Predictive factors for outcome of treatment for alcohol problems

Two samples of problem drinkers were followed up 2 and 4 years after they completed treatment. The first consisted of 72 men and 16 women admitted to a program for alcoholics (the inpatient sample), and the second, of 57 men and 35 women who participated in a program of outpatient treatment (the outpatient sample). At start of treatment, the outpatient sample, was generally characterized by a higher degree of social integration and more moderate alcohol problems than those found in the inpatient sample. These differences were sustained during the part of the follow-up period for which comparative data existed. In both samples it was possible to identify subgroups whose alcohol consumption throughout the observation period did not exceed average consumption in a comparative group of the Norwegian population. The most important predictive factors for alcohol consumption in the inpatient sample were degree of social integration, consumption before start of treatment, and sex. In the outpatient sample the most important factors were level of consumption and relative contribution of heavy drinking to the drinking pattern before start of treatment and the client's own goals as regards to alcohol. In both samples there was a close connection between alcohol consumed, total situation, and individual degree of satisfaction. For both groups, less frequent drinking and reduction of heavy drinking were most important for feeling satisfied with the drinking outcome. The therapeutic implications of the qualitative changes in drinking patterns are discussed.     

Splenic rupture after colonoscopy

Over a 12 month period, we prospectively evaluated the use of an ambulatory infusion pump for intra-arterial and intravenous chemotherapy in patients with colorectal liver metastases. In all, 274 separate infusions were given with minor complications occurring on six occasions. Administering treatment on an outpatient basis rather than as an inpatient has resulted in savings of over Pounds 17000 in the first year.     

Effectiveness of and Consumer Satisfaction With an Assertive Community Treatment Program for the Severely Mentally Ill: A 3-Year Follow-Up.

Assertive community treatment (ACT) programs have made substantial strides in reducing inpatient hospitalizations and in improving the lives of individuals with a severe mental illness. However, few studies have investigated their effectiveness outside of a 24-month treatment period. The present study investigated treatment outcomes in an ACT program over a 36-month period. Results indicate that participants experienced a statistically significant reduction in hospital bed days during the first 2 years of treatment. Positive outcomes were demonstrated on other variables, including an increase in compliance with outpatient psychiatric appointments and a reduction in emergency outpatient contacts. Results indicate that clients and family members were satisfied overall with ACT services, but family members reported greater satisfaction than clients in all areas assessed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of multidisciplinary team care programs in rheumatoid arthritis

OBJECTIVE: To assess the efficacy of multidisciplinary team care programs in rheumatoid arthritis (RA). METHODS: Data were obtained by a Medline and a manual search of the literature through January 1997. Both the design and analysis aspects of controlled trials were evaluated. RESULTS: Forty-two papers reporting on 35 clinical trials of multidisciplinary team care were initially identified. Fifteen trials had a controlled design, nine of which were randomized. Patient characteristics, interventions, end point measures, and presentation of the data varied widely among the controlled studies. In 12 trials, inpatient (n = 6) or outpatient (n = 6) multidisciplinary programs were compared with regular outpatient care. Inpatient programs (average duration, 10 to 28 days) had a direct favorable effect on disease activity, lasting up to 1 year. The effect of outpatient programs (average duration, 1 to 2 years) was less marked, with greater improvement of functional status at the end of the treatment program shown in one study. In three trials, inpatient multidisciplinary programs were compared with similar outpatient programs. One study showed that inpatient care was more effective, whereas in two studies similar results were obtained in both groups. CONCLUSION: Favorable effects on disease activity were seen in most trials comparing short inpatient team care with regular outpatient care. Proof of efficacy of prolonged outpatient team care is scanty. Results of trials comparing inpatient with outpatient team care remain inconclusive.     

Cost effectiveness of alcoholism treatment in partial hospital versus inpatient settings after brief inpatient treatment: 12-month outcomes.

174 alcoholics (mean age 41.37 yrs) were randomly assigned to partial hospital treatment (PHT) or extended inpatient (EIP) rehabilitation after inpatient evaluation and/or detoxification. 12-mo follow-up results for the 115 Ss who consented to continue in the study show few differences in clinical outcomes between the PHT and EIP groups. Both reported more than 80% abstinent days during follow-up, and over 70% had a full-time occupational role, although almost a third experienced job losses during the year. Ss showed significant improvements in psychological well-being and social behavior. One-third were rehospitalized during the follow-up year. Costs for the PHT group were significantly lower than the EIP group, leading to an overall conclusion that PHT provides a cost-effective alternative to EIP treatment for many alcoholics. Implications for health care planning are addressed. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Determinants of chemical dependency treatment placement: Clinical, economic, and logistic factors.

Studied 319 adult alcoholics with or without concurrent drug use disorders to determine the relative efficacy of inpatient, outpatient, and inpatient-to-outpatient treatment and to identify patient characteristics associated with differential outcome by treatment type. Successful 6-mo follow-up of 73% of the Ss revealed a 67% abstinence rate, with no significant differences by treatment setting. The routine use of standardized instruments and procedures for diagnosis and assessment is recommended, along with changes in service delivery systems and insurance coverage, as steps toward optimal treatment placement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed behavioral health services for children under carve-out contracts

OBJECTIVE: Service costs and utilization patterns of children in carved-out behavioral health care plans were examined and compared with those of adults. METHODS: Twelve-month data on utilization and costs of behavioral health care from one managed behavioral health care carve-out organization, United Behavioral Health, were examined for three age groups of children--birth to five years, six to 12 years, and 13 to 17 years-and for adults. More than 600,000 enrollees in 108 different plans were included in the data. Rates of use and intensity of use were examined separately by type of service-inpatient, outpatient, and partial hospitalization. RESULTS: Only a small number of all enrollees used any behavioral health care services--4.2 percent used outpatient services, .3 percent used inpatient services, and .2 percent used partial hospitalization services. Adolescents were more than twice as likely as adults and about seven times as likely as children aged 6 to 12 to use inpatient services. Adolescents also had a slightly higher probability of using outpatient care than adults, while younger children had lower rates of outpatient use than adolescents or adults. Adolescents were also more likely than adults and other children to have very high costs of inpatient care (mean costs=$8,975 for adolescents and $4,750 for adults). Adults were more likely than other groups to have higher outpatient costs ($640 for adults and $513 for all children). CONCLUSIONS: The finding that children, and adolescents in particular, are more likely to have very high inpatient costs compared with adults implies that they may benefit most from the elimination of caps on mental health care costs covered by insurance. This profile of children's behavioral health care utilization patterns can be useful to policy makers in considering expansions in children's health insurance coverage.     

Costs and use of mental health services before and after managed care

This paper tracks access, utilization, and costs of mental health care for a private employer over nine years during which mental health benefits were carved out of the medical plan and managed care was introduced. Prior to the carve-out, mental health costs increased by around 30 percent annually; in the first year after the change, costs dropped by more than 40 percent; in the six follow-up years, costs continued to decline slowly. This cost reduction was not attributable to decreased initial access, as the number of persons using any mental health care increased following the change. Instead, the cost reduction was the result of (1) fewer outpatient sessions per user, (2) reduced probability of an inpatient admission, (3) reduced length-of-stay for an inpatient episode, and (4) substantially lower costs per unit of service.     

Personality disorders predict relapse in alcoholic patients

This prospective study examines the association of DSM-III-R Axis II comorbidity with (time to) relapse since the end of treatment in a sample of 105 outpatient and 82 inpatient alcoholics. Furthermore, this study addresses the role of motivation for change, time in program, and working alliance in the mechanism underlying the association between Axis II and relapse. We found that Axis II comorbidity in alcoholics is a robust predictor of relapse following treatment, while the effect is strongest in outpatients with low motivation for change and/or short time in program. Motivation for change and time in program did not mediate the association of Axis II with relapse. We also found poor working alliance to be related to personality pathology among inpatients, and from our findings it can be hypothesised that poor working alliance is part of the mechanism underlying the observed impact of Axis II on treatment outcome in outpatients. A preliminary model of the role of personality pathology in the mechanism of relapse is proposed.     

Pretest expectancies and cognitive impairment in alcoholics.

Alcoholics' neurological deficits have been attributed to cognitive impairment associated with brain dysfunction. Because alcoholics perceive themselves as impaired in higher cognitive functions, we investigated the alternative hypothesis that their deficits are predicted by lowered expectancies for successful performance. Ss were 48 male, middle-aged Veterans Administration inpatient alcoholics and 36 community controls. Subjects completed a standard series of neuropsychological tests. Before taking each test, Ss were asked how well they expected to do on that test in relation to members of their community. As predicted, means for the overall measures of expectancies and perfomance were significantly lower for alcoholics than for control Ss. Although expectancies were significantly correlated with performance, regression analyses indicated they could not account for the obtained performance differences. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of health services by children and young people according to ethnicity and social class: secondary analysis of a national survey

OBJECTIVE: To assess whether equity is achieved in use of general practitioner, outpatient, and inpatient services by children and young people according to their ethnic group and socioeconomic background. DESIGN: Secondary analysis of the British general household survey, 1991-94. SUBJECTS: 20 473 children and young people aged between 0 and 19 years. MAIN OUTCOME MEASURES: Consultations with a general practitioner within a two week period, outpatient attendances within a three month period, and inpatient stays during the past year. RESULTS: There were no significant class differences in the use of health services by children and young people, and there was little evidence of variation in use of health services according to housing tenure and parental work status. South Asian children and young people used general practitioner services more than any other ethnic group after controlling for socioeconomic background and perceived health status, but the use of hospital outpatient and inpatient services was significantly lower for children and young people from all minority ethnic groups compared with the white population. CONCLUSIONS: Our results differ from previous studies, which have reported significant class differences in use of health services for other age groups. We found no evidence that children and young people's use of health services varied according to their socioeconomic status, suggesting that equity has been achieved. A child or young person's ethnic origin, however, was clearly associated with use of general practitioner and hospital services, which could imply that children and young people from minority ethnic groups receive a poorer quality of health care than other children and young people.     

Normal and psychopathological personality characteristics of individuals in alcohol rehabilitation.

Relations between normal and psychopathological personality characteristics were investigated in 72 inpatient male alcoholics, who were administered the Personal Styles Inventory (PSI) and the Minnesota Multiphasic Personality Inventory (MMPI). Results support the PSI circumplex model for normal personality traits. All PSI scales correlated significantly with one or more MMPI scales, including the basic MMPI orthogonal factors Anxiety (r?=?.55) and Repression (r?=?-.47), showing a relation between normal and pathological personality attributes. The mean MMPI profiles for subjects categorized by normal (PSI) personality traits corresponded significantly to basic MMPI profile types identified in previous research. Implications for counseling alcoholics and developing treatment programs using information from a broader based personality assessment approach are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy and psychoanalysis in patient management: results of the Heidelberg Catamnesis Project

In the "Heidelberg Long Term Psychotherapy Follow-up Project", a naturalistic study design, all types of treatment were included that had been performed at the Psychosomatic Clinic of the University of Heidelberg for a certain period (combined inpatient and outpatient individual and group therapy, as well as outpatient dynamic psychotherapies and psychoanalyses). The specific value of this project is due to the fact that--apart from many other, for instance psychological, assessment evaluations--three to five individual therapy goals had been predetermined for each patient before starting the treatment (goal attainment scaling). After the end of therapy and at the time of follow-up (3.5 years later on the average), attainment of these goals was assessed by an independent rater. A total of 208 patients were examined who were evaluated according to their diagnosis (neurotic, functional or psychosomatic disorders) and the kind of treatment. With regard to symptomatology, individual therapy goals, psychological assessment and patient satisfaction, the overall results were good, partly very good, and were almost invariably stable during the long follow-up period. Two particular results are discussed separately: 1. As far as symptomatology was concerned, the group of psychoanalysis patients could not maintain the good outcome at the end of therapy during the long follow-up period. 2. Patients with "psychosomatic disorders" attained remarkably good results, particularly if the treatment had initially been an inpatient setting.     

Partner violence before and after individually based alcoholism treatment for male alcoholic patients.

This study examined partner violence in the year before and the year after individually based, outpatient alcoholism treatment for 301 married or cohabiting male alcoholic patients and used a demographically matched nonalcoholic comparison sample. In the year before treatment, 56% of the alcoholic patients had been violent toward their female partner, 4 times the rate of 14% in the comparison sample. In the year after treatment, violence decreased significantly to 25% of the alcoholic sample but remained higher than in the comparison group. Among remitted alcoholics after treatment, violence prevalence of 15% was nearly identical to the comparison sample and half the rate among relapsed patients (32%). Thus, partner violence decreased after alcoholism treatment, and clinically significant violence reductions occurred for patients whose alcoholism was remitted after treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Increasing treatment adherence among outpatients with depression and cocaine dependence: results of a pilot study

OBJECTIVE: This pilot study examined the effect of a modified motivational therapy intervention on outpatient treatment adherence and completion for patients with comorbid depressive disorder and cocaine dependence. METHOD: Depressed cocaine patients, stabilized with antidepressant medications on an inpatient psychiatric unit, were consecutively assigned on discharge to motivational therapy (N = 11) or treatment-as-usual (N = 12) during the first month of outpatient care. Patients were compared on treatment adherence and completion and on 1-year rehospitalization rates. RESULTS: Motivational therapy patients attended significantly more treatment sessions during month 1, completed 30 and 90 days of outpatient care at higher rates, and experienced fewer psychiatric rehospitalizations and days in the hospital during the first year from entry into outpatient treatment. CONCLUSIONS: An outpatient program combining individual and group motivational therapy sessions holds promise for improving treatment adherence and completion among depressed patients with cocaine dependence.     

Coping and the decision to hospitalize in emergency psychiatry

This study was done to clarify whether and in what way a patient's coping repertoire can be linked to the disposition decision in a psychiatric emergency service. For 1 year, all consultations (N = 1439) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the disposition decision. Depending on disposition, three groups were identified: outpatients (N = 530), inpatients (N = 481), and a nonintervention group (N = 428). In addition, over a 5-month period, patients were requested to fill in the "Bernese Coping Modes" questionnaire. Thus, a sample of 28 patients undergoing outpatient crisis intervention and 28 patients referred to inpatient treatment was obtained. Statistical analysis included Chi square-test, t-test, Mann-Whitney U-test, and logistic regression analysis. Assessment of coping repertoire contributed more than the diagnosis to the decision to hospitalize. Outpatients have a larger coping repertoire (t = 3.48, p = 0.001) than inpatients and show higher values in "acceptance-stoicism," "dissimulation," "tackling," "giving meaning," "altruism," "optimism," and "relativizing." Logistic regression revealed relativizing, altruism, and optimism as being most important. Self-referral to emergency psychiatry was also correlated with outpatient treatment. Other criteria such as being without work, living alone, history of previous hospitalization, and the diagnosis of a psychotic or mood disorder were significantly correlated with referral to inpatient treatment. More attention should be paid to patients' coping repertoires in emergency services when deciding about the need for inpatient treatment.     

Factors affecting engagement of dual diagnosis patients in outpatient treatment

This study examined factors associated with engagement in outpatient treatment of patients with dual diagnoses of psychiatric disorder and substance use disorder. The charts of all 57 patients referred to a dual diagnosis treatment program during a six-month period were reviewed, and data on patients' substance use diagnosis, psychiatric diagnosis, sex, ethnicity, and referral source were collected. Patients referred from inpatient treatment were more likely to attend three or more appointments at the dual diagnosis program than those referred from outpatient treatment. Substance of abuse interacted with both referral source and sex in predicting engagement.     

A comparison of inpatient and outpatient women with eating disorders

The purpose of this study was to compare two groups of women with eating disorders, one inpatient and one outpatient, on selected variables. The study was undertaken to clarify differences in the two samples about (1) current standards/criteria for hospitalization of individuals with eating disorders, (2) the criteria for inpatient/outpatient treatment selection, and (3) definition of severity of illness. Six hypotheses were developed and tested by using t-test, chi(2), and discriminant function analysis. The findings supported the current standards for practice. Compared with the outpatient group the inpatient group had significantly more reported physical signs and symptoms, were more anxious and depressed, had more somatization, and had more prior hospitalizations. Prior hospitalization and physical signs, along with the eating disorder dimension, ineffectiveness, were the best predictors of hospitalization. Implications for practice that focus on more comprehensive assessments and early detection of eating disorders are presented.     

Patient-treatment matching improves compliance of alcoholics in outpatient treatment

In chronic medical disorders, patient compliance is very poor and often less than 50%. The purpose of this investigation was to determine whether the proper matching of patient, treatment, and therapist would improve patient compliance in the outpatient treatment of alcoholics. We randomly placed 119 alcoholics who had commenced protracted outpatient treatment for alcoholism in either low or high structured treatments. These 119 patients were offered 12 months of individual treatment. Interruption of this treatment was recorded as noncompliance. The treatment courses were expressed in survival curves. The consequence of compliance for long-term prognosis was described by means of the Addiction Severity Index. The form of treatment in itself had no importance for compliance. However, correct matching of a patient and a treatment structure resulted in a compliance rate of 63% as opposed to 38% compliance among mismatched patients. Twenty-four months after the initiation of treatment, patients in the compliance group had a significantly higher level of function than those in the noncompliance group. Our investigation of alcoholics involved in outpatient treatment shows that the correct matching of patients and treatment structure improves compliance and long-term prognosis. It is hoped that the present investigation will generate interest in future research on correct matching to gain improved compliance in patients with a chronic medical disorder.     

Predicting Outpatient Mental Health Program Withdrawal Among Recently Discharged Inpatients With Schizophrenia.

Recently discharged inpatients with schizophrenia are vulnerable for hospital readmission when they prematurely self-terminate outpatient interventions (J. S. Brekke, M. Ansel, J. Long, E. Slade, & M. Weinstein, 1999). This study explored risk factors for community care nonadherence and the effectiveness of various inpatient practices in maintaining continuous post-discharge service use among 264 individuals with schizophrenia or schizoaffective disorder. In addition to previously established risk factors for outpatient care nonadherence, such as service dissatisfaction and medication noncompliance, results suggest that at-risk individuals are also more likely to have an arrest history and that inpatient substance abuse treatment can help prevent community mental health program withdrawal. Policy, practice, and research implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)