A test of the reliability and validity of the Multnomah Community Ability Scale.

Previous research shows that the Multnomah Community Ability Scale (MCAS) total score is reliable and has predictive validity. This study evaluates the MCAS total and sub-scale scores on a sample of 1,250 outpatient mental health clients in Washington State. The MCAS sub-scales are reliable, and there is evidence for their concurrent validity. However, the factor structure of the MCAS only partially replicated the hypothesized sub-scales, and the authors recommend that sub-scales as currently constructed not be used as performance indicators. If only the total MCAS is of interest to users, the authors recommend using the single-item SOFAS rather than the 17-item MCAS.

Management of negative symptoms among patients with schizophrenia attending multiple-family groups.

OBJECTIVE: Outcomes for negative symptoms over a one-year period were examined in two groups of patients, one receiving psychoeducational multiple-family group treatment and one receiving standard care. METHODS: A total of 63 outpatients, ages 18 to 45 years, with DSM-IV diagnoses of schizophrenic disorders were randomly assigned to standard care or multiple-family group psychoeducation treatment at a large mental health center in Spokane, Washington. Treatment assignment was stratified by whether patients were taking typical or atypical antipsychotic medications. Negative symptom status was monitored monthly for one year by raters blind to group assignment and measured as a composite of five symptoms using the Modified Scale for the Assessment of Negative Symptoms. RESULTS: When the analysis controlled for baseline negative symptoms, participants in the multiple-family group experienced significantly reduced negative symptoms compared with those receiving standard care. Taking atypical antipsychotic medication or having a diagnosis of substance abuse was not associated with the severity of negative symptoms. An additional analysis of the five individual negative symptoms indicated small but consistent group differences on all dimensions except inattention. Negative symptoms were significantly correlated with relapse to acute illness but not with outpatient or inpatient service use. CONCLUSIONS: The study demonstrated that a psychoeducational multiple-family group intervention was more effective than standard care in managing negative symptoms over a 12-month period. The results are particularly relevant because negative symptoms are associated with relapse, poor social and occupational functioning, cognitive impairment, and lower subjective quality of life.

Predictors of burden and infectious illness in schizophrenia caregivers.

OBJECTIVE: The objective of the study was to test predictive models of schizophrenia caregiver burden and infectious illness episodes for caregivers who had regular contact with their mentally ill family members. METHODS: A nurse interviewer, blind to the patient's symptoms, caregiver burden, and psychosocial status, administered the Health Review to 70 caregivers. A second family interviewer, blind to caregiver health status and patient symptoms, assessed caregiver resources (eg, active coping and social support), vulnerabilities (eg, anger expression and passive coping) and burden. Concurrently, independent patient raters, blind to caregiver health and psychosocial status, assessed caregiver stressors. The Brief Psychiatric Rating Scale and the Modified Scale for the Assessment of Negative Symptoms were used to assess the severity of positive (eg, hallucinations and delusions) and negative (eg, anhedonia and asociality) symptoms, respectively. RESULTS: Predictive models, including measures of stressors, resources, and vulnerability factors for caregiver burden and for presence of infectious illness, were each highly significant, accounting for 40% and 29% of the variance, respectively. However, the specific measures that predicted burden and infectious illness differed. Greater burden was predicted by more severe patient negative symptoms (stressor), greater anger control and blame self-coping (vulnerability), and decreased tangible social support (resource). Presence of infectious illness episodes was predicted by more severe patient positive symptoms (stressor) and less satisfaction with social support while controlling for the frequency of reporting on the Health Review. When scores from the Brief Psychiatric Rating Scale (stressors) were categorized into quartiles, it was found that the frequency of infectious illness in the highest quartile was four times that in the lowest quartile. Other results indicated that even though burden was not associated with infectious illness, it was associated with "continuing health problems," perceived stress, and depression. CONCLUSIONS: These data indicate that although schizophrenia caregiver burden and infectious illness are predicted by measures of patient stressors, vulnerabilities, and resources, the specific measures predicting these outcomes differ. The results also call attention to the powerful influence of patient symptoms as a predictor of burden and the presence of infectious illness among caregivers.

Risk-adjusted outcome models for public mental health outpatient programs.

OBJECTIVE: To develop and test risk-adjustment outcome models in publicly funded mental health outpatient settings. We developed prospective risk models that used demographic and diagnostic variables; client-reported functioning, satisfaction, and quality of life; and case manager clinical ratings to predict subsequent client functional status, health-related quality of life, and satisfaction with services. DATA SOURCES/STUDY SETTING: Data collected from 289 adult clients at five- and ten-month intervals, from six community mental health agencies in Washington state located primarily in suburban and rural areas. Data sources included client self-report, case manager ratings, and management information system data. STUDY DESIGN: Model specifications were tested using prospective linear regression analyses. Models were validated in a separate sample and comparative agency performance examined. PRINCIPAL FINDINGS: Presence of severe diagnoses, substance abuse, client age, and baseline functional status and quality of life were predictive of mental health outcomes. Unadjusted versus risk-adjusted scores resulted in differently ranked agency performance. CONCLUSIONS: Risk-adjusted functional status and patient satisfaction outcome models can be developed for public mental health outpatient programs. Research is needed to improve the predictive accuracy of the outcome models developed in this study, and to develop techniques for use in applied settings. The finding that risk adjustment changes comparative agency performance has important consequences for quality monitoring and improvement. Issues in public mental health risk adjustment are discussed, including static versus dynamic risk models, utilization versus outcome models, choice and timing of measures, and access and quality improvement incentives.

Interleukin-2 and -6 induce behavioral-activating effects in mice.

Interleukin (IL)-1, IL-2 and IL-6 influence central monoamine activity in a cytokine-specific manner. We demonstrated that whereas IL-2 increased hypothalamic and hippocampal norepinephrine (NE) utilization, and DA turnover in the prefrontal cortex, IL-6 induced profound elevations of serotonin (5-HT) and mesocortical dopamine (DA) activity in the hippocampus and prefrontal cortex [S. Zalcman, J.M. Green-Johnson, L. Murray, D.M. Nance, D.G. Dyck, H. Anisman, A. H. Greenberg, Cytokine-specific central monoamine alterations following IL-1, -2 and -6 administration, Brain Res. 643 (1994) 40-49]. IL-1, in contrast, induced a wide range of central monoamine alterations. We presently report that these cytokines also differentially influence behavior. Profound reductions in non-ambulatory and ambulatory exploration were induced in BALB/c mice following IL-1 administration. In contrast, IL-2-treated mice displayed significant increases in the time spent engaged in non-ambulatory exploration, digging, rearing (particularly the number of free rears), and in the investigation of a novel stimulus (i.e., increased number and duration of stimulus contacts). IL-6-treated mice, moreover, exhibited significant increases in the time spent engaged in ambulatory exploration, digging and rearing (particularly the number of free rears, which tended to be of short duration). Modest increases in locomotion and grooming were also observed in IL-6-treated animals. Plasma corticosterone levels did not vary significantly as a function of IL-6 treatment. Hence, cytokine-specific behavioral-activating effects were induced following administration of IL-2 and IL-6. We suggest that these effects have adaptive significance and relevance to sickness behavior; however, pathological outcomes (e.g., schizophrenia, anxious-like states, anxious depression, motor abnormalities) could develop should these cytokines be overproduced or dysregulated.

Development of outcome indicators for monitoring the quality of public mental health care.

OBJECTIVE: The study attempted to develop a brief and integrated set of reliable and valid outcome measures that could be used by both consumers and providers to assess the quality of public mental health care. METHODS: A model of outcomes in four domains-consumer satisfaction, functioning, quality of life, and clinical status-was developed from the literature and from the priorities expressed by members of an advisory group of stakeholders. Based largely on extant measures, a consumer survey and a case manager survey were then created to assess these domains. A total of 236 adult consumers of mental health services from six community mental health centers in Washington State were surveyed. The four-item case manager survey to rate consumers' clinical status was completed by 163 of the participants' case managers. Scores and ratings on the survey were analyzed using correlational analysis and principal components analysis to determine whether the data provided empirical support for the four-domain model. RESULTS: Principal components analysis demonstrated support for the four-domain model. Internal consistency of the outcome indicators was adequate, and their concurrent validity was partly supported. CONCLUSIONS: The described outcome measures provide a practical, empirically supported structure for monitoring and improving public mental health services.

A comparison of suicidal and nonsuicidal elders referred to a community mental health center program.

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.

Representative payee practices of community mental health centers in Washington State.

OBJECTIVE: A survey was conducted to evaluate the representative payee practices of community mental health centers (CMHCs) in Washington State, with emphasis on whether and how benefit disbursement practices were linked to patients' clinical behaviors, especially substance use. METHODS: A survey was pilot tested with several clinicians and sent to all 80 licensed CMHCs in Washington State. Data were analyzed using t tests, Pearson r correlations, and regression analysis. RESULTS: Of 41 responding agencies, 30 (73 percent) reported providing payee services for at least some of their patients, approximately one-third of whom had a dual diagnosis of a mental illness plus an alcohol or drug disorder. The frequency of benefit disbursement, but not the overall amount of funds disbursed, was moderately to highly linked by contingency management to patients' money management skills, substance use, and level of functioning; it was less tightly linked to treatment attendance. Larger and more experienced programs reported tighter linkage between benefit disbursement frequency and patients' behavior than did smaller programs. Responses also indicated a significant need for more clearly articulated guidelines for payee benefit management. CONCLUSIONS: Despite a lack of studies demonstrating the effectiveness of representative payee practices, CMHCs appear to be using contingency techniques to link benefit disbursement to clinical behaviors. Further studies of these practices, their outcomes, and associated ethical issues are needed.

A model gatekeeper program to find the at-risk elderly.

This article describes the client characteristics and services needs of community-dwelling older adults found through a unique case-finding model developed at the Spokane Mental health Center. The model trains the employees of community businesses and corporations who work with the public to serve as community gatekeepers by identifying and referring community-dwelling older adults who may be in need of aging and/or mental health services. These community case-finders perform a gatekeeping function for older adults that is similar to that performed by schools and the workplace for younger persons. Information was collected on 777 individuals aged 60 and older referred over an 18-month period (January 1, 1994, to June 30, 1995) to the Spokane Mental Health Clinical Case Management Program in Spokane, Washington, which provides aging and mental health services to older adults residing in the county. Findings indicate that 40% of clients referred were found by community-based gatekeepers. Clients referred by gatekeepers were more frequently socially isolated, economically disadvantaged, and less likely to have a physician. Gatekeeper clients were also more likely to be women and to be younger than others referred to the agency. Gatekeeper clients were receiving fewer services at referral and were identified as needing more services at intake. Gatekeepers find a distinct population of community-dwelling older adults who are not found by more traditional referral sources. The need to integrate this model within a comprehensive clinical case management system is discussed.

Pavlovian conditioning of LPS-induced responses: effects on corticosterone, splenic NE, and IL-2 production.

The present study used a taste aversion paradigm to condition lipopolysaccharide (LPS)-induced suppression of splenic lymphocyte interleukin-2 (IL-2) production, with concurrent measurement of corticosterone production and splenic norepinephrine (NE) content). In training, two groups of rats received saccharin and IP LPS in a paired (P) manner and a third group in a specifically unpaired (U) manner. In the test, the unpaired group (group U) and one of the paired (group P) groups were re-exposed (R) to the cue and the other not (NR). An additional group controlled for the effects of cues (conditional stimulus) and fluid deprivation (negative control; NC). A robust taste aversion in the P-R group was accompanied by suppression of IL-2 production, reduced splenic NE content, and elevated corticosterone production, relative to combined controls (i.e., groups U-R, P-NR, and NC). The conditioned modulation of IL-2 secretion, along with the concomitant alteration of adrenocortical and sympathetic mediators, supports the involvement of bidirectional central nervous-immune system pathways in this paradigm.

A collaborative approach to reduce hospitalization of developmentally disabled clients with mental illness.

Developmentally disabled clients with a concomitant mental illness are often underserved or inappropriately treated because of interorganizational barriers, leading to unnecessary hospitalization and lengthy delays in community placement. To overcome these barriers, agencies responsible for developmental disabilities and mental health services in Spokane County in Washington State developed a collaborative system of care in 1989. An interagency consortium was established to promote coordination of services between the community mental health center, the state hospital, the county human services agency, the state's regional developmental disability service agency, the state institution for the developmentally disabled, and several community agencies serving developmentally disabled persons. Between 1990 and 1992, admissions of developmentally disabled persons to the state hospital were more likely to be appropriate admissions of persons suffering from a mental illness, developmentally disabled clients were discharged more efficiently, and crisis respite services were used in place of hospitalization. In addition, anecdotal reports indicated a reduction of interagency tensions.

Relationship between preferences for decisional control and illness information among women with breast cancer: a quantitative and qualitative analysis.

This study examined relationships between cancer patients' preferences for involvement in making treatment decisions and preferences for information about diagnosis, treatment, side effects, and prognosis. Participants were 35 women with stage I and II breast cancer recruited from two medical oncology and radiation oncology clinics. Following administration of card sort measures of preference for involvement in treatment decision making and information needs, a semi-structured interview was conducted to provide patients with an opportunity to elaborate on their role preferences and health care experiences. Results showed that patients who desired an active role in treatment decision making also desired detailed information. This relationship was not as clear for passive patients. Relative to passive patients, active patients desired significantly more detailed explanations of their diagnosis, treatment alternatives, and treatment procedures. Active patients also preferred that their physicians use the words 'cancer' or 'malignancy' when referring to their illness while passive patients preferred that their physicians use a eupheumism. Further research is needed to critically detail the advantages and disadvantages of the active and passive roles and their impact on disease progression and psychological well-being.

Type A behavior and alcohol consumption: effects on resting and post-exercise bleeding time thromboxane and prostacyclin metabolites.

The vasoactive eicosanoids, prostacyclin and thromboxane, are thought to play an important role in the genesis of cardiovascular disease. Since an altered basal production of these eicosanoids among individuals exhibiting the Type A behavior pattern had previously been observed by the authors, the present study evaluated the extent to which the TABP-eicosanoid relationship would be altered by two lifestyle variables known to affect platelet activity: alcohol consumption and stressful physical activity. 55 male participants aged 18-25 years, participated in the study. They were classified as either Type A or Type B on the basis of the Structured Interview and as either moderate, heavy, or abstinent alcohol drinkers. Bleeding times were performed and bleeding time thromboxane and prostacyclin metabolites were measured in all subjects both before and following treadmill exercise. The results indicated that following exercise, Type A participants, who reported moderate alcohol intake, had decreased levels of thromboxane B2 formation relative to Type As reporting heavy consumption. Further, prostacyclin production, measured as the primary metabolite, 6-keto-prostaglandin F1 alpha, was significantly suppressed following exercise among drinkers as compared with participants reporting abstinence. These results were discussed in relation to the proposition that moderate alcohol consumption reduces coronary heart disease risk.

Central administration of interleukin-1 beta increases norepinephrine turnover in the spleen.

We have previously shown that intracerebroventricular (ICV) injection of interleukin-1 beta (IL-1 beta) suppressed splenic macrophage function. Sympathetic noradrenergic innervation of the spleen was implicated as a mediator of this IL-1 beta signal as surgical sympathectomy ablated the macrophage suppression. In this study, we have determined whether ICV administration of IL-1 beta has an effect on sympathetic outflow and norepinephrine (NE) turnover in the spleen. Adult male rats were injected with 5 ng of IL-1 or saline, and NE turnover in the spleen was determined using the rate of decline of NE content in the spleen after synthesis inhibition. The splenic NE turnover rate was increased significantly from 69.52 ng/g/h in saline-treated animals to 111.05 ng/g/h in IL-1-treated animals. In addition, serum corticosterone and ACTH were significantly elevated in IL-1 beta-treated animals 4 h postinjection. These data indicate that central administration of IL-1 beta increases both sympathetic outflow to the spleen and activates the hypothalamic-pituitary-adrenal axis during the period when IL-1 beta induces immunosuppression.

Aerobic fitness level (VO2max) moderates the increased cardiovascular function and basal thromboxane formation of young healthy Type A males.

The authors evaluated the interaction between physical fitness and Type A behavior on vascular production of prostacyclin and platelet thromboxane in response to a standard vessel injury. Ninety-seven male university students were classified as Type A or B on the basis of the Structured Interview of Rosenman. Reactivity, as measured by changes in systolic blood pressure (SBP), and heart rate (HR), measured before and after a stressful Stroop task 1 week later, showed that Type A individuals were more reactive to the stressor than Type Bs, providing independent confirmation of the behavioral interview assessment procedure. Fitness level was determined by a graded treadmill test and was not different for Type As and Type Bs. Basal thromboxane production, measured as the primary metabolite, thromboxane B2, in blood oozing from the bleeding-time site, was highest among unfit Type A subjects. Fit Type As and Type Bs showed significantly lower thromboxane production. No significant differences in prostacyclin production were seen. This study marks the first time that behavior pattern has been linked to an adverse aspect of a thrombosis-related parameter likely to be involved in the genesis of cardiovascular disease. The present results also indicate that physical fitness may, in some fashion, ameliorate the "toxic" effects of Type A behavior.

Predicting postpartum depressive symptoms: a structural modelling analysis.

In this prospective, longitudinal study, 42 first-time mothers, recruited through prenatal classes, were assessed on variables predictive of postpartum depressive symptoms. Using a causal modelling structural analysis, it was found that prenatal depression, partners' support, and infant-related factors all contributed to the development of depression following childbirth.

The structured interview elicits a differential prostacyclin response in A and B behaviour types.

OBJECTIVE: To determine whether individuals exhibiting the type A behaviour pattern have a different extent of prostacyclin or thromboxane production after relaxation or after a structured interview compared to individuals exhibiting the type B behaviour pattern. DESIGN: Subjects were randomized to receive prospectively either a relaxation session or a mildly stressful interview first. Each then received the alternate treatment second. SETTING: Students attending an introductory psychology course at the University of Manitoba received a relaxation session (20 mins lying down listening to a tape) and an interview session (the structured interview of Rosenman). OUTCOME MEASURES: Type A/B behaviour pattern was rated using the structured interview of Rosenman. Production of 6-keto prostaglandin F1-alpha and thromboxane B2, metabolites of prostacyclin and thromboxane A2, respectively, were measured in response to a standardized vascular injury-bleeding time. MAIN RESULTS: No significant differences were observed in the length of bleeding time, in bleeding time thromboxane production or in prostacyclin production after relaxation between individuals exhibiting type A and B behaviour patterns. Prostacyclin production after the interview was lower in type A individuals (3.29 +/- 0.29 pg/min) than in individuals exhibiting type B behaviour (4.76 +/- 0.63 pg/min) (P = 0.04). No significant post interview differences in bleeding time or in thromboxane production were seen. CONCLUSION: After relaxation, type A and B subjects are similar in their prostacyclin and thromboxane responses to vascular injury. However, type A individuals show a less favorable prostacyclin response than type B when confronted with the structured interview; type A individuals responded in an aggressive or hostile fashion, while the type B individuals exhibited a more relaxed response.

Conditioned taste aversion but not adrenal activity develops to ICV administration of interleukin-1 in rats.

In a previous investigation with mice, the paired presentation of either odor or taste cues with the peripheral (IP) administration of the immunoactive peptide interleukin-1 (IL-1) led to the conditioned enhancement of glucocorticoid production. The present study found that an initial central infusion of IL-1 in the presence of saccharin cues produced a robust taste aversion but not a conditioned elevation of either ACTH or corticosterone production. These results indicate that the glucocorticoid response induced by centrally administered IL-1 in rats is independent of the behaviorally aversive properties of this cytokine which are conditionable. The differential effects of IP versus ICV administration of IL-1 on glucocorticoid conditioning requires a clearer specification of the respective signaling mechanisms and pathways activated by these two routes of administration.

Suppression of splenic macrophage interleukin-1 secretion following intracerebroventricular injection of interleukin-1 beta: evidence for pituitary-adrenal and sympathetic control.

Intracerebroventricular (ICV) injections of interleukin-1 beta (IL-1 beta) produced a dose-dependent increase in plasma corticosterone and adrenocorticotropic hormone (ACTH) within 2 hr of injection and then declined over the next 24 hr. Using a potent steroidogenic dose of IL-1 beta (5 ng), ICV injection resulted in suppression of splenic macrophage IL-1 secretion following stimulation by LPS in vitro. Macrophage TGF-beta secretion was not affected, indicating a differential action of ICV IL-1 beta on macrophage cytokine production. Following adrenalectomy (ADX), the suppressive effect of ICV IL-1 beta was reversed and resulted in stimulation of macrophage IL-1 secretion, indicating that the suppression was mediated by adrenocorticol activation. However, surgical interruption of the splenic nerve to eliminate autonomic innervation of the spleen also prevented the macrophage suppressive signal in rats given ICV IL-1 beta. Furthermore, the combination of ADX and splenic nerve section resulted in a potent stimulatory effect of ICV IL-1 beta on splenic macrophage IL-1 secretion which was greater than either ADX or splenic nerve section alone. These results support the concept of a negative feedback on macrophage IL-1 secretion by the central action of IL-1 beta and indicate that both the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system mediate this effect.

The interactive effects of Type A behavior and hostility on bleeding time thromboxane and prostacyclin formation.

Sixty-six male university students were classified as Type A or B on the basis of the Structured Interview of Rosenman and as hostile or non-hostile on the basis of the Cook-Medley scale. Vascular production of prostacyclin and platelet thromboxane in response to a standard vessel injury was evaluated. Basal thromboxane production, measured as the primary metabolite, thromboxane B2, in blood oozing from the bleeding-time site, was highest among hostile Type A subjects with significantly lower thromboxane production in hostile Type Bs and all non-hostile groups combined. Following an exercise treadmill test hostile subjects produced more thromboxane than non-hostile ones, and hostile Type As had significantly shorter bleeding times than hostile Type Bs. No significant differences on any measure were observed following a stressful color naming task. The observed interaction of hostility and Type A behavior on bleeding time thromboxane formation links behavior to an adverse aspect of a thrombosis-related parameter thought to be involved in the genesis of cardiovascular disease.