The Camberwell elderly mentally ill and their needs for services.

BACKGROUND: Previous studies on the elderly mentally ill (graduates) have been undertaken in mental hospital settings and on populations being resettled from hospitals. This paper aims to assess the characteristics and service needs of an epidemiological sample of elderly mentally ill. AIMS: The aim of this study was to identify the characteristics, problems, service utilization and needs of a sample of elderly patients with functional psychosis in a defined epidemiological area. METHOD: Data collected by PRiSM on psychotic patients who lived in two districts of Maudsley Hospital's catchment area were analyzed using the characteristics, problems and the needs for mental health services of those patients who were over the age of 64. These patients were compared with younger patients using the same data. RESULTS: The elderly patients differed significantly in their characteristics and problems from the younger mentally ill persons. The needs assessment procedure (Camberwell Assessment of Needs, CAN) was less sensitive to physical and psychiatric needs of the elderly as it did not reflect the differences between the two age groups. CONCLUSIONS: The lower rate of schizophrenia in the elderly mentally ill compared to the younger community patients and asylum mentally ill is discussed. The explanation may lie in the natural history of the disorder or more plausibly in the implementation of ;community care policy'. The paper concluded that a needs assessment procedure specifically designed to assess the needs of the elderly is required.

Dentistry in the Armed Forces.

This paper describes the way dentistry is practiced in the Armed Forces and highlights the differences with civilian practice, especially during military operations. The military lifestyle is discussed and the various training pathways and career options available to Armed Forces dentists are outlined.

Alcohol's interactions with circadian rhythms. A focus on body temperature.

The complex interaction between alcohol and the body's circadian rhythm has become a rapidly expanding area in chronopharmacology. This area has key implications for the field of alcohol research, because understanding alcohol's effects on the body's internal clock will aid scientists in designing medications and behavioral interventions for treating alcohol abuse and dependence. A number of studies provide evidence that alcohol sensitivity and preference vary with circadian timing. However, only a few studies support alcohol's ability to influence the circadian phase directly. This review focuses on studies examining how alcohol and the body's circadian rhythm interact, using body temperature as an index of circadian rhythm function. Though the research is limited, findings indicate that alcohol sensitivity and preference for drinking to indeed appear to vary with circadian timing and that alcohol may act directly on the central pacemaker to alter circadian functioning.

Case management: an update.

BACKGROUND: Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial. AIMS: To update after a decade a previous review article (Holloway, 1991). METHODS: Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts. RESULTS AND CONCLUSIONS: The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.

Case management and assertive community treatment in Europe.

OBJECTIVE: Case management studies from Europe and the United States continue to yield conflicting results. At a symposium at the World Psychiatric Conference in Hamburg in 1999, researchers from four European countries explored the possible reasons for differences in outcome. They also examined reasons for the differing foci of case management studies across the different cultures. The authors summarize the symposium's findings. METHODS: Individual case presentations were given of studies and services from the United Kingdom (three studies), Sweden (two studies), Germany, and Italy (one each). Outcomes, methodologies, and national service context were examined. RESULTS AND CONCLUSIONS: A significant influence of national culture is evident both in the acceptability of case management and in approaches to researching it. Case management is perceived as an "Anglophone import" in Italy but is now national policy for persons with severe mental illness in the other three countries. Studies from the United Kingdom emphasized methodological rigor, with little attention to treatment content, whereas those from Sweden accepted a less disruptive research approach but with a more prescriptive stipulation of treatment content. Studies from Italy and Germany emphasized the importance of differing descriptive methodologies. Marked differences in the range of social care provision were noted across Europe. Overall, European researchers are less concerned than U.S. researchers with studying the impact of case management on hospital use.

5-HT 3 receptor antagonist ICS 205-930 alters the discriminative effects of ethanol.

The ability of a selective 5-hydroxytryptamine (5-HT(3)) receptor antagonist, ICS 205-930 (3-tropanyl-indole-1-carboxylate, tropisetron), to block the discriminative stimulus effects of ethanol was investigated in rats that were trained to discriminate ethanol (1.25 g/kg ip) from saline with food as the reinforcement. Prior administration of ICS 205-930, at the dose of 0.01 mg/kg, significantly decreased ethanol's discriminative stimulus effect at ED(75) dose of ethanol, while higher doses of ICS 205-930 (10 and 17 mg/kg) showed enhancement of ethanol's discriminative effects at ED(0), ED(25), and ED(50) doses of ethanol. Under conditions where ICS 205-930 (10, 17 mg/kg) was tested alone, rats responded exclusively on the saline-appropriate lever. These effects occurred without significantly altering response rates or blood ethanol concentrations. The results suggest that the 5-HT(3) antagonist ICS 205-930 at lower concentration decreases, and at higher concentration enhances the discriminative stimulus effects associated with a lower to moderate dose of ethanol.

Conditioned place aversion to the "hangover" phase of acute ethanol administration in the rat.

The purpose of this study was to examine ethanol's delayed effects (termed hangover) using conditioned place testing. Four groups of rats received a single pairing of a distinctive environment (tactile and visual) 10 h after injection with ethanol (0, 2, 3, 4 g/kg, i.p. ) or saline in a counterbalanced design. Rats receiving 3 and 4 g/kg ethanol showed a conditioned place aversion to ethanol hangover. Conditioning 10 h after 0 or 2 g/kg ethanol did not produce a significant place preference or aversion. The results suggest that the hangover following an acute injection of high doses of ethanol (3-4 g/kg) produces a significant and dose-related conditioned place aversion in the rat.

Opiate delta-2-receptor antagonist naltriben does not alter discriminative stimulus effects of ethanol.

The ability of a selective 2-opiate receptor antagonist, naltriben, to modulate ethanol discrimination was investigated in a rat model using a drug discrimination procedure. Rats were trained to discriminate ethanol (1.25 g/kg, IP) from saline on a fixed-ratio schedule, FR10. Once rats had acquired the ethanol-saline discrimination, ethanol dose-response tests were conducted with 15-min pretest injections. Following the characterization of the ethanol dose-response curve, the effect of naltriben on ethanol's discriminative stimulus was assessed by administering naltriben (0. 032-5.6 mg/kg, IP) 15 min before the ethanol administration. In the present study, naltriben did not have any modulatory effect on ethanol discrimination, suggesting that either Delta(2)-opiate receptors are not involved in the formation of ethanol's discriminative stimulus or the antagonism of Delta(2)-opiate receptors is not sufficient to alter ethanol's compound discriminative stimulus.

The new long stay in an inner city service: a tale of two cohorts.

We assessed the long-stay inpatients (length of stay > 6 months) from a deprived inner-city catchment area with a population of 210,000 in 1993 and 1995 on a variety of measures, following up both cohorts after 24 months. Total numbers of long-stay inpatients were reduced from 56 (26.7 per 100,000 total population) to 35 (16.7 per 100,000) between 1993 and 1995, in line with the closure of dedicated long-stay beds. The 1995 cohort were more symptomatic according to the BPRS (t = 2.8, p = 0.007, 95% confidence interval 18.1, 3.0), more commonly detained under the Mental Health Act (chi 2 = 6.07 p = 0.05) and more commonly from an ethnic minority (chi 2 = 3.7 p = 0.05). At 2 year follow-up 57% of the 1993 cohort were living out of hospital, compared with 60% of the 1995 cohort. Patients were discharged to a variety of settings, some highly supported. For the combined sample the presence of certain challenging behaviours (absconding, disturbance at night, noncompliance with treatment and violence) predicted continuing inpatient status as did three items on the Social Behaviour Schedule (bizarre behaviour, laughing to oneself and violence). Only five (9%) of the original sample remained inpatients for the entire four year follow-up.

Peripheral opioid receptors may mediate a portion of the aversive and depressant effect of EtOH: CPP and locomotor activity.

Previous investigators have reported that peripheral opioid receptors (located in the gut) may produce aversive effects when activated. Opioid receptors can be activated by endogenous opioids or by-products of ethanol (EtOH) metabolism [e.g., tetrahydroisoquinolines (TIQs)]; both are stimulated following EtOH consumption. Therefore, we tested the hypothesis that a portion of the aversive or depressant effects of EtOH may be mediated through, or modulated by, peripheral opioid receptors. Conditioned place preference (CPP) and locomotor activity were the dependent variables. Prior to EtOH gavage, we antagonized the peripheral opioid receptors with methylnaltrexone (MNTX), an opioid antagonist that does not easily pass through the blood-brain barrier. The effects of EtOH were found to be dose dependent: 1.5 g/kg was hedonically neutral but depressed locomotor activity; 2.25 g/kg EtOH was aversive and also depressed locomotor activity. MNTX (32 mg/kg) treatment was rewarding and stimulated motor activity (especially during the first conditioning session). When combined, 1.5 g/kg EtOH tended to enhance the rewarding effects of MNTX whereas MNTX blocked the aversive effects of 2.25 g/kg EtOH. During the first conditioning session EtOH attenuated the motor stimulant effects of MNTX whereas MNTX antagonized the motor depressant effects of EtOH; there was little effect of MNTX on EtOH-induced motor depression during subsequent conditioning sessions. Pretreatment with various doses of MNTX (0.1, 1.0, 10.0, 32.0 mg/kg) of rats receiving 1.5 g/kg EtOH indicated the effects of MNTX were dose dependent. Drug-induced locomotor activity and time spent in the conditioned compartment were positively correlated, suggesting that both behaviors were homologous. The data suggest that peripheral opioid receptors participate in mediating or modulating a portion of the behavioral effects of EtOH.

Subjective quality of life, psychopathology, satisfaction with care and insight: an exploratory study.

We have investigated the determinants of global subjective quality of life (GSQOL) using data from a controlled trial of intensive case management for the severely mentally ill. In a multiple regression analysis depression, age, objective quality of life and domain-specific quality of life together explained 59% of the variance in GSQOL. GSQOL was not significantly correlated with measures of positive psychotic symptomatology, insight or attitudes to treatment but was correlated with satisfaction with care (r = .21, p = .011). Change in GSQOL over 18 months was correlated with change in domain-specific quality of life (r = -.45, p = .002) and depression (r = -.43, p = .01): multiple regression analysis confirmed that both variables had an independent effect on change in GSQOL.

Zuclopenthixol acetate (Clopixol Acuphase) for rapid sedation.

This case report documents the effects of accidental intravenous administration of zuclopenthixol acetate and briefly discusses its appropriate use in the management of psychiatric emergencies.