Dimensional vs. categorical diagnosis in psychosis.

OBJECTIVE: To compare dimensional measures vs. categorical diagnosis of psychopathology in their prediction of disability and outcome in psychotic illness. METHOD: A community study of 980 subjects with psychotic illness was included in the Australian National Survey of Mental Health and Wellbeing. The study instrument [including the Schedules for Clinical Assessment in Neuropsychiatry (SCAN)] yielded symptom data along with Operational Criteria for Psychotic Illness (OPCRIT) diagnoses by several diagnostic schemata. Factor analysis of symptoms yielded five dimensions of psychopathology (positive symptoms, negative symptoms, dysphoria, mania and substance use). Variance in service demand and disability explained by the diagnostic schemata was compared with the variance explained by the dimensions of psychopathology. RESULTS: Dimensional measures of psychopathology explained more of the variance in service demand, dysfunctional behaviour, social adaptation and global occupation and function. Only use of support services and illness course were better predicted by categorical diagnosis. Dimensional scores explained significant extra variance when added to categorical diagnoses. CONCLUSION: Dimensional measures of psychopathology explain more variance in behaviour, disability and outcome than does categorical diagnosis in functional psychosis. Dimensions provided significant extra information not provided by diagnosis and would be a more useful basis for clinical management.

Characterising psychosis in the Australian National Survey of Mental Health and Wellbeing Study on Low Prevalence (psychotic) Disorders.

OBJECTIVE: This study examines the factorial structure of symptoms and signs in psychosis in data from the Study on Low Prevalence (psychotic) Disorders which is part of the National Survey of Mental Health and Wellbeing, Australia 1997-1998. METHOD: The present study examined a wide variety of symptoms taken from the Schedules for Clinical Assessment in Neuropsychiatry items and the substance use items in the Diagnostic Interview for Psychosis, an instrument specially constructed for the national study. The instrument was applied to 980 community and hospital subjects with a wide range of psychotic illness diagnoses. The data were factor analysed and scales of 'domains of psychopathology' derived. RESULTS: The data were best fitted by five principal factors ('domains') which can be approximately labelled dysphoria, positive symptoms, substance use, mania and negative symptoms/incoherence. These factors together explained 55.4% of variance in symptoms. Solutions with more numerous factors did not improve the representation. CONCLUSION: The five domains successfully characterise a large part of the variance in psychopathology found in the present study of low prevalence (psychotic) disorders. The approach allows sufferer's symptom range and severity to be well expressed without multiple comorbid diagnoses or the limits imposed by categorical diagnosis. Knowledge of alternative dimensional representations of psychopathology may usefully complement our use of categories, enhance awareness of symptoms and ensure that important psychopathology is heeded in practice and research.

Efficacy of continuing advocacy in involuntary treatment.

OBJECTIVE: The effectiveness of an experimental model of personal advocacy for involuntarily hospitalized psychiatric patients was examined. In the model, a personal advocate represented the needs and best interests of patients throughout the period of involuntary hospital treatment. METHODS: The sample consisted of 105 involuntarily hospitalized psychiatric inpatients in Canberra, Australia. Fifty-three consecutive patients received personal advocacy, which started soon after they entered the hospital and lasted through the commitment process to the time of discharge from involuntary care. The outcome of this group was compared with that of 52 consecutive patients in a control group who received routine rights advocacy from hospital entry through the commitment hearing only. RESULTS: The experimental and control groups were similar in demographic characteristics, diagnosis, and severity of illness. At the start of hospital care, satisfaction with care was similar in both groups; however, it improved significantly in the experimental group while it declined in the control group. Aftercare attendance was significantly better in the experimental group. The experimental subjects' risk of involuntary rehospitalization was less than half the risk of control subjects, and community tenure was significantly increased. Clinical staff reported that the experimental advocacy facilitated management of patients. CONCLUSIONS: Compared with routine rights advocacy, the experimental advocacy based on patients' needs and best interests, which was maintained throughout the patients' involuntary hospitalization, significantly improved patients' and staff members' experience of involuntary treatment. Better compliance with aftercare among patients receiving personal advocacy led to a statistically and economically significant reduction in rehospitalization.

Psychiatrists and compulsion: a map of ethics.

OBJECTIVE: The aim of this study is to analyse the ethical underpinning of involuntary treatment and to create a guide for psychiatric practice which clarifies its relationship with modern mainstream clinical ethics. METHOD: Literature on ethics, involuntary treatment, civil commitment, diagnosis and law was searched and examined. RESULT: Hospitalisation for involuntary treatment and control has blurred two important discriminations: the discrimination between clinical and social constructions of mental illness and the discrimination between therapeutic actions and policing control. Plotting these discriminations creates a map of ethics in involuntary treatment. Although there are clinical roles throughout involuntary treatment, the ethical issues vary according to whether clinical actions are taken on clinically or socially constructed diagnosis and whether the purpose of the actions is therapy or control. CONCLUSION: Paternalist involuntary treatment should be undertaken more readily when it is for clinically defined illness and for the benefit of the patient. Where the conditions are defined by social behaviours alone, where treatment is not useful to the patient, or where actions have policing intent, particular ethical approaches need to be taken to defend the patient, the clinician-patient relationship and the reputation of the profession.

Computerised diagnosis in acute psychiatry: validity of CIDI-Auto against routine clinical diagnosis.

The validity of the self-administered CIDI-Auto for detecting ICD-10 diagnoses was assessed in a study of 126 patients admitted to an acute psychiatry unit. A comparison was made between the level of agreement of the CIDI-Auto with a psychiatrist and that between two psychiatrists. The CIDI-Auto generated an average of 2.3 diagnoses per subject, and the psychiatrists 1.3. Agreement measured by overall agreement and by Kappas between the CIDI-Auto and the psychiatrist's principal diagnosis was poor, whereas agreement between psychiatrists was good. At the level of general diagnostic class (e.g. substance use disorder, schizophrenic disorder, mood disorder), agreement between CIDI-Auto and psychiatrist on principal diagnosis was poor, Kappa = 0.23, while agreement between psychiatrists was good, Kappa = 0.69. The findings indicate that the self-administered CIDI-Auto has poor validity measured against clinical diagnosis for hospitalised patients of acute psychiatric services. Poor validity of computer-based diagnosis limits the diagnostic utility of these methods in clinical situations. It also creates uncertainty of diagnostic findings in survey use.

Clinical utility and patient acceptance of the computerized Composite International Diagnostic Interview.

OBJECTIVE: The study evaluated the utility to clinicians and the acceptability to patients of the self-administered computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in an acute psychiatric setting. METHODS: Patients admitted to an acute psychiatric unit completed the CIDI-Auto. Reports of CIDI-Auto diagnoses and symptoms were given to treating psychiatrists, who completed a questionnaire evaluating the accuracy and usefulness of the reports. Patients answered a questionnaire about their attitudes toward computers before completing the CIDI-Auto, and after completing it, they answered a questionnaire about their reactions to the interview. RESULTS: Psychiatrists agreed with only 50 percent of CIDI-Auto current diagnoses and indicated that only 22 percent of CIDI-Auto reports provided useful new diagnoses, although 63 percent helped to clarify diagnoses and 58 percent could save clinicians some time. They endorsed the CIDI-Auto as a possible aid to indirect or remote diagnosis where histories would be taken by nonexpert staff. Ninety-four percent of patients liked the computerized interview, and 83 percent understood the questions without difficulty. Sixty percent felt more comfortable with the computerized interview than with a doctor. Education and previous computer experience promoted positive attitudes and satisfaction with the computerized interview. CONCLUSIONS: Psychiatrists considered the current CIDI-Auto completed by patients to be of limited value in diagnosis and history taking. Despite patients' acceptance and positive reactions to the computer interview, satisfactory computerized diagnosis is yet to be attained.

Acute psychiatric beds: distribution and staffing in NSW and ACT.

This study examined the availability and staffing of acute psychiatry beds in NSW and ACT. "Gazetted" acute psychiatry hospitals (which take compulsory admissions under mental health law) were polled directly for bed numbers, occupancy and staffing for the year 1990-1991. The NSW Department of Health provided beds numbers for non-gazetted and private hospitals. Four analyses sequentially reallocated beds according to the origin of patients to estimate acute bed availability and use by regional populations. Socio-demographic determinants of acute admission rates were measured. Acute "gazetted" beds averaged 13.2 per 100,000 population but ranged from 6.9 to 49.1 per 100,000 when cross-regional flows were considered. "Non-gazetted" beds raised the provision to 15.5 per 100,000 and private beds raised provision further to 24.5 per 100,000. Inner metropolitan provision was higher than rural or provincial provision. The only determinant of the admission rate to gazetted beds was the number of available beds. Bed availability did not affect either bed occupancy or referral of patients to remote hospitals. Nursing staffing of gazetted units was reasonably uniform, although smaller units had significantly more nurses per bed. Medical staffing was highly variable and appears determined by staff availability. The average provision of acute psychiatric beds approximates lowest levels seen in international models for psychiatric services. Average occupancy rates suggest that there is not an overall shortfall of acute psychiatric beds, but uneven bed distribution creates barriers to access. Referral of patients to remote hospitals is not related to actual bed provision in the regions, but appears to reflect attitudes to ensuring local care. Recommendations about current de facto standards are made. Current average nursing and medical staffing standards are reported.

Cytokine-induced expression of vascular cell adhesion molecule-1 (VCAM-1) by astrocytes and astrocytoma cell lines.

Astrocytes in the central nervous system (CNS) associate intimately with vascular endothelial cells and are integral to the blood-brain barrier (BBB). Leukocyte transmigration across the BBB is a cardinal feature of CNS inflammation, as observed in experimental autoimmune encephalomyelitis, and very late antigen-4 (VLA-4)/vascular cell adhesion molecule-1 (VCAM-1) interactions have recently been proposed as essential for this process. VCAM-1 expression by astrocytes was recently reported. We addressed the regulation of VCAM-1 expression by inflammatory cytokines in primary human astrocytes and two human astrocytoma cell lines. Astrocytoma cells up-regulated surface VCAM-1 expression in response to cytokines in the following order: IFN-gamma plus TNF-alpha > IFN-gamma plus IL-1 beta > TNF-alpha > IFN-gamma. Cytokine-activated astrocytoma cells expressed 7-domain VCAM-1, as indicated by accumulation of 3.2-kb VCAM-1 mRNA and immunoprecipitation of a 100-kDa protein with anti-VCAM-1 mAb. Lymphoblast adhesion to cytokine-activated astrocytoma cell monolayers was significantly blocked by mAb specific for VCAM-1 and VLA-4, indicating that astrocytoma cell VCAM-1 was functional. Astrocytoma cell expression of VCAM-1 could be a constituent of the astrocyte phenotype. To support this possibility, we demonstrated that cytokine-treated adult human and rat primary astrocytes expressed VCAM-1, and the rank order of cytokine potency for VCAM-1 induction in primary and neoplastic astrocytes was strikingly similar. This is the first documentation of VCAM-1 expression by adult human astrocytes. Expression of VCAM-1 by astrocytes at the BBB could play a role in mononuclear leukocyte entry into the CNS.

Mental health law: an idea whose time has passed.

In this paper I argue that specific mental health law should not exist and should be replaced by modern guardianship law which is non-discriminatory and which intervenes according to need rather than diagnostic classification. Substituted consent provided by a guardian protects the patient and the treatment provider. Custody to prevent danger to others should remain with courts rather than informal proceedings where individual rights to freedom are less carefully protected. Special mental health law stigmatises people with mental illness and degrades their treatment. It also diminishes the standing of the psychiatric profession which advocates the continuation of such laws.

Inequalities in the regional distribution of private psychiatric services provided under Medicare.

An analysis was carried out on Medicare data to find out if there are inequalities in the geographical distribution of private psychiatric services in Australia. The number of psychiatric services and persons becoming patients per 100,000 population was calculated for each federal electorate for the year 1985/86 and related to social indicators derived from the 1986 census. As a comparison, services provided by consultant physicians were analyzed as well. The data were based on the electorate of the patient rather than the electorate of the practitioner. Consultant psychiatrist services were found to be received more often in high socio-economic status electorates and those with older populations, and less often in rural areas. A similar pattern was found for consultant physician services, although the relationship with socio-economic status was not as strong. Frequent psychiatric consultations of longer duration, which are an indicator of insight psychotherapy, were more common in higher socioeconomic status electorates. A limitation of the Medicare data is that they cover only private services. To overcome this limitation, a supplementary analysis was carried out on the distribution of consultations for mental disorders using data from the National Health Survey. These data confirmed that individuals of high socio-economic status with a mental disorder are more likely to receive specialist treatment.

Syn-capping of human T lymphocyte adhesion/activation molecules and their redistribution during interaction with endothelial cells.

Lymphocyte-endothelial cell interactions are mediated in part by multiple lymphocyte surface adhesion/activation molecules and their cognate ligands. We investigated the surface localization of several of these molecules implicated in T cell adhesion and transendothelial migration mechanisms to determine if spatial regulation of their distribution contributes to these processes. T lymphocyte suspensions were stained to define distribution, ability to be aggregated into energy-dependent caps, and potential cocapping of several adhesion structures. CD2, CD44, L-selectin (LAM-1, LECCAM-1), and CD11a/CD18 (LFA-1) exhibited uniform distribution on the T cell surface by direct immunofluorescence but formed caps in an energy-dependent, and therefore cytoskeletally driven, manner when examined by indirect immunofluorescence. CD2 was shown to syn-cap (unidirectionally cocap) with CD44 and CD11a/CD18 (LFA-1), an observation potentially related to functional cooperation among these molecules in T cell activation. T cells were also added to endothelial cell monolayers to assess, in a physiologically relevant context, potential surface molecule reorganization. Lymphocytes co-cultured with human umbilical vein endothelial cells (HUVEC) underwent a profound shape change, from essentially round cells to polarized cells bearing pseudopodia. Immunofluorescent localization of T cell adhesion/activation molecules using confocal microscopy revealed the redistribution of CD2, CD44, and L-selectin to the pseudopod. In contrast, CD11a/CD18 remained globally distributed on the cell surface, even in severely deformed cells. Both lymphocyte shape change and membrane molecule redistribution appear to be cell-cell contact-dependent phenomena requiring intact, viable endothelial cells. Mechanisms that control these events may be critical to lymphocyte recirculation and inflammation.

General practitioner services under Medicare.

This paper examines how general practitioner numbers, bulk-billing rates and sociodemographic variables determined usage of general practitioners and services delivered over the period from 1984 to 1990. A 10 per cent sample of patient services, maintained by the Commonwealth Department of Health, Housing and Community Services, provided the data. Data were aggregated into 148 electorates. Separate regression analyses examined the determinants of the proportion of the population attending a general practitioner and of the number of general practitioner services delivered per patient. Determinants of the growth of these levels over the seven-year period were also examined. Region (metropolitan versus rural), age structure and general practitioner supply were significant factors in these analyses. Bulk-billing rates explained nine per cent of variance in patient numbers and 22 per cent of variance in service numbers after sociodemographic variables and general practitioner supply had been taken into account. The analyses suggest that bulk-billing and general practitioner supply influence the behaviour of patients and doctors and that the effect of bulk-billing is independent of indices of medical need. This implies that bulk-billing may increase service rates and this increase is not clearly directed to improving access to medically necessary services. Because no measures of treatment outcome are available. it is not possible to decide whether the effects observed represent an improvement in health care or are better seen as overuse by patients and demand inducement by practitioners.

Trends in general practitioner distribution from 1984 to 1989.

An analysis of the distribution of general practitioners by electorates during the six years 1984 to 1989 showed that the maldistribution of practitioners in Australia has worsened despite significant increases (26%) in total general practitioner numbers. One in five rural electorates had worse population-to-general-practitioner ratios in 1989 than in 1984. The changes in distribution of general practitioners ran counter to the changes in distribution of the population over the period studied. In 1984, the 38.7% of the population living in rural Australia was served by 33% of the nation's general practitioners. By 1989, more of the population (39.8%) lived in rural areas but they were served by a smaller proportion (32%) of the general practitioner workforce. It is clear that many urban electorates have fewer people per general practitioner than the most generous ideal ratios, while most rural electorates have more people per general practitioner than the least generous.

Cell surface glycoconjugates in intercellular and cell-substratum interactions.

Progress in understanding the role of the carbohydrate moieties of cell surface adhesion molecules is evaluated. Functional roles of the oligosaccharides of extracellular matrix glycoproteins are also considered. Selected examples of glycoconjugate participation in cell-cell and cell-substratum interactions are presented with emphasis on systems in which structures of functionally important glycosyl moieties of glycoproteins and glycolipids have been determined. Where available, cases of altered cell adhesive behavior attributable to transformation-associated alterations in glycosylation of adhesion molecules are cited.