Mixed state discrimination using optimal control.

We present theory and experiment for the task of discriminating two nonorthogonal states, given multiple copies. We implement several local measurement schemes, on both pure states and states mixed by depolarizing noise. We find that schemes which are optimal (or have optimal scaling) without noise perform worse with noise than simply repeating the optimal single-copy measurement. Applying optimal control theory, we derive the globally optimal local measurement strategy, which outperforms all other local schemes, and experimentally implement it for various levels of noise.

Recognition and management of depression in a substance use disorder treatment population.

This study examines the association between depressive symptomatology and return to substance use among a sample of 126 veterans consecutively admitted to treatment at a VA intensive outpatient program for substance use disorders. Controlling for numerous demographic and health-related covariates, depressive symptomatology measured at treatment exit with a Beck Depression Inventory (BDI) was significantly predictive of substance use at three-months post-treatment (p < .05). Analysis with a recoded BDI showed that the moderately-to-severely symptomatic (BDI = 20+) were 4.1 times more likely to have returned to substance use than those with a BDI score of under 20.

Short-term course of drinking in an untreated sample of at-risk drinkers.

OBJECTIVE: We know little about the short-term course of drinking, particularly the stability or instability of at-risk drinking in untreated drinkers. Because few at-risk drinkers obtain help for their drinking, it is important to understand the short-term fluctuations between at-risk drinking and full-fledged alcohol use disorders, as well as remission of at-risk drinking. METHOD: We used four waves of data (each 6 months apart) from a probability community sample of 733 at-risk drinkers in six states in the southern United States to determine variation in abstinence, drinking patterns and alcohol use disorders over a 2-year period. For this analysis, we excluded those who reported receiving services for drinking during the 2-year study period (retrospectively at baseline), leaving a sample size of 664 (444 male); 479 (306 male) completed all four interviews. RESULTS: Although the majority (88%) of the sample was nonabstinent throughout the study, we found significant decreases in average number of drinks per drinking day and recent (past 6 months) alcohol disorders, and an increase in 6-month abstinence. Almost 30% of those with no recent alcohol disorder at baseline (n = 280) later met diagnostic criteria in at least one interview. Of those with a recent alcohol disorder at baseline (n = 199), one third met criteria in at least two subsequent interviews. CONCLUSIONS: There is some evidence for short-term progression from at-risk drinking to alcohol disorder. However, there is stronger evidence for declining problems and a fluctuation in and out of recovery and relapse, which may reflect an effort to maintain controlled drinking. Understanding this short-term course is important for primary and secondary prevention efforts and for screening of at-risk drinking in primary care and in the workplace.

Correlates and 6-month outcomes for co-occurring cannabis use in rural and urban at-risk drinkers.

We know little about the functional correlates of recent cannabis use when such use is additional to an "alcohol disorder" in non-treatment populations. We report on data from a prospective study of a large probability community survey of 733 at-risk drinkers in six Southern U.S. states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee) conducted from 1995 to 1996. Twenty-one percent reported cannabis use during the past six months at the baseline interview. These cannabis users were significantly less likely to be married, employed, or a high school graduate (p < .05). They were also more likely to have a diagnosis of "antisocial personality disorder" or "panic disorder." Recent cannabis users also reported more negative consequences of their alcohol use, including more frequent recent diagnoses of an "alcohol disorder," legal difficulties associated with their drinking, and more social consequences attributed to drinking. At the six-month follow-up interview, negative alcohol outcomes were associated with concurrent cannabis use, including higher frequency and quantity of alcohol consumption, greater frequency of recent "alcohol abuse" and "dependence," and greater social consequences of drinking. These results all point to substantially poorer functioning and experiences of individuals with concurrent at-risk alcohol and cannabis use. We suggest that cannabis use may be a marker for greater impairment associated with at-risk drinking.

Substance use health services research.

This report provides an introduction to substance use health services research based upon the conceptual model of Andersen and Aday and demonstrates how the subsequent papers provide important insights into issues raised in this conceptual model. These issues include access and barriers to health care, needs for care, health care utilization, outcomes of care, and costs of care. We show how these issues are also expanded beyond more traditional definitions. We conclude by indicating some broad areas for further research.

The impact of problem drinking on employment.

Social cost studies report that alcohol use and misuse impose a great economic burden on society, and over half of the total economic costs are estimated to be due to the loss of work productivity. Controversy remains, however, as to the magnitude and direction of the effects of alcohol consumption on productivity. Furthermore, most of the studies have looked at the relationship between problem drinking and wages. This paper investigates the impact of problem drinking on employment by analysing a random sample of men and women of prime working age from six Southern states in the US (Alabama, Arkansas, Georgia, Louisiana, Mississippi and Tennessee). The data set contains 4898 females and 3224 males, with information on both employment and problem drinking. To eliminate the bias that may result from single-equation estimation, we used a bivariate probit model to control for possible correlation in the unobservable factors that affect both problem drinking and employment. We find no significant negative association between problem drinking and employment for both men and women, controlling for other covariates. The findings are consistent with other research and highlight several methodological issues. Furthermore, the study suggests that estimates of the costs of problem drinking may be overstated owing to misleading labour supply relationships.

Comparing outcomes of routine care for depression: the dilemma of case-mix adjustment.

The purpose of this study was to formulate and test two case-mix models for depression treatment that permit comparisons of patient outcomes across diverse clinical settings. It assessed demographics; eight, diagnostic-specific, case-mix variables; and clinical status at baseline and follow-up for 187 patients. Regressions were performed to test two models for four dependent variables including depression severity and diagnosis. Individual treatment settings were then ranked based on a comparison of actual versus predicted outcomes using regression coefficients and predictor variables. A model inclusive of baseline physical health status and depression severity predicted depression severity, mental health, and physical health functioning at follow-up. A simpler model performed well in predicting depression remission. This study identifies variables to be included in case-mix adjustment models and demonstrates statistical methods to control for differences across settings when comparing depression outcomes.

Diversity in relapse prevention needs: gender and race comparisons among substance abuse treatment patients.

Attempts to address high relapse rates following substance abuse treatment have focused on identifying relapse prevention needs and development of subsequent relapse prevention programs. Few studies have examined whether women and African-Americans have unique relapse prevention needs. Research in this area could provide an initial basis for the development of alternative relapse prevention approaches that could be more appropriate for this pop ulation. This study examined gender and race differences in psychosocial concerns among patients recruited from substance abuse treatment as potential indicators of relapse prevention needs. Participants (N = 331) completed several questionnaires during their first month of substance abuse treatment. Assessment packets included measures of coping, self-efficacy, resource needs, cravings, social influences, exposure, and leisure activities. Analyses focused on gender and race differences in these variables before and after controlling for background characteristics (i.e., age, marital status, income, polysubstance use, treatment type, and problem severity). Gender differences found were that men reported poorer coping skills and more negative social influences and exposure to substances than women; these differences remained significant when controlling for background characteristics. Significant race differences were found on all scales except negative social influences. After controlling for background characteristics, African-Americans reported significantly greater coping skills and self-efficacy than did Caucasians; however, African-Americans also reported greater resource needs in comparison to Caucasians. Results highlight the diversity in psychosocial issues among substance abusers in treatment, particularly between Caucasians and African-Americans. Implications for developing alternative relapse prevention approaches to address this diversity are discussed.

Rural-urban differences in service use for memory-related problems in older adults.

The reduced availability of providers and travel difficulties in rural areas may thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether rural-urban differences exist in the probability of any service use of primary care physicians and mental health specialists in a full sample of older adults and in a subset of impaired respondents. In the full sample, rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the subgroup, rural individuals were 0.26 times as likely (p = .02). In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine the causes.

The military environment: risk factors for women's non-fatal assaults.

Little is known regarding environmental exposures for non-fatal violence toward women in the workplace. We sought to identify factors associated with non-fatal physical assault occurring to women during military service. A cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service was conducted; 537 women were interviewed. Twenty-three percent experienced non-fatal physical assault during military service. Rates of assault were consistent across eras of service. Military environmental exposures, including sexual harassment allowed by officers (P < 0.0001) and unwanted sexual advances while on duty (P < .0001) and in sleeping quarters (P < 0.0001), were independent risk factors for assault. Environmental factors in the military workplace, including leadership behavior, appeared to promote violence toward military women. Such occupational factors can be identified and should be eliminated.

Persistence of impaired functioning and psychological distress after medical hospitalization for men with co-occurring psychiatric and substance use disorders.

OBJECTIVE: To measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans. DESIGN: A random sample followed observationally for 1 year after study enrollment. SETTING: Inpatient medical and surgical wards at 3 university-affiliated Department of Veterans Affairs Medical Centers. PATIENTS/PARTICIPANTS: A random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%). MEASUREMENTS AND MAIN RESULTS: All participants were administered a computerized structured psychiatric diagnostic interview for 13 psychiatric (include substance use) disorders and received longitudinal assessments at 3 and 12months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P <.05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P <.001) except physical functioning (P <.05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services. CONCLUSIONS: General medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated posthospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time.

Depression after alcohol treatment as a risk factor for relapse among male veterans.

We examined the association between relapse-to-drinking and depressive symptomatology measured during inpatient treatment for alcohol disorder and 3 months posttreatment. Data were obtained from 298 veterans who completed 21-day inpatient treatment. Follow-up interviews were conducted at 3, 6, 9, and 12 months posttreatment. We used multiple logistic regression to assess the association between relapse and baseline/3-month posttreatment measures of depression (Beck Depression Inventory; BDI), controlling for important covariates. Our results showed that (a) the mild-to-moderately symptomatic participants (BDI = 14-19) at 3 months posttreatment were on average 2.9 times more likely than the nondepressed to have relapsed across follow-ups, and (b) the severely symptomatic participants (BDI = 20+) at 3 months posttreatment were on average 4.9 times more likely to have relapsed across follow-ups. Other analyses revealed that those with persistent depressive symptomatology reported at both baseline and 3 months posttreatment did not experience worse outcomes that those who reported symptomatology at 3 months posttreatment alone.

Barriers to and need for alcohol services for women in rural populations.

BACKGROUND: This article reviews and summarizes the research on alcohol problems and issues related to alcohol services for rural women. METHODS: We discuss the prevalence of alcohol problems, help-seeking behavior and barriers to help-seeking for rural women and suggest directions for future research for rural women with alcohol problems. We also address key methodological issues in measuring rurality that must be considered when designing research on rural women. RESULTS: Little is known about these topics, specifically for rural women, and much has to be currently inferred either from studies of psychiatric disorders in rural populations, from studies of urban or suburban women, or from general research about rural life. CONCLUSIONS: Increased knowledge regarding specific issues for women with alcohol problems in rural areas, particularly about gender-specific barriers to obtaining services and gender-specific needs for particular services, will be beneficial for developing programs designed to meet the unique needs of this group of women.

Health-related consequences of physical and sexual violence: women in the military.

OBJECTIVES: To identify differences in health-related quality of life among women veterans who were raped, physically assaulted (not in the context of rape or domestic violence), both, or neither during military service. METHODS: We did a cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service. A stratified survey design selected subjects according to era of service and location. The interview included socioeconomic information, lifetime violence history, the Women's Military Environment Survey to assess women's military experiences, and the Medical Outcomes Study Short Form-36 to assess health-related quality of life. RESULTS: Five hundred thirty-seven women completed the interview. Half (48%) experienced violence during military service, including rape (30%), physical assault (35%), or both (16%). Women who were raped or dually victimized were more likely to report chronic health problems, prescription medication use for emotional problems, failure to complete college, and annual incomes less than $25,000 (P <.05). Women who were physically assaulted or raped reported significantly lower health-related quality of life (P <.05). Those who had both traumas reported the most severe impairment, comparable to women with chronic illnesses. CONCLUSION: This study suggests that the sequelae of violence against women are an important public health concern. More than a decade after rape or physical assault during military service, women reported severely decreased health-related quality of life, with limitations of physical and emotional health, educational and financial attainment, and severe, recurrent problems with work and social activities.

A comparison of substance abuse patients' and counselors' perceptions of relapse risk: relationship to actual relapse.

This study compared substance abuse patients' and their counselors' perceptions of relapse risk during treatment and evaluated whether these perceptions predict actual relapse 2 years later. Participants (N = 240) completed the Relapse Risk Index (RRI), which assesses confidence in abilities and need for services across four domains: coping skills, social support, resources, and leisure activities. Participants reported greater confidence and greater needs than counselors reported. Determinants of counselors' relapse risk perceptions included income, whereas participants' perceptions were related to polysubstance use. Counselors' ratings of coping skills predicted alcohol relapse; counselors' ratings did not predict drug relapse. Participants' ratings of coping skills and leisure activities predicted alcohol relapse; social support predicted drug relapse. When including background characteristics, counselors' ratings did not predict alcohol or drug relapse; participants' ratings predicted alcohol relapse but not drug relapse. Findings suggest the potential utility of considering patient perceptions to understand and possibly prevent relapse.

Predictors of patient entry into alcohol treatment after initial diagnosis.

To improve the quality of care for alcohol-related disorders, key transitions in the continuum of care, including treatment entry, must be fully understood. The purpose of this study was to investigate identifiable predictors of patient entry into a substance-use treatment program following the initial diagnosis of an alcohol-related disorder on a medical or surgical inpatient unit. An administrative computerized database was used to identify the sample for this study. Inpatient and outpatient records were obtained from the Little Rock VAMC/DHCP. Predictors of patient entry into treatment within six months of the initial diagnosis of an alcohol related disorder included age younger than than 60 (odds ratio [OR] = 4.6), not married (OR = 1.7), primary diagnosis of an alcohol-related disorder (OR = 7.7), diagnosis of a comorbid drug (OR = 4.3) or psychiatric disorder (OR = 3.6), diagnosis by a medical as opposed to a surgical specialty (OR = 6.0), and African American (OR = 1.7).

Rural at-risk drinkers: correlates and one-year use of alcoholism treatment services.

OBJECTIVE: The purpose of this study was to identify a community sample of rural and urban at-risk drinkers, to compare them in terms of sociodemographics, access measures and severity of illness, and to study them prospectively to identify rural/urban differences in use of 12-month alcoholism treatment services. METHOD: A brief telephone screening interview of over 12,000 respondents in six southern states identified a sample of at-risk drinkers. A baseline interview was administered to 733 individuals (67% men, 50% rural residents) that obtained information on substance use and psychiatric disorders, psychosocial factors, social support, four dimensions of access to alcoholism treatment services and prior alcoholism service use. Interviews at 6 and 12 months obtained self-reports of subsequent receipt of alcoholism treatment services. RESULTS: We identified modest differences between rural and urban at-risk drinkers. The rural sample was significantly less well-educated and reported significantly less affordability, accessibility and acceptability of some treatment services (p < .05). Rural at-risk drinkers also appeared to possess significantly greater illness characteristics, including more lifetime DSM-IV criteria for alcohol use disorders, more frequent recent alcohol disorders and more chronic medical problems (p < .05). The longitudinal sample comprised 579 participants, of whom 7% reported receiving some form of alcoholism treatment services in the year after the initial interview. In bivariate analysis, rural drinkers in the sample reported greater use of help for their drinking, more use of psychiatrists and more use of inpatient, outpatient and ER treatment settings than did their urban counterparts. However, significant independent predictors of 12-month alcoholism treatment use in multiple logistic regression were female gender (OR = 0.3), greater social support (OR = 2.2) and illness or severity characteristics including recent diagnosis of alcohol dependence (OR = 3.3), social consequences of drinking (OR = 1.7), concurrent medical problems (OR = 2.1) and prior treatment experience (OR = 4.4). CONCLUSIONS: We found modest differences among rural and urban at-risk drinkers and some evidence of greater barriers to treatment and greater illness severity among rural inhabitants. Further research is needed to know whether community interventions with social networks and other interventions to improve social support may help bring at-risk drinkers into treatment in both urban and rural settings as well as provide other support for sobriety.

Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose.

OBJECTIVE: This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. DESIGN, SETTING, PARTICIPANTS: The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. MAIN OUTCOME MEASURE: The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. RESULTS: At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n = 69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. CONCLUSIONS: Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.

Rural and urban problem drinkers in six Southern states.

In 1994-1997 we conducted a four-wave longitudinal study of rural and urban problem drinkers in six Southern United States states to examine rural/urban differences in predictors of service use and course of drinking. This report describes early rural/urban differences from a brief interview with over 3,000 community individuals and among 525 identified problem drinkers. Overall, we found rural/urban differences in alcohol consumption at the community level but only demographic differences among problem drinkers. Our newly developed screening interview for alcohol disorders had excellent agreement (kappa = 0.72) for lifetime disorders and good agreement (kappa = 0.53) for recent disorders against structured diagnostic interviews for DSM-IV criteria.