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1.
Psychiatr Serv ; 52(3): 313-22, 2001 Mar.
Article in English | MEDLINE | ID: mdl-11239097

ABSTRACT

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.


Subject(s)
Employment, Supported , Evidence-Based Medicine , Mental Disorders/rehabilitation , Community Mental Health Centers , Employment, Supported/economics , Employment, Supported/organization & administration , Financing, Government , Humans , Program Development , Program Evaluation , Randomized Controlled Trials as Topic , United States
2.
Schizophr Res ; 46(2-3): 209-15, 2000 Dec 15.
Article in English | MEDLINE | ID: mdl-11120433

ABSTRACT

The recent publication of the Wechsler Adult Intelligence Scale (WAIS-III), the most widely used standard test of intelligence, requires the development of a new short form for use with patients with schizophrenia for many clinical and research purposes. We used regression analyses of complete WAIS-III data on 41 outpatients with schizophrenia and 41 education-, and age-matched healthy subjects to determine the best combination of subtests to use as a short form. Excluding three subtests that are time-consuming to administer, and requiring that the solution includes one subtest from each of the four WAIS index scores, the combination that most fully accounted for the variance in full-scale IQ (FSIQ) for both participants with schizophrenia (R(2)=0.90) and healthy controls (R(2)=0.86) included the information, block design, arithmetic, and digit symbol subtests. When the restrictions regarding which subtests could enter were relaxed, the best four-subtest solution included information, block design, comprehension, and similarities. Although the latter explained 95% of the variance in FSIQ for schizophrenia participants and 90% of the variance for healthy controls, it consistently overestimated FSIQ for the schizophrenia group. We recommend the four-factor short form for use in future research and clinical practice in which a quick, accurate IQ estimate is desired.


Subject(s)
Antipsychotic Agents/therapeutic use , Intelligence , Schizophrenia/diagnosis , Schizophrenia/drug therapy , Wechsler Scales , Adult , Female , Humans , Male
3.
Am J Psychiatry ; 155(4): 516-22, 1998 Apr.
Article in English | MEDLINE | ID: mdl-9545998

ABSTRACT

OBJECTIVE: Severe and persistent mental illnesses are often lifelong and characterized by intermittent exacerbations requiring hospitalization. Providing needed care within budgetary constraints to this largely publicly subsidized population requires technologies that reduce costly inpatient episodes. The authors report a prospective randomized trial to test the clinical effectiveness of a model of acute residential alternative treatment for patients with persistent mental illness requiring hospital-level care. METHOD: Patients enrolled in the Montgomery County, Md., public mental health system who experienced an illness exacerbation and were willing to accept voluntary treatment were randomly assigned to the acute psychiatric ward of a general hospital or a community residential alternative. There were no psychopathology-based exclusion criteria. Treatment episode symptom improvement, satisfaction, discharge status, and 6-month pre- and postepisode acute care utilization, psychosocial functioning, and patient satisfaction were assessed. RESULTS: Of 185 patients, 119 (64%) were successfully placed at their assigned treatment site. Case mix data indicated that patients treated in the hospital (N = 50) and the alternative (N = 69) were comparably ill. Treatment episode symptom reduction and patient satisfaction were comparable for the two settings. Nine (13%) of 69 patients randomly assigned to the alternative required transfer to a hospital unit; two (4%) of 50 patients randomly assigned to the hospital could not be stabilized and required transfer to another facility. Psychosocial functioning, satisfaction, and acute care use in the 6 months following admission were comparable for patients treated in the two settings and did not differ significantly from functioning before the acute episode. CONCLUSIONS: Hospitalization is a frequent and high-cost consequence of severe mental illness. For patients who do not require intensive general medical intervention and are willing to accept voluntary treatment, the alternative program model studied provides outcomes comparable to those of hospital care.


Subject(s)
Hospitals, General , Mental Disorders/therapy , Residential Treatment , Adult , Attitude to Health , Chronic Disease , Community Mental Health Services/economics , Crisis Intervention/economics , Episode of Care , Female , Health Care Costs , Hospitalization , Hospitals, General/economics , Humans , Male , Mental Disorders/diagnosis , Mental Disorders/psychology , Outcome Assessment, Health Care , Patient Satisfaction , Prognosis , Prospective Studies , Psychiatric Status Rating Scales/statistics & numerical data , Residential Treatment/economics , Severity of Illness Index
4.
Br J Psychiatry ; 171: 265-8, 1997 Sep.
Article in English | MEDLINE | ID: mdl-9337982

ABSTRACT

BACKGROUND: Although movement disorders have been noted among patients never exposed to neuroleptic medications, the specificity of spontaneous dyskinesia to schizophrenia has rarely been examined. METHOD: By abstracting detailed case records, we compared the prevalence of dyskinetic movements between 94 neuroleptic-naïve schizophrenic patients and 179 patients with other psychiatric disorders. RESULTS: Dyskinetic movements were more common among patients with schizophrenia than among those with all other diagnoses, and were most often noted in the body areas typically associated with tardive dyskinesia. CONCLUSIONS: Spontaneous dyskinesia appears to be relatively specific to schizophrenia and may be intrinsic to the pathophysiology of the disorder.


Subject(s)
Movement Disorders/complications , Schizophrenia/complications , Adolescent , Adult , Age Factors , Aged , Electroconvulsive Therapy , Female , Humans , Male , Maryland/epidemiology , Mental Disorders/complications , Mental Disorders/epidemiology , Mental Disorders/therapy , Middle Aged , Movement Disorders/epidemiology , Prevalence , Schizophrenia/epidemiology , Schizophrenia/therapy
5.
Schizophr Res ; 26(1): 15-23, 1997 Jul 25.
Article in English | MEDLINE | ID: mdl-9376334

ABSTRACT

In this paper we suggest a new method, conceived by Maher, to assess lateralized motor performance in schizophrenia. Subjects draw two straight lines with each hand. The lines are scanned into a computer, and a regression is run on the points of the line. The root mean squared error (RMS) of the regression equation indicates the deviation from straightness of the line. The average RMS of all four lines is taken as an overall measure of motor disorder, and the difference in performance between the two hands serves as an index of motoric laterality. Scores on the motor disorder index were significantly positively related to clinical ratings of Parkinsonism among schizophrenic inpatients. A marginal relation was found to ratings of voluntary movement disorders, and the task was not associated with dyskinetic movements. Scores on the motor disorder measure were significantly worse for schizophrenic subjects than for staff controls. The laterality index significantly differentiated right- and left-handed subjects, but did not differentiate schizophrenic from control subjects. Maher's simple line drawing task yields objective continuous ratings of motor disorder and handedness and may be a useful tool for examining associations between motor functioning and cognition and symptomatology in schizophrenia.


Subject(s)
Functional Laterality/physiology , Handwriting , Movement Disorders/diagnosis , Neuropsychological Tests , Psychometrics/methods , Schizophrenia/physiopathology , Adult , Aged , Case-Control Studies , Chi-Square Distribution , Cross-Sectional Studies , Factor Analysis, Statistical , Female , Humans , Image Processing, Computer-Assisted , Male , Middle Aged , Movement Disorders/physiopathology , Neuropsychological Tests/standards , Psychometrics/standards , Psychomotor Performance/physiology , Regression Analysis , Reproducibility of Results , Schizophrenic Psychology , Severity of Illness Index , Visual Perception/physiology
6.
Am J Psychiatry ; 154(2): 199-204, 1997 Feb.
Article in English | MEDLINE | ID: mdl-9016268

ABSTRACT

OBJECTIVE: Suicide is the single largest cause of premature death among individuals with schizophrenia. This report examines the relationship between positive or negative symptoms, illness subtype, and suicidal behavior among patients with schizophrenia and schizophrenia spectrum disorders in a long-term follow-up cohort. METHOD: Based on index admission records, patients from the Chestnut Lodge Follow-Up Study with schizophrenia (N = 187), schizoaffective disorder (N = 87), schizophreniform disorder (N = 15), and schizotypal personality disorder (N = 33) were retrospectively assessed with the Positive and Negative Syndrome Scale, classical subtype criteria, and criteria for the deficit syndrome. Completed suicide, suicide attempts, and suicidal ideation during the follow-up period (average = 19 years) were ascertained by means of interviews with patients and/or surviving relatives. RESULTS: Over the follow-up period, 40% of the patients reported suicidal ideation, 23% reported suicide attempts, and 6.4% died from suicide. Patients dead from suicide had significantly lower negative symptom severity at index admission than patients without suicidal behaviors. Two positive symptoms (suspiciousness and delusions), however, were more severe among successful suicides. The paranoid schizophrenia subtype was associated with an elevated risk (12%) and the deficit subtype was associated with a reduced risk (1.5%) of suicide. CONCLUSIONS: The impact of positive and negative symptoms on suicide risk has not been reported. These findings suggest that prominent negative symptoms, such as diminished drive, blunted affect, and social and emotional withdrawal, counter the emergence of suicidality in patients with schizophrenia spectrum disorders and that the deficit syndrome defines a group at relatively low risk for suicide. Prominent suspiciousness in the absence of negative symptoms defines a relatively high-risk group.


Subject(s)
Psychotic Disorders/classification , Psychotic Disorders/diagnosis , Schizophrenia/classification , Schizophrenia/diagnosis , Schizophrenic Psychology , Suicide/statistics & numerical data , Adult , Cohort Studies , Female , Follow-Up Studies , Hospitalization , Humans , Male , Middle Aged , Psychotic Disorders/psychology , Risk Factors , Schizophrenia, Paranoid/classification , Schizophrenia, Paranoid/diagnosis , Schizophrenia, Paranoid/psychology , Schizotypal Personality Disorder/classification , Schizotypal Personality Disorder/diagnosis , Schizotypal Personality Disorder/psychology , Severity of Illness Index , Suicide, Attempted/statistics & numerical data
7.
Schizophr Bull ; 23(4): 637-51, 1997.
Article in English | MEDLINE | ID: mdl-9366000

ABSTRACT

Advances in psychopharmacology have produced medications with substantial efficacy in the treatment of positive and negative symptoms of schizophrenia and the prevention of relapse or symptom exacerbation after an acute episode. In the clinical setting, the individual patient's acceptance or rejection of prescribed pharmacological regimens is often the single greatest determinant of these treatments' effectiveness. For this reason, an understanding of factors that impede and promote patient collaboration with prescribed acute and maintenance treatment should inform both pharmacological and psychosocial treatment planning. We review the substantive literature on medication adherence in schizophrenia and describe a modified health belief model within which empirical findings can be understood. In addition to factors intrinsic to schizophrenia psychopathology, medication-related factors, available social support, substance abuse comorbidity, and the quality of the therapeutic alliance each affect adherence and offer potential points of intervention to improve the likelihood of collaboration. Because noncompliance as a clinical problem is multidetermined, an individualized approach to assessment and treatment, which is often best developed in the context of an ongoing physician-patient relationship, is optimal. The differential diagnosis of noncompliance should lead to interventions that target specific causal factors thought to be operative in the individual patient.


Subject(s)
Antipsychotic Agents/therapeutic use , Patient Compliance , Schizophrenia/drug therapy , Antipsychotic Agents/adverse effects , Comorbidity , Diagnosis, Differential , Drug Administration Schedule , Health Behavior , Humans , Models, Psychological , Patient Care Planning , Physician-Patient Relations , Recurrence , Schizophrenia/epidemiology , Schizophrenic Psychology , Social Support , Substance-Related Disorders/epidemiology
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