Effectiveness and cost of specific treatment elements in a program for homeless mentally ill veterans

OBJECTIVES: The study examined relationships between specific treatment elements and their costs and ten outcome measures using data from a longitudinal outcome study of a Veterans Affairs program for homeless mentally ill veterans. METHODS: Baseline and outcome data over an eight-month period were analyzed for 406 homeless veterans with psychiatric and substance use disorders who were treated in VA's Homeless Chronically Mentally Ill Veterans Program. Multivariate techniques were used to examine the relationship between ten measures of outcome and six treatment elements: program entry via community outreach, the number of contacts with program clinicians, the number of referrals for other services, duration of program involvement, number of days of residential treatment, and increased public support payments. RESULTS: Each of the six treatment elements was significantly related to improvement on at least one of the ten outcome measures. The number of clinical contacts with program staff and the number of days in residential treatment were associated with improvement in the greatest number of outcome domains. However, improvement associated with residential treatment was far more costly than improvement related to other treatment elements. CONCLUSION: This study provides evidence of the effectiveness of a multimodal approach to the treatment of homeless mentally ill persons. However, results indicate that special attention should be paid to to differences in the cost of improvement associated with various treatment elements.     

Effects of increased social support and lifestyle behaviors in a domiciliary for homeless veterans.

For improvement of the psychosocial rehabilitation environment of a homeless Domiciliary Residential Rehabilitation and Treatment Program (DOM-RRTP), increases in lifestyle behaviors (e.g., recreation, social, spiritual/coping, and educational) and altruistic activities (e.g., helping others on the unit or in the community) were targeted. With the use of contingency management in a quasi-experimental design, homeless residents were encouraged to engage in higher rates of desired behaviors. The treatment environment was reported by 66 veterans during a baseline analyses and 35 after the contingency management program was implemented. After the implementation of the contingency management program, a significant increase in healthy lifestyle and altruistic behaviors was observed. Furthermore, comparing patients' perceptions pre- and postimplementation showed significant improvement in the psychosocial rehabilitation environment in both expected areas (e.g., supportiveness) and unexpected areas (e.g., anger and aggression, program clarity). Overall, the study revealed improvements in the number of healthy lifestyle behaviors, and altruistic activities covaried with improvement in the overall rehabilitation environment. Limitations and implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Kinematic analysis of limb movements in neuropsychological research: Subtle deficits and recovery of function.

Argues that an analysis of spatial and temporal characteristics of visually guided limb movements can provide insights into the nature of neuropsychological deficits and the functional organization of the brain. Kinematic analysis of limb movements in both normal Ss and neurological patients can reveal differences in the contribution of the left and right hemispheres to the control of simple visually guided aiming tasks. Examples show how such analysis can be used to address the question of recovery of function in patients with manual apraxia and hemispatial neglect. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of psychosocial characteristics in premature discharge from residential services for homeless veterans.

Residential programs can improve the lives of homeless individuals, but many participants leave prematurely. Certain characteristics evident upon admission may help to identify those at greatest risk of early discharge. The records of 197 unique admissions to a homeless veterans program were reviewed. Subjects completed a psychosocial assessment, a diagnostic interview, and depression and alcohol use severity screenings. Alcohol use severity, days of abstinence, and an antisocial behavior disorder were significant independent predictors of type of discharge. The overall model accounted for 14.5% of the variance in type of discharge. Targeted interventions may be needed to help veterans at risk of premature discharge to remain engaged in treatment and to assist them in the transition back to the community. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exiting homelessness without a voucher: A comparison of independently housed and other homeless veterans.

Studies that have shown the superiority of housing voucher programs over standard care for homeless adults with mental illness have also incidentally shown that many are able to obtain independent housing without subsidies. The current study examined how individuals obtain housing without a voucher and whether greater employment earnings or better clinical outcomes were associated with such housing success. Data from an experimental evaluation of the Housing and Urban Development-Veterans Affairs Supportive Housing program were used for an observational study that compared participants who, at 3 months, were: (1) Independently Housed Without a Voucher (n = 96), (2) Independently Housed With a Voucher (n = 93), (3) Housed In Another Individual's Place (n = 60), or (4) Not Yet Housed (n = 170). Participants who obtained independent housing without a voucher worked more days and had higher employment income than those who did use a voucher, but they were less satisfied with their housing. About a third of participants who lived in independent housing without a voucher had others living with them. Homeless veterans with mental illness are able to use employment and shared housing as naturalistic ways to obtain independent housing. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Hyperglycemia increases neurological damage and behavioral deficits from post-traumatic secondary ischemic insults

The effects of post-traumatic administration of glucose 2.0 g/kg was compared to saline infusion with and without control of brain temperature at 37 degrees C on behavioral and histological measures of brain injury after controlled cortical impact injury complicated by a secondary ischemic insult. The glucose infusion increased blood glucose concentration from 114 +/- 4 to 341 +/- 76 mg/dl prior to the secondary ischemic insult. The resulting outcome measures were significantly worse in the glucose infusion group than in either control group. Mortality rate was significantly increased by the glucose administration, from 0% to 55% (p < 0.001). The median contusion volume was increased from 7.9 to 64.2 by glucose administration (p < 0.001) and the neuronal loss in the CA1 and CA3 areas of the hippocampus were greater in the glucose infusion group. In the animals that survived for the 2 weeks of behavioral studies, the duration of beam balance was shorter; the percent of animals that could balance on the beam for at least 60 s was less, the percent of animals that could perform the beam-walking task was less, and the length of time required to find the platform in the Morris water maze task was longer in the glucose infusion group. These studies demonstrate that the infusion of glucose after the cortical impact injury significantly increases the damage caused by post-traumatic ischemic insults. The adverse effect on neurological outcome could not be explained by the temperature effects of glucose infusion.     

Direct placement versus multistage models of supported housing in a population of veterans who are homeless.

This study presents information about two models of supported housing when combined with ready access to rent subsidies: a direct placement approach (where individuals are placed directly into independent housing from homelessness), and a multistage continuum approach (where individuals are placed first into a residential setting prior to independent housing). Using observational data from the national Housing and Urban Development–Veterans Affairs Supported Housing (HUD-VASH) program, which provided case management and housing subsidies to homeless veterans with psychiatric or substance abuse disorders, participants were categorized as receiving direct placement housing or multistage housing based on where they spent the majority of days prior to entry into HUD-VASH. Results indicate that multistage housing participants had significantly worse scores on baseline measures of alcohol and drug use, quality of life, and social support, and subsequently experienced significantly greater improvements over time so that, with the exception of employment outcomes, between-groups differences were not significant at later time periods. Multistage participants had health care costs that averaged more than three times those of direct placement participants during the initial period of residential care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

The Mothers and Toddlers Program: Preliminary findings from an attachment-based parenting intervention for substance-abusing mothers.

The authors examined pilot data from an attachment-based parenting intervention for substance-abusing mothers of toddlers (ages 12-36 months). The Mothers and Toddlers Program (MTP) is a 20-week individual therapy intervention that aims to help mothers develop more balanced representations of their children and improve their capacity for reflective functioning (i.e., recognition of the intentional nature of children's behavior). The authors hypothesized that improvement in maternal representational balance and maternal capacity for reflective functioning would correspond with improvements in maternal behavior with toddlers (e.g., sensitivity to cues, responsiveness to distress, and social-emotional growth fostering) and reduction in maternal psychiatric distress and substance abuse. Eight mothers who completed MTP showed moderate improvements in representational balance and reflective functioning, and these changes corresponded with significant improvements in maternal behaviors with toddlers. The authors also compared MTP completers and noncompleters on sociodemographic and psychosocial indexes and examined the validity of the intervention's proposed mechanisms of change. Preliminary findings support the importance of attachment mechanisms and indicate that attachment-based interventions may strengthen substance-abusing mothers' capacities to foster their toddlers' socioemotional development. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transient neurological deficits simulating transient ischemic attacks in a patient with meningioma--case report

The purpose of this study was to evaluate in vivo the changes in myometrial thickness throughout pregnancy. Myometrial thickness was measured in 25 singleton uncomplicated pregnancies. Ultrasonographic sagittal and transverse sections were used to measure uterine wall thickness from the low anterior wall (lower segment) and the anterior, posterior, right, and left walls of the upper segment and from the fundus. In each case four measurements were made in the second and third trimesters. Myometrial thickness of the upper uterine segment remains fairly constant in the first and second trimesters of pregnancy, whereas a significant linear trend was found between a decreasing thickness of the lower uterine segment and advancing gestational age. Myometrial thickness is significantly increased behind the placental insertion site as compared to other portions of the uterine wall. These data may serve as baseline reference values for further studies in the antepartum fetal surveillance of high-risk pregnancies.     

Sleep EEG alterations in patients suffering from circulatory disturbances. Relation to neurological and psychopathological changes (author''s transl)

In 30 conscious patients (24 men, 6 women) aged 30-74 years suffering from ischemic lesions in the cerebral hemispheres, polygraphic night sleep recordings were performed about 45 days after the beginning of the illness. The alterations in sleep were characterized by a delay in the onset of sleep, prolonged waking periods, and a reduction of deep synchronous sleep. Statistical analysis revealed a relationship between prolonged waking time with higher age as well as with high complex reaction time and euphoric state of mind, which can be considered as a sign of psycho-organic impairment. In contrast thereto, the degree of the neurological symptomatology is of less importance for the kind and extent of the sleep disturbances.     

Selective deficits in reflective cognition of polydrug abusers: Preliminary findings.

The goal of this study was to determine if drug abusers exhibited specific deficits in reflective cognition similar to that observed in detoxified alcoholics who were otherwise cognitively intact. Fifteen drug abusers and 15 non-drug-abusing control participants were administered a series of cognitive tests, which assessed various learning and memory functions. Drug abusers did not differ from controls with respect to most cognitive domains. However, drug abusers exhibited selective deficits in processing unstructured information and in inhibiting intrusion errors during word recall. Such deficits in reflective functioning may play a role in the initiation of drug use or maintenance of drug dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quantitative analysis of rapid pointing movements in Cree subjects exposed to mercury and in subjects with neurological deficits

To quantify rapid alternating movements (RAMs) we used a simple prototype developed in our laboratory that requires the subject to rotate two hand-held foam spheres connected to optical encoders via flexible rods. Ninety-six participants, including 30 control subjects, 36 Cree subjects exposed to methylmercury, 21 subjects with Parkinson's disease, 6 subjects with cerebellar deficits, and 3 subjects with essential tremor, were involved in the study (though data for 5 were later removed). Twelve characteristics were developed and calculated from the raw data. Conditions examined included two hands at natural cadence (NC2), right and left hands separately at fast cadence (FCl), and both hands at fast cadence (FC2). Two ratios (FC2/NC2) and (FC2/FC1) combining these conditions were also examined. Test-retest reliability was >0.80 for most characteristics but was <0.70 for some characteristics, especially in the conditions executed at normal cadence. Correlations between characteristics and numbers of outliers with respect to the control group distribution were used to reduce the set of characteristics from 12 to 7 (i.e., duration, range, maximum slope, similarity in shape, smoothness, sharpness, and coherence). ANOVAs on the three largest groups generated significant results for most characteristics in the three conditions and the two ratios for Cree subjects and subjects with Parkinson's disease. ANOVAs on 3 age-matched groups (n=6) suggest that methylmercury affects the performance of the Cree subjects with the higher exposure, especially in terms of smoothness, sharpness, and coherence. These preliminary results suggest that this test is sufficiently specific and sensitive to characterize the performance of different groups of subjects. Ratios tend to improve discrimination for Cree subjects in a few characteristics but not for patients with Parkinson's disease.     

Pretreatment with intravenous FGF-13 reduces infarct volume and ameliorates neurological deficits following focal cerebral ischemia in rats

Oocyte growth within the follicle is preponderantly due to the accumulation of hepatically derived yolk protein (vitellogenin, VTG) by receptor-mediated endocytosis; once in the oocyte, VTG is partially processed and stored in yolk globules. In some pelagic egg-laying marine teleosts, additional cleavages of yolk proteins followed by a pronounced water uptake occur concomitantly with final oocyte maturation. The aim of this study was to establish the lysosomal enzymes involved in these two proteolytic processes that characterize oocyte maturation of seabream Sparus aurata. The enzymatic activities of several cathepsins were assessed in the various classes of oocytes. Changes in cathepsin B, D, and L activity were found depending on the oocyte maturation stage; cathepsin B and D were found to be at maximum level in early-vitellogenesis oocytes, and cathepsin L in mid-vitellogenesis ones. Cathepsin D and L were purified from seabream ovary, and their roles in VTG and lipovitellin (LV) proteolysis, respectively, were analyzed. Here we demonstrate directly that one of the catalysts for the intraoocytic processing of VTG in yolk proteins is cathepsin D; however, we cannot exclude also a role of cathepsin B in the same process. On the other hand, cathepsin L is responsible for the second proteolytic cleavage of the LV components. We postulate that the acquisition of buoyancy by eggs through the hydration process may be regulated by enzymatic activation at the appropriate time of oocyte maturation, this process probably being the key event in the reproduction of this marine pelagic egg spawner.     

Neuroprotective effect of an antioxidant, ebselen, in patients with delayed neurological deficits after aneurysmal subarachnoid hemorrhage

OBJECTIVE: The effect of ebselen, a seleno-organic compound with antioxidant activity through a glutathione peroxidase-like action, on the outcome of subarachnoid hemorrhage was evaluated in a multicenter placebo-controlled double-blind clinical trial. METHODS: Patients who suffered aneurysmal subarachnoid hemorrhages of Hunt and Kosnik Grades II through IV at admission and were able to start drug treatment within 96 hours of the ictus were enrolled. Early surgery was performed whenever possible. Oral administration of ebselen granules suspended in water (150 mg, twice a day) or placebo was started immediately after admission and continued for 2 weeks. The major end points were the Glasgow Outcome Scale at 2 weeks, 1 month, and 3 months after the start of treatment. The incidence of delayed ischemic neurological deficits clinically diagnosed as resulting from vasospasm and the incidence and extent of low-density areas on postoperative computed tomographic scans were also studied as secondary outcome measures. RESULTS: Intent-to-treat analysis of the 286 patients enrolled in the trial (145 patients administered ebselen and 141 administered placebo) revealed that the incidence of clinically diagnosed delayed ischemic neurological deficits was unaltered. There were 52 (receiving ebselen) and 58 (receiving placebo) patients with delayed deficits; however, a significantly better outcome was observed after ebselen treatment than after placebo (P = 0.005, chi2 test). There was a corresponding decrease in the incidence and extent of low-density areas (P = 0.032, Wilcoxon rank sum test). CONCLUSION: Ebselen reduced brain damage in patients with delayed neurological deficits after subarachnoid hemorrhage and may be a promising neuroprotective agent.