Sources of diagnostic uncertainty for chronically psychotic cocaine abusers.

OBJECTIVE: This study determined the sources and frequency of diagnostic uncertainty for patients with chronic psychosis and active cocaine abuse or dependence and assessed the usefulness of prospective follow-up in clarifying diagnosis. METHODS: A total of 165 male patients with chronic psychoses and cocaine abuse or dependence on inpatient units of a Veterans Affairs medical center were evaluated using the Structured Clinical Interview for DSM-III-R (SCID-R), urine tests, hospital records, and interviews with collateral sources. An algorithm allowing key SCID-R items and diagnostic criteria to be designated as provisionally met or uncertain was applied, resulting in a provisional diagnosis and a list of alternate diagnoses. The assessment was repeated 18 months later in an attempt to resolve diagnostic uncertainty. RESULTS: In 30 cases (18 percent), initial assessment produced a definitive diagnosis, including 21 cases of schizophrenia, six of schizoaffective disorder, and three of psychostimulant-induced psychotic disorder. In the other 135 cases, a definitive diagnosis could not be reached because of one or more sources of diagnostic uncertainty, including insufficient periods of abstinence (78 percent), poor memory (24 percent), and inconsistent reporting (20 percent). Reassessment at 18 months led to definitive diagnoses in 12 additional cases. CONCLUSIONS: It was frequently difficult to distinguish schizophrenia from chronic substance-induced psychoses. Rather than concluding prematurely that psychotic symptoms are, or are not, substance induced, clinicians should initiate treatment of both psychosis and the substance use disorder in uncertain cases. The persistence or resolution of psychosis during abstinence and additional history from the stabilized patient or collateral sources may clarify the diagnosis.

Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence.

OBJECTIVE: The study investigated whether contingency management could reduce cocaine use by patients with schizophrenia. METHODS: An A-B-A research design, with two-month baseline, intervention, and follow-up phases, was used to study two homeless, treatment-resistant male outpatients with DSM-III-R diagnoses of schizophrenia and cocaine dependence. During the intervention phase, subjects provided daily urine specimens for testing for the cocaine metabolite benzoylecgonine (BE) and received $25 for each negative test. Concentrations of BE and metabolites of other illicit drugs were assayed twice a week to determine the amount of drug use in addition to frequency. Analysis of variance was used to compare drug use during the three study phases. RESULTS: During the intervention, the proportion of tests positive for cocaine was lower for both subjects. Mean urinary concentrations of BE were significantly lower during the intervention than during the baseline. CONCLUSIONS: These results suggest that modest monetary reinforcement of abstinence may decrease cocaine use among cocaine-dependent patients with schizophrenia.

Continuous quality improvement in the care of older patients with hip fractures.

Economic restraints are forcing hospitals to develop and implement patient centered, cost-effective care approaches. This article describes how the quality of care to older patients with hip fractures was improved using Continuous Quality Improvement (CQI) and Managed Care processes. During a six month project, twenty five female patients were treated. Outcomes demonstrated that using CQI and Managed Care are effective in reducing mortality, complications and length of stay. As well, staff and patient satisfaction were very high. The structure, process and outcomes of this project are discussed.

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?

BACKGROUND: Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS: We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS: Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS: Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.

Effectively treating stimulant-abusing schizophrenics: mission impossible?

The development of effective treatment programs for dual diagnosis patients is in its initial stages, hampered by a variety of clinical, theoretical, administrative, and even sociopolitical obstacles. These patients are difficult to engage and treat effectively using standard systems of care. The Dual Diagnosis Treatment Program at the Brentwood VA Hospital integrates treatment for both stimulant abuse and chronic psychosis within one comprehensive program, emphasizing continuous treatment teams, optimal pharmacological management, behavior-shaping strategies, skills-training techniques, and assertive case management. The combination of these treatment approaches within one program appears to have helped some patients in our preliminary, one-year experience. Future publications will describe results from controlled outcome comparisons of DDTP with customary VA care.

Evidence for membrane microheterogeneity in the sarcoplasmic reticulum of fast twitch skeletal muscle.

Sarcoplasmic reticulum (SR) from rabbit back muscles can be readily subfractionated into two morphologically and compositionally different vesicular populations, SRH (heavy) and SRL (light) derived from terminal cisternae and longitudinal SR, respectively. Polyacrylamide gels indicate that SRH contains most of the calsequestrin. Quantitation of freeze-fractured isolated preparations reveals that, while differences in vesicular dimensions are seen in SRH and SRL, the intramembrane particle (Ca2+ ATPase) density is identical. Phospholipid headgroup composition is the same in SRH and SRL, but fatty acyl moieties show significant differences in the ratio of saturated to unsaturated phospholipids in the two fractions. The vesicular dimensions of the purified Ca2+-ATPases, SRHP and SRLP, from the two fractions are identical, but the freeze-fracture particle density is higher in the SRLP fraction. The phospholipid composition remains similar after purification, but the differences in phospholipid fatty acyl composition of the preparations are maintained. SRH and SRHP contain almost twice as much of the unsaturated species as compared to SRL and SRLP. Differences in intramembrane particle density in purified fractions, thermotropic segregation of particles in freeze-fractured purified fractions, as well as differences in turnover of the acyl phosphate, appear to reflect the differences in fatty acyl chain composition of the two SR fractions and provide evidence of microheterogeneity in lipid-protein environment of the SR.