The use of clinical photography by UK general dental practitioners.

AIM: The aim of this study was to assess by means of a postal questionnaire the numbers of general dental practitioners (GDPs) who used clinical photography and for what application. METHOD: The questionnaire was distributed to 1,000 randomly selected dentists in the UK with an explanatory letter and reply paid envelope. The data collected was computerised and analysed statistically. RESULTS: Five hundred and sixty-two replies were received. Of the respondents, 48% used clinical photography, with 59% using a digital camera, 34% a 35 mm camera and 19% a video camera. Principal uses of clinical photography were treatment planning (84%), patient instruction/motivation (75%), medico-legal reasons (71%) and communication with the laboratory (64%). CONCLUSION: Clinical photography was used by 48% of general dental practitioner respondents.

Recruitment, engagement, and retention of people living with HIV and co-occurring mental health and substance use disorders.

People living with HIV/AIDS who have both a co-occurring mental health diagnosis and a substance use disorder (individuals with triple diagnoses) frequently do not receive adequate treatment for one or more of their illnesses. Poverty, risky behaviours, vacillating motivation, and cognitive impairments are additional problems facing many individuals with triple diagnoses. In many communities the service system is inadequately prepared to serve this population. Treatment barriers include stigma associated with the three illnesses, separate funding streams, and lack of co-ordination between medical, mental health, and substance abuse treatment facilities. This paper discusses strategies for recruiting, engaging, and retaining individuals with triple diagnoses in both treatment and research. Recruitment strategies should be directed at both professionals and individuals with triple diagnoses themselves. Recruiting and engaging these individuals in treatment requires that comprehensive services be provided on a 24-hour basis in a flexible and culturally competent manner. A team approach is often the most effective way of providing such services. Retaining individuals with triple diagnoses in a longitudinal research study requires multiple strategies including the collection of detailed tracking information, outreach workers, and financial incentives for completing the interviews.

Prototypical profiles of the Brief Psychiatric Rating Scale.

Three prototypical profiles of the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) were isolated using a Q-type factor-analytic strategy with a sample of homeless men with mental illness (N=165). The 3 profiles--depressed, actively psychotic, and withdrawn--were used to study changes in BPRS profiles over time in a control group and a group that received assertive community treatment (ACT). Over2 time periods (inception to 12 months and 12-24 months), the 2 groups did not differ in terms of changes in profile shape, but they did differ in terms of changes in profile elevation. The ACT group evidenced a decrease in symptom severity during the last 12 months, whereas the control group showed an increase. Although changes in profile shape in both groups did occur, there was a significant tendency for the shape of the BPRS profiles to remain stable from the inception of the study to the 12-month assessment and from that time to the 24-month assessment. We describe the uses of these prototypical profiles and discuss the applicability of this analytical approach to other assessment instruments.

Do consumers who have a choice of treatment have better outcomes?

This study used a non-equivalent control group design to investigate the effect of consumer choice of treatment on both process and outcome variables. All study participants suffered from severe mental illness, were homeless at baseline, and were enrolled in a modified Assertive Community Treatment (ACT) program. Consumers in the choice condition had selected the ACT program from a menu of five treatment programs; clients in the no-choice condition were simply assigned to the ACT program by an intake worker. Results found that consumers in the choice condition visited the ACT staff at their offices more than consumers in the no-choice condition, but there were no significant differences between groups on the other treatment process variables. Although consumers in the choice condition increased their income more than consumers in the no-choice condition, there were no significant differences between groups on the other outcome variables (stable housing, psychotic symptoms, depression, and substance abuse).

The helping alliance in case management for homeless persons with severe mental illness.

This study examined the role of the helping alliance in case management with homeless persons who have a severe mental illness. A strong alliance after two months of treatment was marginally associated with three outcomes: higher consumer satisfaction, less severe global symptom severity, and greater hostility. The only outcome associated with the alliance after fourteen months of treatment was consumer satisfaction. Several variables predicted a strong helping alliance at month two, including: being African American, low hostility, more perceived needs, and more program contacts. The only variable that predicted a strong alliance at month fourteen was a strong alliance at month two.

The impact of assertive community treatment on the social relationships of people who are homeless and mentally ill.

Two randomized experiments compared the effectiveness of the assertive community treatment (ACT) team against other treatments (outpatient therapy, drop-in center, and brokered case management) in improving the social relationships of individuals who were both homeless and suffered from severe and persistent mental illness. In both studies clients assigned to ACT teams reported having more professionals in their social networks than clients assigned to the other treatments. Clients did not report significant differences between treatment conditions on most of the other social relationship dimensions. Further attention to developing social skills and network interventions within ACT teams are recommended.

Factor structure of the expanded Brief Psychiatric Rating Scale.

This study investigated the factor structure of the expanded Brief Psychiatric Rating Scale (BPRS) on a sample of severe mentally ill homeless individuals. A confirmatory factor analysis using the Oblique Multiple Group method supported the typical five factor solution found in previous studies with the original BPRS. The five factors were labeled Thinking Disorder. Withdrawal. Anxiety-Depression, Hostility-Suspicion, and Activity. Alpha coefficients for four of the scales ranged from .73 to .81; however, the alpha coefficient for the Hostility-Suspicion scale was only .49.

An experimental comparison of three types of case management for homeless mentally ill persons.

OBJECTIVE: Three types of case management were compared to determine their relative effectiveness in helping people with severe mental illness who were homeless or at risk of homelessness. METHODS: Subjects recruited from a psychiatric emergency room and inpatient units were randomly assigned to one of the three treatment conditions: broker case management, in which the client's needs were assessed, services were purchased from multiple providers, and the client was monitored; assertive community treatment only, in which comprehensive services were provided for an unlimited period; and assertive community treatment augmented by support from community workers, who assisted with activities of daily living and were available for leisure activities. Of 165 subjects recruited, 135 were followed for 18 months. RESULTS: Compared with clients assigned to broker case management, clients assigned to assertive community treatment only and assertive community treatment with community workers had superior outcomes on several variables. They were number of contacts with the assigned treatment program, resource utilization (for example, use of entitlements), severity of thought disorder, activity level, and client satisfaction. Clients in the assertive community treatment only condition achieved more days in stable housing than those in the other two treatment conditions. No significant treatment group effects were found on income, self-esteem, or substance abuse. CONCLUSIONS: Assertive community treatment is superior to broker case management in assisting individuals with serious mental illness who are at risk of homelessness.

Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients.

OBJECTIVE: In this study the authors compared the cost-effectiveness of three approaches to case management for individuals with severe mental illness who were at risk for homelessness: assertive community treatment alone, assertive community treatment with community workers, and brokered case management (purchase of services). METHOD: Individuals were randomly assigned to the three treatment conditions and followed for 18 months. Eligibility requirements included a severe DSM-III axis I diagnosis, such as schizophrenia, and either current homelessness or risk for homelessness based on prior history of homelessness. Participants were recruited from the emergency rooms and inpatient units of local psychiatric hospitals. Data on 85 people were available for analyses: 28 in assertive community treatment alone, 35 in assertive community treatment with community workers, and 22 receiving brokered case management (purchase of services). RESULTS: Clients assigned to the two assertive community treatment conditions had more contact with their treatment programs, experienced greater reductions in psychiatric symptoms, and were more satisfied with their treatment than clients in the brokered condition. There was no statistically significant difference between treatment conditions in terms of the total costs of treating the participants. However, the assertive community treatment conditions spent less money on inpatient services than brokered case management, but more on case management services and maintenance (i.e., food stamps, housing subsidies, and Supplemental Security Income payments). CONCLUSIONS: Assertive community treatment has better client outcomes at no greater cost and is, therefore, more cost-effective than brokered case management.

Outreach to homeless mentally ill people: conceptual and clinical considerations.

This paper describes a model of outreach predicated on developing a trusting, meaningful relationship between the outreach worker and the homeless person with mental illness. We describe five common tasks inherent in this model of outreach (establishing contact and credibility, identifying people with mental illness, engaging clients, conducting assessments and treatment planning, and providing ongoing service). Other issues discussed include: (a) Responding to dependency needs and promoting autonomy; (b) setting limits while maintaining flexibility; (c) resistance to mental health treatment and follow-up service options.

Helping homeless mentally ill people: what variables mediate and moderate program effects?

This process evaluation study examined what variables moderate and mediate treatment effects on days in stable housing and client satisfaction for homeless mentally ill clients. In general, demographic characteristics did not moderate either outcome variable. Housing contacts, entitlement contacts, mental health contacts, and supportive services were significant mediators of the treatment effect on days in stable housing. Program contacts, mental health contacts, and supportive services were significant mediators of client satisfaction.

Experimental comparison of the effects of three treatment programs for homeless mentally ill people.

A longitudinal experimental design was used to compare the effectiveness of three community-based treatment programs serving homeless mentally ill people: traditional outpatient treatment offered by a mental health clinic, a daytime drop-in center, and a continuous treatment team program that included assertive outreach, a high staff-to-client ratio, and intensive case management. At 12-month follow-up, clients in all three treatment programs spent fewer days per month homeless, showed fewer psychiatric symptoms, and had increased income, interpersonal adjustment, and self-esteem. Clients in the continuous treatment program had more contact with their treatment program, were more satisfied with their program, spent fewer days homeless, and used more community services and resources than clients in the other two programs.

Predicting psychiatric symptoms among homeless people.

Multiple regression was used to predict psychiatric symptoms among homeless people. The following variables were significant predictors of psychiatric symptoms: current life satisfaction, previous psychiatric hospitalization, the number of stressful life events, social support, problem drinking, and childhood unhappiness. The results are discussed in terms of their policy and practice implications, particularly the need for crisis intervention services and for dual-diagnosed clients.

Correlates of problem drinking among homeless men.

Multiple regression analysis was used to identify correlates of problem drinking among 165 homeless men in St. Louis, Missouri. Variables that were the strongest predictors of alcoholism included number of stressful events before becoming homeless, age, current life satisfaction, psychopathology, and prior mental hospitalization. The full-scale model predicting problem drinking produced a total explained variance (R2) of .38. In contrast with findings from previous research on the homeless, the length of time homeless and the degree of transience were not predictive of alcoholism. Similarly, social support had no impact on problem drinking.

A comparison of taxonomic systems for classifying homeless men.

The present study compared the relative merits of two taxonomic systems for classifying homeless men. One system classified homeless men based on their past history of psychiatric disability. The other system classified individuals on the basis of their current psychiatric impairment. Both classification systems displayed significant discriminating power using a set of predictor variables that included demographic variables, childhood happiness, current life satisfaction, social support, stressful life events, and history of homelessness. Based on the percentage of correct classifications the system based on current impairment was superior to the system based on past history.

"Double trouble" phenomenon. Treatment of teens with both psychiatric and substance abuse problems poses a new challenge.

Those in mental health services face a new, exciting clinical challenge for inpatient treatment: the dual-diagnosis mental health patient. The term refers to the presence of emotional disturbance and chemical dependency in the same patient. Only recently have hospitals begun to consolidate psychiatric and addiction treatment services into special units. Such a consolidation occurred in the creation of the Penrose Adolescent Treatment Services (PATS) unit at Penrose Hospital, Colorado Springs, CO. From the beginning, PATS was planned as a "dual-capability" treatment center to treat chemical dependency and psychiatric conditions in separate, distinct tracks in the same milieu. A third track was to focus on the needs of the dual diagnosis patient. Each youth was placed in a "primary" track of psychiatry or chemical dependency, with the dual-diagnosis patients borrowing the necessary services from the opposite track. To maintain the integrity of the preexisting psychiatric and chemical dependency programs, the unit adopted a case management model.

Regulation of enzyme activity in the hibernator. A kinetic and spectroscopic study of muscle pyruvate kinase from the Arctic ground squirrel.

Pyruvate kinase skeletal muscle of the Arctic ground squirrel was purified to homogeneity. The purified enzyme variants from the summer-active and winter hibernating squirrel appear to be identical with a near-neutral pI of 6.9 and a molecular weight of 234,000 as determined by gel filtration chromatography on Bio-Gel A-0.5m. Evidence for subunit interaction during inhibition by L-phenylalanine is demonstrated with ultraviolet derivative spectroscopy. A model for this interaction and its importance for a regulatory role are discussed. The absence of a temperature break in the Arrhenius plot for the pyruvate kinase reaction, the kinetic and physical data, and the near-neutral pI, suggest an amino acid composition that conserves the overall geometry and resultant kinetic behavior which render regulation of the enzyme insensitive to temperature.