Efficacy of lithium vs. valproate in the treatment of mania in the elderly: a retrospective study.

BACKGROUND: This retrospective study was conducted to assess the efficacy of lithium and valproate and associated serum levels in the treatment of mania in elderly patients. METHOD: Records of 59 patients aged 55 years and older with minimal or no neurologic impairment, hospitalized for mania, and discharged on lithium (N = 30) or valproate (N = 29) therapy were reviewed. Data on mood stabilizer choice, serum levels, and type of mania were recorded. A clinician blinded to medications rated improvement in each case with Clinical Global Impressions (CGI) scores based on abstracted notes. RESULTS: Overall, the percentage of patients improved was significantly greater in the lithium group than in the valproate group (67% vs. 38%, chi2 = 4.88, p = .027). Patients taking lithium with serum levels > or =0.8 mmol/L were more improved at discharge than those outside this range (> or =0.8, CGI 2.0+/-0.6 vs. <0.8, CGI 2.6+/-0.8, t = 2.15, p = .043). Patients taking valproate with serum levels between 65-90 microg/mL were more improved at discharge than those outside this range (65-90, CGI 2.1+/-0.6 vs. <65, >90, CGI 3.3+/-0.8, t = 3.73, p = .002). When response rates among only patients with these "therapeutic" levels were assessed, they were similar for lithium (82%) and valproate (75%). The difference in efficacy between drugs was maintained in classic mania, but the 2 drug groups were similar when only mixed mania was analyzed (lithium 63% vs. valproate 67% improved). CONCLUSION: Results suggest that lithium may be more efficacious than valproate overall, but response rates for the 2 drugs were similar when "therapeutic" serum levels were achieved. For lithium, levels similar to those reported for younger adults were associated with response. For valproate, a "therapeutic window" different from that in younger adults was found. While the retrospective and naturalistic design of this study has limitations, these data may help direct further studies and treatment of mania in the elderly.

The development of a partial hospitalization program for mentally ill chemically abusing (MICA) patients.

The article begins with a review of the high prevalence of concurrent mental illness and chemical abuse (MICA) disorders among clinical populations, highlighting the need for development of appropriate services to treat these persons. This is followed by a description of a partial hospitalization program developed at the University of Rochester Medical Center-Strong Memorial Hospital, established to treat MICA patients. The program description includes information pertaining to the mission of the program, treatment setting, staffing, schedule, and diagnostic and sociodemographic data on 50 consecutive patients admitted to the program. It includes a review of the major goals of the program and the manner in which each of these goals is addressed. This is followed by a discussion of several arguments for the inclusion of patients with personality disorders in MICA treatment when there is concurrent substance abuse. It concludes with a case vignette of a patient treated in the MICA program.

Barriers to care: operationalizing the variable.

A measure was developed to operationalize the concept of barriers as the consumer's perceptions of costs or obstacles to care. First, a 12-member panel participated in a three-stage Delphi process to identify indicators of the concept. Of the 81 items generated, 54 were selected as appropriate to a well population seeking preventive care. In a survey of 800 employees of a not-for-profit organization, respondents were asked to rate each barrier indicator on a 5-point Likert scale; the response rate was 70%. Exploratory factor analysis was used to explore the construct validity of the measure. Five factors were found: Provider-Consumer Relationship, Cost, Site-Related, Inconvenience, and Fear. Confirmatory factor analysis was used to refine the indicators for each factor category, producing a scale to measure perceived barriers to secondary preventive care. Based on the factor correlations, a model of the structure of barriers is proposed, showing the relationship factor as central.

Barriers: a critical review of recent literature.

Recent literature regarding barriers to care is reviewed, beginning with a discussion and comparison of the definitions of the barrier concept drawn from the health belief model and Andersen's model of health services utilization. The research literature which includes the barrier concept as a determinant in testing those models is reviewed, as well as research studies examining utilization behavior which do not have a well-articulated theoretical framework. Both nonempirical and empirical articles are reviewed to ascertain how the concept barriers to care is, or might be, operationalized. Although similar indicators are used from study to study, the review uncovers considerable confusion regarding the barrier variable both theoretically and empirically, which apparently results from lack of methodological rigor in defining and operationalizing the concept.

The process of theory analysis: an examination of the nursing theory of Dorothea E. Orem.

The process of theory analysis is undertaken examining the nursing theory of Dorothea E. Orem on three levels, using the analytic framework devised by Barbara J. Stevens. The commonplaces of the theory are described, the elements and principles are identified, the internal construction is examined, and the theory as a whole is then evaluated in terms of its relationship to modern nursing.