Effect of an acid mine drainage effluent on phytoplankton biomass and primary production at Britannia Beach, Howe Sound, British Columbia.

We investigated the effect of acid mine drainage (AMD) from an abandoned copper mine at Britannia Beach (Howe Sound, BC, Canada) on primary productivity and chlorophyll a levels in the receiving waters of Howe Sound before, during, and after freshet from the Squamish River. Elevated concentrations of copper (integrated average through the water column >0.050 mgl(-1)) in nearshore waters indicated that under some conditions a small gyre near the mouth of Britannia Creek may have retained the AMD from Britannia Creek and from a 30-m deep water outfall close to shore. Regression and correlation analyses indicated that copper negatively affected primary productivity during April (pre-freshet) and November (post-freshet). Negative effects of copper on primary productivity were not supported statistically for July (freshet), possibly because of additional effects such as turbidity from the Squamish River. Depth-integrated average and surface chlorophyll a were correlated to copper concentrations in April. During this short study we demonstrated that copper concentrations from the AMD discharge can negatively affect both primary productivity and the standing stock of primary producers in Howe Sound.

Treatment guidelines for depression in pregnancy.

Depression is a ubiquitous disorder in childbearing women with up to 10% of women experiencing depression in pregnancy. Postpartum depression occurs in 12-16% of pregnancies making it a common complication. Moreover, these illnesses are frequently underdiagnosed in obstetric settings, and a recent report of the Surgeon General's Office confirms that many women do not access services, or receive treatment of inadequate intensity or duration. This paper provides current treatment guidelines to aid in appropriate diagnosis and treatment of depression in pregnancy and postpartum. Review of current literature on psychotropic medication use in pregnancy is also provided.

Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial.

BACKGROUND: Studies suggest that 14% of women age 18 to 40 drink alcohol above recommended limits. Of special concern is the increasing use of alcohol by women during pregnancy. This article reports 48 month follow-up data from a subanalysis of a trial for early alcohol treatment (Project TrEAT) focused on women of childbearing age. METHODS: Project TrEAT was conducted in the offices of 64 primary care, community-based physicians from 10 Wisconsin counties. Of 5979 female patients ages 18 to 40 who were screened for problem drinking, 205 were randomized into an experimental group (n = 103) or control group (n = 102). The intervention consisted of two 15 min, physician-delivered counseling visits that included advice, education, and contracting by using a scripted workbook. A total of 174 subjects (85%) completed the 48 month follow-up procedures. RESULTS: No significant differences were found between the experimental and control groups at baseline for alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorder, lifetime drug use, or health care utilization. The trial found a significant treatment effect in reducing both 7 day alcohol use (p = 0.0039) and binge drinking episodes (p = 0.0021) over the 48 month follow-up period. Women in the experimental group who became pregnant during the follow-up period had the most dramatic decreases in alcohol use. A logistic regression model based on a 20% or greater reduction in drinking found an odds ratio of 1.93 (confidence interval 1.07-3.46) in the sample exposed to physician intervention. Age, smoking, depression, conduct disorder, antisocial personality disorder, and illicit drug use did not reduce drinking significantly. No significant differences were found in health care utilization and health status between groups. CONCLUSIONS: This trial provides the first direct evidence that brief intervention is associated with sustained reductions in alcohol consumption by women of childbearing age. The results have enormous implications for the U.S. health care system.

Older patients with at-risk and problem drinking patterns: new developments in brief interventions.

The relationship between alcohol and some of the most prevalent physical and mental health issues of older adulthood and the fact that a large percentage (up to 60% in randomized clinical trials) of older at-risk drinkers may need either more intense or innovative approaches to help them cut down or stop drinking have led to new developments in alcohol screening and brief interventions with older adults. Technological and content innovations are critical elements in providing rapid, effective interventions with a spectrum of alcohol use problems in later adulthood. Both primary and specialty care providers can be trained to provide motivational brief alcohol interventions targeted to the older patient. Novel approaches to screening, brief interventions, and brief therapies can be combined with the use of new technologies to facilitate implementation in a range of health care settings. This will give mental health specialty providers additional strategies for addressing the complex needs of older at-risk drinkers using a family of efficient and effective approaches.

Targeting quality improvement activities for depression. Implications of using administrative data.

BACKGROUND: Large health care organizations may use administrative data to target primary care patients with depression for quality improvement (QI) activities. However, little is known about the patients who would be identified by these data or the types of QI activities they might need. We describe the clinical characteristics and outcomes of patients identified through administrative data in 2 family practice clinics. METHODS: Patients with depression aged 18 to 65 years were identified through review of encounter/administrative data during a 16-month period. Patients agreeing to participate (N=103) were interviewed with the Primary Care Evaluation of Mental Disorders questionnaire and completed the Depression Outcomes Modules (with an embedded Medical Outcomes Short Form-36 [SF-36]), Symptom Check List-25 (SCL-25), and Alcohol use Disorders Identification Test. Follow-up assessments were completed by 83 patients at a median of 7 months. RESULTS: A large majority of identified patients (85%) met full criteria for a Diagnostic and Statistical Manual of Mental Disorders depressive disorder; those not meeting criteria usually had high levels of symptoms on the SCL-25. Seventy-seven percent of the patients reported recurrent episodes of depressed mood, and 60% reported chronic depression. Although most improved at follow-up, they continued to have substantial functional deficits on the SF-36, and 60% still had high levels of depressive symptoms. CONCLUSIONS: QI programs that use administrative data to identify primary care patients with depression will select a cohort with relatively severe, recurrent depressive disorders. Most of these patients will receive standard treatments without QI interventions and will continue to be symptomatic. QI programs targeting this population may need to offer intensive alternatives rather than monitor standard care.

Effectiveness of specialized treatment programs for veterans with serious and persistent mental illness: a three-year follow-up.

This is the first study to test concurrently the effectiveness of four treatment programs for patients with serious mental illness. Three-year outcome data on utilization and functioning demonstrated important positive changes for seriously mentally ill veterans enrolled in specialized, enhanced inpatient and community case management treatment programs, when compared to patients in an enhanced day treatment program or traditional standard care.

The relationship between alcohol problems and health functioning of older adults in primary care settings.

OBJECTIVE: The purpose of this study was to determine the relationship between alcohol use and health functioning in a sample of older adults screened in primary care settings. DESIGN: A cross-sectional study. SETTING: Thirty-seven primary care clinics. PARTICIPANTS: Older adults (n = 8,578; aged 55-97) with regularly scheduled appointments in primary care clinics were screened. MEASUREMENTS: Participants were categorized based on alcohol consumption levels as abstainers, low-risk drinkers, and at-risk drinkers (women: 9 or more drinks/week; men: 12 or more drinks/week). Dependent variables were eight SF-36 health functioning scales. RESULTS: Sixty-one percent of participants were abstainers, 31% were low-risk drinkers, and 7% were at-risk drinkers. ANCOVAs found significant effects of drinking status on General Health, Physical Functioning, Physical Role Functioning, Bodily Pain, Vitality, Mental Health, Emotional Role, and Social Functioning, controlling for age and gender, with low-risk drinkers scoring significantly better than abstainers. At-risk drinkers had significantly poorer mental health functioning than low-risk drinkers. Few significant gender differences were found on SF-36 scales. CONCLUSIONS: Older adults who are at-risk drinkers may not present with poor physical health functioning. Future studies are needed to determine the relationship between drinking limits for older adults and other areas of physical and psychosocial health.

Age-group differences in treatment outcomes for male veterans with severe schizophrenia: a three-year longitudinal study.

Treatment outcomes in later-life schizophrenia are poorly understood and of serious concern for clinicians and mental health policy makers. Age-group differences were examined for 499 male veterans with severe schizophrenia enrolled in enhanced treatment programs at 12 Veterans Affairs hospitals. Participants were separated into three age groups (20-39 years, 40-59 years, 60 years and above), with the following outcomes assessed at enrolment and 1 and 3 years afterwards: psychiatric symptomatology, global functioning, impairment in Instrumental Activities of Daily Living (IADL), and hospital use. All three age groups experienced significant improvement in psychiatric symptoms over time. The oldest group fared worse than younger patients in terms of global functioning and generally required more inpatient services and assistance with IADL. Innovative programming is needed to meet the special needs of the growing population of older adults with schizophrenia.

Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings.

BACKGROUND: Few studies have estimated the economic costs and benefits of brief physician advice in managed care settings. OBJECTIVE: To conduct a benefit-cost analysis of brief physician advice regarding problem drinking. DESIGN: Patient and health care costs associated with brief advice were compared with economic benefits associated with changes in health care utilization, legal events, and motor vehicle accidents using 6- and 12-month follow-up data from Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled clinical trial. SUBJECTS: 482 men and 292 women who reported drinking above a threshold limit were randomized into control (n = 382) or intervention (n = 392) groups. MEASURES: Outcomes included alcohol use, emergency department visits, hospital days, legal events, and motor vehicle accidents. RESULTS: No significant differences between control and intervention subjects were present for baseline alcohol use, age, socioeconomic status, smoking, depression or anxiety, conduct disorders, drug use, crimes, motor vehicle accidents, or health care utilization. The total economic benefit of the brief intervention was $423,519 (95% CI: $35,947, $884,848), composed of $195,448 (95% CI: $36,734, $389,160) in savings in emergency department and hospital use and $228,071 (95% CI: -$191,419, $757,303) in avoided costs of crime and motor vehicle accidents. The average (per subject) benefit was $1,151 (95% CI: $92, $2,257). The estimated total economic cost of the intervention was $80,210, or $205 per subject. The benefit-cost ratio was 5.6:1 (95% CI: 0.4, 11.0), or $56,263 in total benefit for every $10,000 invested. CONCLUSIONS: These results offer the first quantitative evidence that implementation of a brief intervention for problem drinkers can generate positive net benefit for patients, the health care system, and society.

Work and social support: a comparison of consumers who have achieved stability in ACT and clubhouse programs.

A current debate in the field is whether consumers, who have achieved stability in Assertive Community Treatment programs, can be transferred to less intensive services. To bring some data to bear on this question, this study compared consumers and members, who have achieved stability, in either an Assertive Community Treatment (ACT) or a clubhouse program, on domains of vocational activity, social relationships/loneliness and community integration. The 51 stable clients from the two programs who were interviewed, reported similar vocational activity, similar experiences with social relationships and social networks, and similar community integration. Clients in both groups were less lonely than previously reported in the literature. Study results indicate, that for those clients who have achieved stability, there are sufficient similarities between consumers in the two programs, to suggest a potential for movement from more to less intensive programs with less disruption than previously assumed possible.

Brief physician advice for alcohol problems in older adults: a randomized community-based trial.

BACKGROUND: Alcohol use in older adults is common. It is associated with depression, hypertension, diabetes, drug interactions, accidents, and increased rates of emergency department visits and hospitalizations. METHODS: A controlled clinical trial (Project GOAL--Guiding Older Adult Lifestyles) tested the efficacy of brief physician advice in reducing the alcohol use and use of health care services of older adult problem drinkers. Twenty-four community-based primary care practices in Wisconsin (43 family physicians and internists) participated in the trial. Of the 6073 patients screened, 105 men and 53 women met inclusion criteria and were randomized into a control group (n = 71) or an intervention group (n = 87). Intervention group patients received two 10- to 15-minute physician-delivered counseling sessions that included advice, education, and contracting using a scripted workbook. A total of 146 patients (92.4%) participated in the 12-month follow-up procedure. RESULTS: No significant differences were found between the control and intervention groups at baseline in alcohol use, age, socioeconomic status, depression, onset of alcohol use, smoking status, activity level, or use of mood-altering drugs. The older adults who received the physician intervention demonstrated a significant reduction in 7-day alcohol use, episodes of binge drinking, and frequency of excessive drinking (P <.005) compared with the control group at 3, 6, and 12 months after the intervention. There was a 34% reduction in 7-day alcohol use, 74% reduction in mean number of binge-drinking episodes, and 62% reduction in the percentage of older adults drinking more than 21 drinks per week in the intervention group compared with the control group. There were no significant changes in health status. Patterns of health care utilization were not extensively analyzed because of the small number of events. CONCLUSIONS: This study provides the first direct evidence that brief physician advice can decrease alcohol use by older adults in community-based primary care practices.

Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration.

BACKGROUND: In randomized controlled trials, patients with major depression who receive broad-based collaborative treatment by both primary care physicians (PCPs) and mental health providers (MHPs) have better outcomes than patients who receive usual care. However, little is known about the concurrent treatment of patients with depression in the community. This study describes the perceptions of PCPs of the frequency of concurrent treatment in community settings, the degree of collaboration between co-treating providers, and factors associated with greater interaction and collaboration. METHODS: A survey was distributed to a stratified, random sample of 276 eligible family physicians in Michigan. Primary analyses were descriptive statistics (point estimation) of PCP practice patterns. Secondary analyses explored predictors of collaboration with multivariable regression. RESULTS: A total of 162 eligible PCPs (59%) returned the survey. PCPs reported that they co-treated approximately 30% of their depressed patients with MHPs. They made contact with co-treating MHPs in approximately 50% of shared cases; however, provider contact seldom included joint treatment planning. PCPs perceived collaborative treatments to be more problematic when patients were enrolled in managed care programs. In multivariable regression, co-location of MHP and PCP practices (in the same building) was strongly associated with increased interaction and collaboration (P <.001). CONCLUSIONS: Concurrent treatment of depressed patients is common in the community, but these treatments are less interactive and collaborative than the treatment models proven effective in randomized controlled trails. If concurrent treatments are to become more collaborative-with regular contact and effective communication-co-location of practices appears important.

Repeated assaults by patients in VA hospital and clinic settings.

OBJECTIVE: The study aim was to determine the prevalence of repeated assaults on staff and other patients and characteristics of patients who commit repeated assaults in the Veterans Health Administration of the Department of Veterans Affairs. METHODS: Patients in VA medical centers and freestanding outpatient clinics who committed two or more assaults in fiscal years 1995 and 1996 were identified through a survey of facility quality or risk managers. For each repeatedly assaultive patient, structured information, including incident reports, was obtained for all assault occasions. RESULTS: A total of 153 VA facilities responded, for a response rate of 99 percent. The survey identified 8,968 incidents of repeated assault by 2,233 patients, for a mean of 4.02 assaults per patient in the two-year study period. In 92 percent of the incidents, the assaultive patient had a primary or secondary psychiatric diagnosis. The mean age of the repeat assaulters was 62 years. Ninety-eight percent of the repeat assaulters were male, and 76.6 percent were Caucasian. At least 16 percent of the assaulters, 22 percent of the patients assaulted, and 20 percent of the staff assaulted required medical attention for injuries, which, along with the number of lost work days, indicates that repeated assaults are costly. CONCLUSIONS: Repeatedly assaultive patients represent major challenges to their own safety as well as to that of other patients and staff. Identifying patients at risk for repeated assaults and developing intervention strategies is critically important for ensuring the provision of health care to the vulnerable population of assaultive patients.

Longitudinal assessment of inpatient use and functioning of seriously mentally ill veterans with and without co-occurring substance use disorders.

The purpose of this study was to delineate differences in inpatient service utilization and functional and subjective outcomes between veterans with a serious mental illness (SMI) and those with co-occurring serious mental illnesses and substance abuse (SA) disorders. This study assessed 2-year inpatient utilization and outcomes for 682 SMI veterans enrolled in specialized psychosocial treatment programs which did not have a substance abuse focus. Outcomes included psychiatric symptomatology, impairment in activities of daily living, global life satisfaction, days of hospitalization per year, and number of hospital admissions per year. Of the 682 patients, 198 (29%) had secondary diagnoses of substance abuse/dependence. Patients with co-occurring serious mental illness and substance use disorders had significantly more inpatient admissions per year than other SMI patients but did not differ in cumulative inpatient stays. The SMI/SA patients improved more than the other patients in terms of clinician rating of Global Assessment of Functioning. Patients with SMI/SA had significantly fewer psychiatric symptoms on the Brief Psychiatric Rating Scale, and all patients showed improvement on the BPRS, instrumental activities of daily living, and general life satisfaction rating. Seriously mentally ill patients with co-occurring substance use disorders fared as well as other SMI patients when enrolled in intensive, specialized state-of-the-art treatment programs.

Agreement between seriously mentally ill veterans and their clinicians about medication compliance.

OBJECTIVES: Levels of agreement about medication compliance in a large cohort of seriously mentally ill veterans and their clinicians were examined to determine whether agreement increased with exposure to enhanced treatment programs emphasizing compliance and whether compliance reports were associated with hospitalization. METHODS: A total of 1,369 seriously mentally ill patients and their treating clinicians at 14 Veterans Affairs medical centers rated medication compliance at enrollment in enhanced programs or comparison programs offering standard care. Patients and clinicians reassessed compliance one and two years after enrollment. Overall agreement, agreement about compliance and noncompliance, and kappa statistics were determined for concurrent assessments. RESULTS: Overall, patients rated themselves as significantly more compliant with medication than did clinicians at enrollment. Cohen's kappa at enrollment was .095, indicating little patient-clinician agreement beyond that expected by chance. Kappa values increased significantly at one and two years for patients in the enhanced programs but continued to indicate poor-to-modest levels of agreement. Patient-clinician pairs in enhanced programs did not differ from those in comparison programs in overall agreement. Reports of good compliance by both patients and clinicians were associated with significantly decreased odds of hospital admission in the 30 days after the report was made. CONCLUSIONS: Seriously mentally ill patients and their clinicians showed little agreement about medication use beyond that expected by chance. Intensive programming appeared to have little effect on agreement. Both patients' and clinicians' compliance assessments predicted hospitalization and thus can be used in research models that attempt to predict relapse and readmission.

At-risk drinking in an HMO primary care sample: prevalence and health policy implications.

OBJECTIVES: This study was designed to determine the prevalence of at-risk drinking using varying alcohol use criteria. METHODS: A period prevalence survey was conducted in 22 primary care practices (n = 19372 adults). RESULTS: The frequency of at-risk alcohol use varied from 7.5% (World Health Organization criteria) to 19.7% (National Institute on Alcohol Abuse and Alcoholism criteria). A stepwise logistic model using National Institute on Alcohol Abuse and Alcoholism criteria found male gender, current tobacco use, never married status, retirement, and unemployment to be significant predictors of at-risk alcohol use. CONCLUSIONS: Public health policy needs to move to a primary care paradigm focusing on identification and treatment of at-risk drinkers.

Prevalence of and factors associated with current and lifetime depression in older adult primary care patients.

BACKGROUND: Depression in late life is a significant health problem in the United States. This study examined the relationship between depression and alcohol, cigarette use, family history, and sociodemographic factors in older adult primary care patients. METHODS: As part of a larger clinical trial, 2,732 patients in 24 primary care offices were recruited to complete a self-administered health screening survey. Depression was assessed using Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for lifetime and current depression. RESULTS: A total of 17.8% of females and 9.4% of males age 60 and over met DSM-III-R criteria for lifetime depression; 10.6% of the females and 5.7% of the males met current depression criteria. Depression was significantly and positively correlated with female gender and family history of mental health problems and negatively correlated with social contact. CONCLUSIONS: Older adults, especially women, should be considered at elevated risk for depression when a family history of mental health problems and self-report of inadequate social connection can be established.

Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors.

BACKGROUND: Primary care settings are an ideal system in which to identify and treat substance use disorders. OBJECTIVE: To ascertain the prevalence of tobacco, alcohol, and drug use in the office of 88 primary care clinicians by gender, age and ethnicity. METHOD: 21,282 adults ages 18-65 completed a self-administered Health Screening Survey while participating in a trial for early alcohol treatment. RESULTS: The period prevalence of tobacco use was 27%. For alcohol: abstainers 40%, low risk drinkers 38%, at-risk drinkers 9%, problem drinkers 8%, and dependent drinkers 5%. Twenty percent of the sample reported using illicit drugs five or more times in their lifetime and 5% reported current illicit drug use. There were marked differences in alcohol use disorders by age and ethnicity. The majority of persons who smoked reported the desire to cut down or stop using tobacco. SIGNIFICANCE: This is the first report on the combined prevalence of tobacco, alcohol and drug disorders in a large sample of persons attending community-based non-academic primary care clinics. This report confirms the high prevalence of these problems and suggests that patients will accurately complete a self-administered screening test such as the Health Screening Survey. The office procedures developed for this study provide Managed Care Organizations with a system of care that can be used to screen all persons for tobacco, alcohol and drug use disorders.

Conduct disorder and antisocial personality in adult primary care patients.

BACKGROUND: Conduct disorder has been linked to substance use disorders in clinical populations. This study examined the relationships of conduct disorder and antisocial personality (ASP) disorder to substance use, substance abuse problems, depression, and demographic factors in primary care settings. METHODS: As part of a larger clinical trial, a survey of 1898 patients in the offices of 64 primary care physicians was conducted using a self-administered health habits questionnaire. Childhood conduct disorder and adult antisocial personality disorder were assessed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. RESULTS: Eight percent of men and 3.1% of women met criteria for a diagnosis of ASP disorder. The frequency of a history of childhood conduct disorders was higher, with 13.4% for men and 4% for women. Antisocial personality disorder was predicted by male sex, being unmarried (single, separated, divorced), lifetime history of depression, binge drinking, self-reported history of drug problems, current smoking, and younger age. The predictors of a history of child conduct disorder were similar to those of ASP. CONCLUSIONS: Primary care physicians treat many patients who have personality disorders and other conditions such as alcohol problems and depression. These patients need to be identified because of the high potential for comorbidity and the barriers to treatment inherent in these disorders.

Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices.

OBJECTIVE: Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers. DESIGN: Randomized controlled clinical trial with 12-month follow-up. SETTING: A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties. PARTICIPANTS: Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures. INTERVENTION: The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information. MAIN OUTCOME MEASURES: Alcohol use measures, emergency department visits, and hospital days. RESULTS: There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01). CONCLUSIONS: This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.