Does 'errorless learning' compensate for neurocognitive impairments in the work rehabilitation of persons with schizophrenia?

BACKGROUND: Because neurocognitive impairments of schizophrenia appear to be 'rate limiting' in the acquisition of skills for community functioning, it is important to develop efficacious rehabilitative interventions that can compensate for these impairments. Procedures based on errorless learning may facilitate work rehabilitation because they effectively automate training of work and other skills, thereby reducing the cognitive burden on persons with schizophrenia. METHOD: The present study examined the ability of a training method based on errorless learning to compensate for neurocognitive deficits in teaching two entry-level job tasks (index card filing and toilet-tank assembly) to a sample of 54 unemployed, clinically stable schizophrenic and schizoaffective disorder out-patients. Participants were randomly assigned to one of two training groups, errorless learning v. conventional trial-and-error type instruction. Prior to randomization, all subjects were administered a neurocognitive battery. Job task performance was assessed by percentage accuracy scores immediately after training. RESULTS: For three of the six inter-relationships among neurocognitive functioning and training condition, the pattern was the same: the errorless learning group scored high in job task performance regardless of neurocognitive impairment, whereas the conventional instruction group showed a close correspondence between job task performance and degree of neurocognitive impairment. CONCLUSIONS: These findings support errorless learning as a technique that can compensate for neurocognitive deficits as they relate to the acquisition of new skills and abilities in the work rehabilitation of persons with schizophrenia.

Demographic, family, and occupational characteristics associated with major depression: the Harvard study of moods and cycles.

OBJECTIVE: This study assesses the extent to which women with and without major depression differ by demographic, familial, and occupational characteristics. METHOD: From a community-based sample, the authors identified 332 women with and 644 women without current or past major depression based on Structured Clinical Interviews for DSM-IV. Demographic and background interviews were conducted in-person. RESULTS: Depressed women were more likely to have gained >or =35 lbs between age 18 and study enrollment (OR=1.6, 95% CI 1.1-2.5), experienced divorce (OR=2.0, 95% CI 1.4-2.8), or changed occupations (OR=1.5, 95% CI 1.1-2.1) compared with non-depressed women. Compared with women with no brothers, those with > or =1 brothers were less likely to have a history of depression (OR=0.8, 95% CI 0.6-1.1), whereas compared with women with no sisters, those with > or =1 sisters were more likely to have current or past depression (OR=1.4, 95% CI 1.0-1.9). These findings were not influenced by family sibship size. CONCLUSION: These results illustrate demographic differences between women with and without major depression and that sibship gender rather than size may also influence risk.

Social functioning and quality of life comparisons between obsessive-compulsive and schizophrenic disorders.

Treatment of obsessive-compulsive disorder has focused almost exclusively on symptom reduction; however, deficits in social functioning and quality of life of individuals with this disorder may contribute more to their "burden," suffering, and disability. To gauge the significance of social dysfunction and quality of life of persons with obsessive-compulsive disorder (OCD), we made comparisons with a group of persons with schizophrenia matched for age and gender. Thirty-one patients with OCD participating in a partial hospital treatment program were compared with 68 schizophrenic outpatients participating in a day rehabilitation program. The Independent Living Skills Survey (ILSS) and Lehman Quality of Life Scale (QOL) were administered before and after treatment for both cohorts. QOL scores were significantly lower for the OCD patients both before and after treatment, but improved significantly during treatment. OCD and schizophrenic patients had similar scores on almost every domain of the ILSS at pretreatment. The OCD patients improved significantly on many of the domains of social and independent living skills as a result of treatment and acquired significantly greater skills by post-treatment than did their counterparts with schizophrenia; however, the performance of social and independent living skills by OCD patients remained less than satisfactory even in domains where they improved. In the areas of job and leisure skills, there were significant group-by-time interactions. We concluded that patients with severe OCD and patients with schizophrenia are equally socially impaired. However, OCD patients experience greater significant functional improvement with multimodal treatment.

Requirements for multidisciplinary teamwork in psychiatric rehabilitation.

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.

Dissemination of educational classes for families of adults with schizophrenia.

Despite the well-documented efficacy of psychoeducational and behavioral approaches in family interventions for persons with serious mental illness (1), clinicians have rarely included these methods in their professional repertoires (2). Journal publications, books, continuing education courses, and advocacy by the National Alliance for the Mentally Ill and its local affiliates have induced few professionals to provide family psychoeducation. Mental health professionals adopt new services primarily for the same reason that employees of any firm change their work practices-namely, because the authority structure and contingencies of reinforcement that impinge on their daily activities are altered in a direction favoring change. Therefore, administrative clout must be brought to bear to mandate the inclusion of family psychoeducation in the spectrum of services provided by a clinic, mental health center, community support program, hospital, or independent provider (3). In addition, the consequences of clinicians' services must differentially reward the use of these methods of involving families in services for the seriously mentally ill (4). Differential rewards could come from performance standards and evaluations, performance-based pay, third-party payments, positive feedback from clients and families, public recognition, and increased self-efficacy. Use of in-service training or workshops to persuade clinicians to adopt innovations such as family psychoeducation and family management techniques has a checkered and unremarkable track record. For example, brief training has failed completely in efforts to bring about adoption of family interventions. On the other hand, more extended efforts to train staff, including organizational consultation, have been more successful (5). In one study, two days of staff training produced no change, whereas intensive training over several months resulted in the implementation of new family programs at the majority of study sites (6). Staff from sites that received extensive training but did not adopt the interventions rated family interventions as less consistent with their professional philosophy and agency norms and identified more obstacles to intervention, notably intense work pressure, uncertainty about financing the intervention, agency bureaucracy, lack of leadership, skepticism about the interventions, problems with confidentiality, and inability to provide services in the evenings or on weekends (6). In this Rehab Rounds column, Amenson and Liberman describe a three-phase, multilevel dissemination effort designed to overcome the above-mentioned barriers to the incorporation of family psychoeducation into the routine care provided at community mental health centers in an ethnically diverse urban setting. Moreover, Amenson and Liberman demonstrate the need for continued support and nurturance of the project to ensure that the original enthusiasm associated with a novel intervention is not lost once it becomes a standard part of treatment.

CASIG: a consumer-centered assessment for planning individualized treatment and evaluating program outcomes.

This paper reports the psychometric characteristics of a measure that assesses the treatment outcomes of individuals with serious and persistent mental illness. Unlike other outcome measures, this one is designed to be embedded in the clinical process of planning and evaluating treatment. It collects individualized data, structures how the data are used to plan and evaluate a client's treatment, and produces aggregate information relevant for research and program purposes. Two parallel versions were developed: one for the client's self-report, and one for an informant's report. The self-report measure was administered by peer-interviewers to 244 community interviewees, and by inpatient peer-interviewers to 93 inpatient interviewees. The community interviewees also completed the BASIS-32 and SF-36. Informants for 103 of the community interviewees completed the informant version of the measure, and the CCAR. Inpatient staff completed the informant version for 161 inpatient residents without regard for matching the 93 inpatient interviewees. The two versions had acceptable internal consistency, test--retest, and interrater reliabilities. Correlations of the community interviewees' and informants' results with the BASIS-32, SF-36, and CCAR provided evidence of convergent and discriminant validity, as did contrasts between community and inpatients interviewees. The usefulness of the instrument for clinical, program and research purposes is discussed, with emphasis on the characteristics that enhance its value in clinical practice --- assessment of meaningful outcomes, operationalization of client empowerment, comprehensiveness, easy administration, and continuity across time and provider. Also discussed is a computer-based program to summarize and present the results in a rapid, clinically meaningful manner.

Serum and follicular fluid hormone levels during in vitro fertilization after short- or long-course treatment with a gonadotropin-releasing hormone agonist.

OBJECTIVE: To examine the impact of flare (short) vs. down-regulation (long) GnRH agonist (GnRH-a) on serum and follicular fluid (FF) LH and androgen concentrations in women undergoing IVF treatment cycles. DESIGN: Prospective observational study. SETTING: IVF clinic. PATIENT(S): One hundred sixteen ovulatory subjects undergoing IVF. INTERVENTION(S): Fifty-eight ovulatory patients undergoing a down-regulation regimen matched with 58 undergoing the flare regimen as part of an IVF cycle. MAIN OUTCOME MEASURE(S): Serum concentrations of LH, FSH, Progesterone (P4), Androstenedione (A), T, and E(2) on the day of hCG administration were compared between the two groups. In addition, the FF P4, 17OHP4, A, T, and E(2) levels were compared in the two groups. RESULT(S): Serum LH was significantly higher with the flare regimen (15.2 +/- 1.14 IU/L, P<.05) when compared with results with the down-regulation protocol (9.5 +/- 0.77 IU/L). In addition, FF A was significantly higher in the flare protocol (57.3 +/- 13.3 ng/mL, P<.05) compared with in the down-regulation protocol (27 +/- 2.44 ng/mL). Serum and FF P4, 17OH P4, T, and E(2) were not statistically significantly different between the two groups. CONCLUSION(S): Serum LH and FF A are significantly higher in the flare regimen in comparison with the down-regulation regimen. Circulating LH appears to play a role in determining FF A concentration.

Effect of repeated vertical loads on microleakage of IRM and calcium sulfate-based temporary fillings.

Temporary fillings are commonly used to seal endodontic access cavities between visits. IRM and Cavidentin were selected to represent two widely used groups of temporary filling materials. The first is a reinforced zinc oxide-eugenol preparation that is mixed at chairside, whereas the second is a ready-to-use calcium sulfate-based material that gained popularity due to its convenience of application. The seal provided by the aforementioned materials was studied using a radioactive tracer quantitative assay. When compared as passive temporary filling, the two provided a similar quality of seal. However, when subjected to repetitive "occlusal" cyclic loading of 4 kg, IRM was clearly superior to the calcium sulfate-based material. Whereas IRM maintained a reasonable seal, the calcium sulfate-based fillings deteriorated and lost the ability to seal. These results suggest that even though calcium sulfate-based materials may be useful when not subjected to any occlusal forces, IRM should be preferred whenever occlusal loads may be applied. Furthermore it is demonstrated that testing such materials for microleakage with no reference to mastication forces may be of limited value.

Identifying and using reinforcers to enhance the treatment of persons with serious mental illness.

Successful engagement of clients with serious and persistent mental illnesses in the planning and implementation of treatment requires the identification of individualized reinforcers through motivational analyses. Reinforcer surveys are interviews or questionnaires that list numerous objects, persons, activities, and settings, and then assess the client's perception of the value of each item. Such surveys help identify the type of reward that might be useful for motivating the client. If properly assessed and delivered, reinforcers can increase clients' skill acquisition, attainment of goals, and feelings of self-efficacy.

Release of a soluble ATPase from the rabbit isolated vas deferens during nerve stimulation.

The properties of the ATPase released during electrical field stimulation (EFS) (8 Hz, 25 s) of the sympathetic nerves of the superfused rabbit isolated vas deferens were investigated. Superfusate collected during EFS rapidly metabolised exogenous ATP (100 microM) and 50% was broken down in 5.67+/-0.65 min. The main metabolite was ADP, virtually no AMP was produced and adenosine was absent. No enzyme activity was seen in samples collected in the absence of EFS. Lineweaver-Burke analysis of the initial rates of ATP hydrolysis gave a K(M) of 40 microM and V(max) of 20.3 nmol ATP metabolized min(-1) ml(-1) superfusate. ATPase activity was unaffected by storage at room temperature for 24 h, but was abolished at pH4 or by heating at 80 degrees C for 10 min. ARL 67156 inhibited ATP breakdown in a concentration-dependent manner (IC(50)=25 microM (95% confidence limits=22-27 microM), Hill slope=-1.06+/-0.04). When EFS was applied three times at 30 min intervals, ATP metabolism was 20-30% less in superfusate collected during the second and third stimulation periods compared with the first. ATPase activity was released in a frequency-dependent manner, with significantly greater activity seen after stimulation at 4 and 8 Hz than at 2 Hz. In conclusion, EFS of the sympathetic nerves in the rabbit vas deferens causes release of substantial ATPase, but little ADPase activity into the extracellular space. This contrasts with the guinea-pig vas deferens, which releases enzymes that degrade ATP to adenosine. Thus, the complement of enzymes released by nerve stimulation is species-dependent.

The independent living skills survey: a comprehensive measure of the community functioning of severely and persistently mentally ill individuals.

The research reported in this article investigated the psychometric characteristics of the Independent Living Skills Survey (ILSS), a comprehensive, objective, performance-focused, easy-to-administer measure of the basic functional living skills of individuals with severe and persistent mental illness (SPMI). Two versions were developed, one for informants and one for self-report. Data from three research projects were analyzed to determine the versions' internal consistency, stability, interrater reliability, sensitivity to the effects of skills training, and concurrent and predictive validity. The results indicated that the two versions have acceptable psychometric characteristics, and suggestions are offered for their use in planning individualized treatment, evaluating programmatic services, and determining eligibility for benefits.

Complications of hysteroscopic surgery: predicting patients at risk.

OBJECTIVE: To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure. METHODS: We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions. RESULTS: Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4-7 times higher odds for operative complications. CONCLUSION: Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.

A hybrid supported employment program for persons with schizophrenia in Japan.

INTRODUCTION BY THE COLUMN EDITORS: Because the mental health system in Japan has emphasized hospital-based treatment (1), patients with schizophrenia often remain institutionalized for long periods, even after their symptoms have stabilized. In addition, the introduction of modern community-based methods of treatment and rehabilitation was delayed by an antipsychiatry movement in the 1970s and the ascendance of a reductionistic biological approach to services (2). Lack of adequate outpatient services and community residential care in Japan has been a serious obstacle to destigmatization of mental disorders and has contributed to the heavy burden and stress experienced by families of mentally ill persons (3). More than 80 percent of patients discharged from mental hospitals return to live with their families, who are ill prepared to provide the supportive services required for community tenure. Involvement in work activities can facilitate community reentry for people with serious and persistent mental illness because employment displaces symptoms, provides structure and meaning in daily life, offers socialization with peers, and permits workers to earn income for shelter and food. In this issue's Rehab Rounds column, the authors describe an innovative vocational rehabilitation program for patients with schizophrenia that was designed to overcome obstacles to discharge and community adjustment. The program at Yabuki Prefecture Psychiatric Hospital, in the northern prefecture of Fukushima, Japan, has been successful in training patients for competitive work while capitalizing on the importance of work in Japanese culture and its traditionally supportive employer-employee relationships. The program is termed "hybrid" because it combines elements of transitional employment with supported employment (4).

A case-control study of galactose consumption and metabolism in relation to ovarian cancer.

Consumption or metabolism of dairy sugar and ovarian cancer have been linked based on evidence that galactose may be toxic to ovarian germ cells and that ovarian cancer is induced in animals by depletion of oocytes. We assessed consumption of dairy products and obtained blood for biochemical and molecular genetic assessment of galactose metabolism in 563 women with newly diagnosed epithelial ovarian cancer and 523 control women selected either by random digit dialing or through lists of residents in eastern Massachusetts and New Hampshire. We observed no significant differences between cases and controls in usual consumption of various types of dairy products or total daily lactose (the principal source of galactose in the diet); nor did we find that RBC activity of either galactose-1-phosphate uridyl transferase (GALT) or galactokinase differed. The mean (and SE) activity of uridine diphospho-galactose 4'-epimerase (in micromoles per hour per gram of hemoglobin) was, however, significantly lower (P < 0.005) in cases compared with controls, 20.32 (0.31) versus 21.64 (0.36). Ovarian cancer cases were also more likely to carry the N314D polymorphism of the GALT gene, generally predisposing to lower GALT activity. The difference was most evident for endometrioid and clear cell types of ovarian cancer, in which 3.9% of cases were found to be homozygous for N314D compared with 0.4% of controls, yielding an odds ratio and 95% confidence interval of 14.17 (2.62-76.60). We conclude that, whereas adult consumption of lactose carries no clear risk for the disease, certain genetic or biochemical features of galactose metabolism may influence disease risk for particular types of ovarian cancer.

Predictive value of serum and follicular fluid leptin concentrations during assisted reproductive cycles in normal women and in women with the polycystic ovarian syndrome.

Leptin is an adipocyte-derived hormone which plays a central role in the regulation of body weight and energy homeostasis and in signalling to the brain that adequate energy stores are available for reproduction. Although leptin may affect reproduction by regulating the hypothalamic-pituitary-gonadal axis, recent in-vitro observations indicate that leptin may also have direct intra-ovarian actions. Leptin concentrations were measured in women who succeeded in becoming pregnant within three cycles of in-vitro fertilization (IVF) or gamete intra-fallopian transfer (n = 53), in women who failed to become pregnant within three cycles (n = 50), and in women with polycystic ovarian syndrome (PCOS) (n = 22). It was found that lower follicular fluid leptin concentrations were a marker of assisted reproduction treatment success in normal women. Women with PCOS had higher leptin concentrations than women without such a diagnosis, but this was due to their higher body mass index (BMI). After adjustment for age and BMI, women with PCOS who became pregnant tended to have lower mean follicular fluid leptin concentrations than women with PCOS who did not succeed at becoming pregnant. Further studies exploiting the strengths of the IVF model are needed to assess whether the prognostic role for follicular fluid leptin in human reproduction is independent of other factors, and to elucidate the underlying mechanisms.

Recent trends in assisted reproductive techniques and associated outcomes.

OBJECTIVE: We examined recent trends in success rates for assisted reproduction and determined the influence of changes in patient selection and treatment characteristics on these trends. METHODS: We collected baseline information and abstracted treatment-related details and outcomes on 1244 couples accepted for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) at three clinics in greater Boston from 1994-1998. RESULTS: Delivery rates per initiated cycle improved significantly from 14.9% for IVF and 20.6% for GIFT in 1994-1995 to 22.5% for IVF and 28.0% for GIFT in 1997-1998 (P < or = .001). After adjusting for female age, the two treatment-related variables that appeared most likely to explain this trend were decreased use of GnRH agonists in short course (flare) regimens and increased use of highly purified forms of urinary gonadotropins. CONCLUSION: There were significant improvements in the success rates for IVF and GIFT from 1994-1998 that correlated with changes in ovulation induction regimens.