate of major depressive disorder was 26.6 percent; 6.4 percent of the sample showed evidence of psychotic thinking. Almost one-third reported previous hospitalization for emotional problems, and about one-third reported a suicide attempt. The estimated lifetime prevalence rate of alcohol or drug abuse or dependence was almost 60 percent. CONCLUSIONS: Although mental illness, especially psychosis, and substance abuse may be somewhat less prevalent among homeless persons in lower-density population areas than in large urban areas, they are nevertheless significant problems.     

Eighteen-month follow-up data on a treatment program for homeless substance abusing mothers

In response to the dearth of data on substance abuse treatment among homeless mothers, this study breaks new ground in presenting 18-month follow-up data on 149 homeless mothers with young children enlisted in a substance abuse treatment program. The effects of residential compared to nonresidential services were evaluated over the follow-up period. Although dropout rates were high, predictors of dropout were identified, and the residential had a lower dropout rate compared to the nonresidential comparison group. Members of both residential and nonresidential groups evidenced improvement in alcohol and drug problems and in housing stability, regardless of the amount of time they spent in the program. This project demonstrated that homeless mothers can be more successfully engaged in substance abuse programs with provisions of residential placement in addition to participation in a therapeutic community. Future interventions can take advantage of this knowledge in designing more effective programs.     

The relationship of public support payments to substance abuse among homeless veterans with mental illness

OBJECTIVE: A suspicion that disability payments may exacerbate substance use among persons with chemical addictions recently led Congress to limit federal disability entitlements of applicants whose disability status is related to substance abuse, even if they have another serious mental disorder. This study empirically explored the relationship between receipt of disability payments and substance use among homeless mentally ill veterans. METHODS: The study sample included 2,474 homeless veterans with a current diagnosis of schizophrenia and a substance abuse or dependence disorder who were assessed in a community outreach program sponsored by the Department of Veterans Affairs. RESULTS: After adjustment for other relevant factors, receipt of disability payments showed no significant relationship to the number of days of substance use a month, even among frequent users of alcohol and drugs. CONCLUSIONS: Findings about substance use among the homeless veterans with serious mental disorders in this study provide no support for the assertion that disability payments exacerbate substance use.     

Utilization of on-site primary care services by HIV-seropositive and seronegative drug users in a methadone maintenance program

The feasibility of on-site primary care services and their use by human immunodeficiency virus HIV-seropositive and seronegative injecting drug users within an outpatient methadone maintenance program are examined. A 16-month prospective study was conducted within an ongoing cohort study of HIV infection at a New York City methadone program with on-site primary care services. The study group consisted of 212 seropositive and 264 seronegative drug injectors. A computerized medical encounter data base, with frequencies of primary care visits and with diagnoses for each visit, was linked to the cohort study data base that contained information on patients' demographic characteristics, serologic status, and CD4+ T-lymphocyte counts. Eighty-one percent of the drug injectors in the study voluntarily used on-site primary care services in the methadone program. Those who were HIV-seropositive made more frequent visits than those who were seronegative (mean annual visits 8.6 versus 4.1, P < .001), which increased with declining CD4+ T-lymphocyte counts; 79 percent of those who were seropositive with CD4 counts of less than 200 cells per cubic millimeter received on-site zidovudine therapy or prophylaxis against Pneumocystis carinii pneumonia, or both. Common primary care diagnoses for patients seropositive for HIV included not only conditions specific to the human immunodeficiency virus but also bacterial pneumonia, tuberculosis, genitourinary infections, asthma, dermatologic disease, psychiatric illness, and complications of substance abuse; those who were seronegative were most frequently seen for upper respiratory infection, psychiatric illness, complications of substance abuse, musculoskeletal disease, hypertension, asthma, and diabetes mellitus. Vaginitis and cervicitis,other gynecologic diseases, and pregnancy were frequent primary care diagnoses among both seropositive and seronegative women.     

Determinants of regular source of care among homeless adults in Los Angeles

OBJECTIVES: The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In addition to those factors found to be barriers to regular sources of care in the general population, we hypothesized that psychosocial characteristics of the homeless and the homeless lifestyle would negatively impact their likelihood of having a regular source of care. METHODS: The authors conducted a multiple logistic regression to predict regular source of care among the homeless, using an adaptation of the Behavioral Model of health services utilization as an analytic framework. RESULTS: Fifty-seven percent of the sample reported that they had a regular source of care. Of those with a source of care, 30% reported a hospital outpatient department; 25% reported a community or homeless clinic; 23% reported a hospital emergency room; 14% reported a government clinic; and 9% reported a private physician's office as their source of care. Some factors found to be barriers to having a regular source of care in the general population (male, Hispanic, young age) also were barriers among homeless adults. Additional barriers in this sample included homelessness-related characteristics such as competing needs, long-term homelessness, and social isolation. Chronic mental illness and chronic substance dependence were not related to having a source of care among the homeless. Characteristics that increased the likelihood of having a regular source of care in the general population (poor health status, Medicaid) were not related to having a regular source of care among the homeless. CONCLUSIONS: In a context of limited resources, the distribution of regular source of care among the homeless appears to be highly inequitable. Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.     

Use of a screening instrument in women's health care: detecting relationships among victimization history, psychological distress, and medical complaints

The interactive relationship between psychological distress and physical health is a particularly salient one for women. Routine screening for abuse history and current psychological disturbance is essential in providing comprehensive patient care. The present study examines the utility of a brief screening measure in detecting psychological factors in female patients at a primary care facility. Sixty-nine percent of 108 women screened at a women's health clinic reported a history of trauma and almost half (49%) reported having been sexually harassed. Women presenting to treatment for gynecological problems were more likely to be victims of sexual assault and were more likely to report a history of childhood sexual abuse. In addition, women seeking specialized health care also reported increased rates of stress. Relationships among victimization histories, substance use, and eating disturbances were also found. These data suggest the importance of assessing psychological disturbances and trauma histories as part of a comprehensive medical evaluation.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

Personal, medical, and healthcare utilization among homeless veterans served by metropolitan and nonmetropolitan veteran facilities.

This study assessed differences in personal, medical, and health care utilization characteristics of homeless veterans living in metropolitan versus nonmetropolitan environments. Data were obtained from a Veterans Health Administration (VHA) network sample of homeless veterans. Chi-square tests were used to assess differences in demographics, military history, living situation, medical history, employment status, and health care utilization. Moderator analyses determined whether predictors of health care utilization varied by metropolitan status. Of 3,595 respondents, 60% were residing in metropolitan areas. Age, sex, and marital status were similar between metropolitan and nonmetropolitan homeless. Metropolitan homeless were less likely to receive public financial support or to be employed, to have at least one medical problem, one psychiatric problem, or current alcohol dependency, but more likely to be homeless longer. Of the 52% of the sample who used VHA care in the last 6 months, 53% were metropolitan versus 49% nonmetropolitan (p = .01). Metropolitan status predicted at least one VHA visit within the prior 6 months (OR:1.3, CI:1.1, 1.6). Significant differences occur in the personal, medical, and health care utilization characteristics of homeless veterans in metropolitan versus nonmetropolitan areas. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Frank J. Sullivan: Award for Distinguished Professional Contributions to Public Service.

Announces Frank J. Sullivan as the recipient of the Award for Distinguished Professional Contributions to Public Service for 2002. A biographical statement is included, along with major works and contributions for the field. Sullivan received this award for a variety of contributions to public service, including responding to the needs of people with severe mental illness, AIDS, and dual diagnoses; bridging chasms between agencies; increasing the number of minority researchers; pulling people and policies together in polarized areas of animal welfare and mental health vs substance abuse; rationalizing mental health research and service systems; funding national services; creating services for neglected populations of children, depressed women on Medicaid, and the homeless; and contributing to the implementation of the Surgeon General's report on mental health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of psychosocial and situational variables on substance abuse among homeless adults.

Finding direct and indirect influences of salient psychosocial and situational variables on problem substance use among homeless people is important in designing evidence-based, effective, and relevant interventions for this special population. A stress-coping paradigm in conjunction with situational items specialized for homeless people was used to explore predictive relationships in a sample of homeless adults (N = 664) among (a) psychosocial variables of self-esteem, social support, positive and negative coping, and emotional distress, (b) situational variables of homelessness history and quality of recent housing, and (c) outcomes of alcohol use, injection drug use (IDU), and non-IDU. Lower self-esteem predicted greater emotional distress, lower positive coping, greater negative coping, and more alcohol use. Social support predicted less emotional distress and more positive coping. Chronic homelessness predicted more emotional distress, less positive coping, greater alcohol use, and IDU. Poor housing was associated with more alcohol use and IDU. Substance abuse interventions among the homeless should have a dual focus that includes attention to psychological issues and negative coping patterns while also addressing situational, environmental factors, including encouraging provision of permanent supportive housing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Obstacles for rural American Indians seeking alcohol, drug, or mental health treatment.

The purpose of this study was to identify factors associated with 4 clusters of obstacles (self-reliance, privacy issues, quality of care, and communication and trust) to mental health and substance abuse treatment in 3 treatment sectors for residents of 3 reservations in the United States. Participants (N = 3,084) disclosed whether they had sought treatment for emotional, drug, or alcohol problems in the past year and, if so, whether they had faced obstacles in obtaining care from Indian Health Services, tribal services, and other public or private systems. Correlates of these obstacles included negative social support, instrumental social support, utility of counselors, utility of family doctors, treatment sector, treatment type, diagnosis of an anxiety disorder, and tribe. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

Children of substance abusers: the life experiences of children of opiate addicts in methadone maintenance

We interviewed 70 substance abusers in methadone maintenance treatment regarding the life experiences of their 188 children. Sixty-four percent of the mothers reported using psychoactive drugs during their pregnancies. Eighty percent of parents reported an arrest during the time the child was growing up, 34% reported receiving treatment for an emotional disorder, and 14% were hospitalized. Four percent of the parents reported that their children had been placed in adoptive care, 9% in foster care, and 1% had a child in a group home. Forty-one percent of the parents reported that at least one of their children repeated a grade in school, 19% were involved in truancy, and 30% had been suspended from school. Twenty percent of parents reported their children's involvement with the law, and 17% reported drug or alcohol use. Problems with the law correlated highly with 1) being held back a grade, 2) truancy, 3) suspension from school, 4) expulsion from school, and 5) treatment for alcohol or drug abuse.