Families living with parental mental illness and their experiences of family interventions.

WHAT IS KNOWN ON THE SUBJECT?: Coping with parental mental illness in families can be challenging for both children and parents. Providing evidence-based family interventions to families where a parent has a mental illness can enhance the relationships in the family. Although psychiatric research has shown that evidence-based family interventions may improve the communication and understanding of parental mental illness, there is a lack in this area of research from an everyday clinical context. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Our study reinforces the fact that parents with mental illnesses are searching for support from psychiatric services in order to talk to their children about their illness. The finding that under-age children comply when they are told by their parents to join an intervention in psychiatric services supporting the family is something not observed earlier in research. This study once more illuminates the fact that partners of a person with parental mental illness are seldom, in an obvious way, included in family support interventions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Psychiatric services, and especially mental health nurses, have an important task in providing families with parental mental illness with support concerning communication with their children and in including the "healthy" partner in family support interventions. ABSTRACT: Introduction Although research has shown that evidence-based family interventions in research settings improve the communication and understanding of parental mental illness, there is a lack of knowledge about interventions in an everyday clinical context. Aim This study explores how families with parental mental illness experience family interventions in a natural clinical context in psychiatric services. Method Five families with children aged 10-12 were recruited from psychiatric services in southern Sweden and interviewed in a manner inspired by naturalistic inquiry and content analysis. Both family and individual interviews were performed. Results In striving to lead an ordinary life while coping with the parental mental illness, these families sought the support of the psychiatric services, especially in order to inform their children about the mental illness. Despite different family interventions, the family members felt supported and reported that the number of conflicts in the family had decreased. The parents were appreciative of help with child-rearing questions, and the children experienced a calmer family atmosphere. However, the partner of the person with mental illness experienced being left without support. Implications for practice Our study shows that psychiatric services, and especially mental health nurses, are in a position to more regularly offer family interventions in supporting the children and the healthy partners.

How Professionals View Multifamily Psychoeducation: A Qualitative Study.

Severe mental illness causes suffering for the patient as well as the patient's immediate family. The Swedish National Board of Health and Welfare has recommended the implementation of multifamily psychoeducation in order to assist patient and family in the recovery process. The aim of this study was to determine how introducing multifamily psychoeducation in Sweden has been viewed by professionals. Semi-structured interviews were conducted with 11 service providers, who were involved in evaluating multifamily psychoeducation. Our main findings fell under the headings of defensive culture and unsuitable model. Resistance to introducing the new intervention was found on multiple levels. The model proposed was considered too rigid for both the target group and the organizations because it could not be adjusted to the needs of patients, families, or facilitators. Despite good evidence for the effectiveness of the intervention, there were difficulties introducing the multifamily psychoeducation model in clinical practice. The feasibility of an intervention needs to be evaluated before adopting it as a national guideline.

Oral Assessment Guide--test of reliability and validity for patients receiving radiotherapy to the head and neck region.

Radiotherapy to the head and neck region leads to severe side effects in the oral cavity but knowledge about severity and onset is scarce among oncology nurses in a radiotherapy department. The aim was to test the Oral Assessment Guide for reliability and validity for patients receiving radiotherapy to the head and neck region. A prospective design with repeated assessments was selected. Thirty-six outpatients admitted to the department for radiotherapy to the head and neck region were included. In connection with the treatment session, the oral cavity was examined every second day by a nurse and once a week by an oncologist. The results were documented on separate forms. All patients showed alterations in the oral cavity and side effects started early during the first week of treatment. The result from inter-rater reliability showed a high concordance in all categories (>71%). Cohen's kappa (k) showed good agreement for voice, swallow and saliva and moderate for lips, tongue, mucous membranes, gums and teeth/dentures. The association, the sensitivity, between dose of radiation and side effects was weak or moderate and the acceptability with patients and staff was generally good.

Monitoring oral health and dental attendance in an outpatient psychiatric population.

Impaired mental health has been associated with an increased need for dental care. Population surveys have indicated that people with enduring mental health problems make less frequent planned visits to the dentist and report a greater number of missing teeth than the general population. The study aims to examine oral health status, attendance to dental care, and medication in an outpatient psychiatric sample. A descriptive study combining a structured interview with a visual oral examination carried out in 113 outpatients under psychiatric care. Dental health was described in terms of sound, missing and/or filled teeth, and showed a relation between these categories and types of psychiatric diagnosis, age and numbers of antidepressant and neuroleptic drugs. Oral hygiene was found to be more neglected among men and in patients with the diagnosis of schizophrenia. The need of dental treatment was widespread, although regular dental visits were commonly reported. In order to maintain good oral health, regular dental check-ups should be encouraged for patients under psychiatric care. Further studies are required to reveal contributory causes for/to decreased oral health. The difficulty such individuals have in maintaining additional self-efficacy raises questions about the necessity for oral health interventions in outpatient psychiatric services.

Impaired myocardial t-PA release in patients with coronary artery disease.

AIMS: Myocardial ischemia remains a significant perioperative complication in coronary artery disease (CAD) patients. We hypothesized that noxious stimuli during major surgery are associated with an acute release of tissue-type plasminogen activator (t-PA) into the coronary circulation, and that this response is reduced by CAD. METHODS AND RESULTS: Two patient groups, with (n=14) and without (n=8) CAD, were studied during the initial phase of heart surgery. After retrograde great cardiac vein catheterizations during closed-chest conditions, coronary arterial-venous concentration gradients of t-PA and plasminogen activator inhibitor type-1 (PAI-1) were measured together with coronary blood flow measurements, allowing derivation of coronary net release rates. Pre-surgery atrial pacing, performed to evaluate the influence of increases in heart rate (+ 40 beats/min) and coronary blood flow (+ 80 ml/min), did not significantly alter coronary net release of t-PA or PAI-1 in either patient group. Sternotomy induced a prominent increase in coronary net release of both total and active t-PA in the non-CAD group. This response was considerably reduced in the CAD group. CONCLUSIONS: This study provides the first analysis of coronary t-PA release during major surgery and demonstrates a deficient local endothelial t-PA release in patients with CAD. This suggests a reduced local fibrinolytic capacity in CAD patients, which may explain the increased risk for coronary thrombosis in this patient group.

Leachability and metal-binding capacity in ageing landfill material.

In order to study the stability of landfilled heavy metals, landfill material from a combined household and industrial waste landfill was aerated for 14 months to simulate the natural ageing processes as air slowly begins to penetrate the landfill mass. During aeration, the pH of the landfill material decreased from around 8.6 to 8.1 and the carbon content also decreased. In order to investigate the possible fate of metals in ageing landfills, a four-stage sequential extraction technique was applied. The ability of the materials to bind metal ions by electrostatic attractions and to form stronger complexes was studied separately. The amount of exchangeable cations, the capacity to bind metal ions by electrostatic attraction and the capacity of the landfill material to complex copper ions were increased by the aeration process. However, results from the sequential analysis showed an increased solubility of sulphur and some metals (Cd, Co, Cu, Ni and Zn). Equilibrium speciation models (Medusa) indicated that the organic matter deposit had a significant capacity to bind metal ions provided that pH was sufficiently high. However, as carbonates are consumed over time, the risk for metal mobility increases. Therefore, the landfills can become an environmental risk, depending on variations in the solubility of metal ions due to changes in pH, redox status and the availability of organic material.

Potential of e-health in relation to depression: short survey of previous research.

E-health is developing at a high rate and represents an opportunity for the development and spreading of information and communication channels to interested parties. The aim of this study was to get an overview and comprehension of the e-health field, with special focus on depression. A survey of initiatives and studies regarding e-health and depression was carried out. Relevant articles were found through searches on databases, search engines and reference lists. This paper shows that many different initiators with differing goals and motives are active within the e-health field. In the field of e-health and depression, the following areas show interesting results: studies mapping users' profile and habits, the quality of health-related information and the effectiveness of online therapies and supportive communities. Numerous initiators have launched different kinds of e-health initiatives. The potential of the Internet to be used constructively by health-care professionals and health-care consumers for health-enhancing purposes still needs to be mapped, evaluated and developed.

Metal and organic matter contents in a combined household and industrial landfill.

A combined household/industrial landfill in a humid and cold temperate climate was characterised with respect to its chemical composition. Cores taken at three randomly chosen sites on the landfill and at different depths at each site were analysed. Carbon, nitrogen and pH were measured by standard laboratory methods. The chemical elements analysed included metals and the non-metals B, P and S. pH ranged between 8.0 and 8.5. The total carbon content was in the interval 4.5-26.9% and the total nitrogen content in the interval 0.05-0.48%. The C/N ratio was high, indicating that there was not enough nitrogen available to ensure the stabilisation of carbon. The metal contents varied substantially. The water and carbon contents were related to each other as well as to the metal content, which increased with the content of water. Based on the results obtained regarding the chemical composition of the landfill, it is evident that the landfill consists of two layers. This indicates that the landfill body might have different levels of chemical development, due to water content, and different long-term leachability in the future.

Family burden and participation in care: differences between relatives of patients admitted to psychiatric care for the first time and relatives of re-admitted patients.

Studies on emotional and physical strain imposed on family members in connection with their responsibility of caring for a person with a severe mental illness have focused on the chronic patients. The situation of family members with patients who are at an early stage of illness and admitted for the first time may illuminate different patterns. In this Swedish multi-centre study, 162 relatives of patients in acute psychiatric wards, both those admitted for the first time and those re-admitted, were interviewed concerning their experience of family burden and their participation in care. There were relatively few differences found in burden measures and participation in care between the two subgroups of relatives. However, relatives who were in a career of being a relative to a person with severe mental illness earlier, more often viewed the psychiatric services to be of good quality, although they had had less contact with the staff of the psychiatric services during the last year. The relatives of re-admitted patients experience more often psychological aspects of burden, equivalent to associated stigma. The future task of maintaining the relatives' good opinion of psychiatric services, as well as the issue of giving informationare discussed.

The relationship between coping strategies and family burden among relatives of admitted psychiatric patients.

Coping strategies as assessed by a projective coping instrument, showed only a weak relationship to perceived family burden and participation in care among 78 close relatives of voluntarily and compulsorily admitted psychiatric patients in this study conducted in two psychiatric services in Sweden in 1997. The results rather indicate that problem solving coping strategies are used when the relatives are in situations amenable to change and that emotion-focused coping strategies are used in situations that are chronic and unchangeable. Furthermore, no differences in coping strategies were found between the relatives and a Swedish normative sample. No relationships were found between coping strategies and when the relative thought that the patient's mental health had led to mental problems in the relative or if the relative experienced that the relationship with the patient had been negatively affected by the mental illness. The usefulness of coping instruments based on personality components in research on family burden is called into question, and a reconsideration of qualitative research methods is recommended.

Family burden, participation in care and mental health--an 11-year comparison of the situation of relatives to compulsorily and voluntarily admitted patients.

SUMMARY The changes in family burden and participation in care of relatives to both voluntarily and compulsorily admitted patients were investigated as part of a longitudinal study of the quality of the mental health services in a Swedish county performed between 1986 and 1997. The relationship between the relative's mental health and family burden, participation in care and need of own support was also investigated. The results showed similar and high levels of burden and a non-sufficient participation in care in both periods investigated despite the ongoing changes in the delivery of psychiatric services and a change in the compulsory legislation in Sweden during the period. More relatives experienced an own need of care and support from the psychiatric services in the 1997 investigation. Relatives who experienced mental health problems of their own more often experienced other forms of burden, experienced less participation in the patient's treatment and also more often had own needs of care and support. It is concluded that interventions in families where relatives experience mental health problems will be useful, since a well-functioning network around the mentally ill person has shown to reduce relapse.

Need for support and participation in treatment differences among subgroups of relatives to compulsorily and voluntarily admitted mentally ill individuals.

The need for support and participation in treatment of relatives to voluntarily and compulsorily admitted patients was addressed in a study of the quality of mental health services in two Swedish county councils. The aims of the study were to investigate differences in the above aspects between subgroups of relatives, the differences between two years of investigation, 1986 and 1991, and the differences between relatives of voluntarily and compulsorily admitted patients. The relatives investigated consisted of 79 spouses, 118 parents and 31 grown-up children. The results showed that there were only minor differences between the subgroups concerning their participation in care. Grown-up children experienced significantly less need of support and received less help for this need. In 1991, relatives participated more in the care situation, were more interested in support with regard to their own life situation, and also showed more positive attitudes towards the psychiatric services than in 1986. The relatives of the voluntarily admitted patients felt more involved in the patient's treatment, whereas the relatives of those compulsorily admitted felt less involved and perceived obstacles to admission.

Comparison of hemodynamic, electrocardiographic, mechanical, and metabolic indicators of intraoperative myocardial ischemia in vascular surgical patients with coronary artery disease.

To compare mechanical, electrocardiographic, and metabolic indices of myocardial ischemia, the cardiokymogram (CKG), the V5 ECG, left anterior descending coronary artery territory lactate extraction, and pulmonary capillary wedge pressure (PCWP) were measured in 53 vascular surgical patients with coronary artery disease. Measurements were performed preoperatively and at four specific intraanesthetic intervals: after tracheal intubation, before surgery, and 10 and 30 min after incision. Measurements and sampling sequence took 5-7 min, and therapy for the probable cause of ischemia was instituted following completion of this sequence. Myocardial ischemia was defined as type II or III CKG, 0.1 mV or greater horizontal or downsloping depression of V5 ECG ST segment, 0.2 mV or greater elevation of V5 ECG ST segment, or myocardial lactate production. Thirty-nine patients (74%) had a total of 89 episodes of myocardial ischemia. Seventy-four episodes (83%) were detected by the CKG, 31 (44%) were evident on the ECG, and 13 (15%) by evidence of lactate production. The concordance among the indices of myocardial ischemia was poor. Patients with an abnormal preoperative ECG experienced a greater number of ischemic episodes (P less than 0.001). Elevation of PCWP or the presence of A-C or V-waves greater than 5 mmHg above the mean did not individually reflect ischemia reliably. Intraoperative myocardial ischemia is common in vascular surgical patients and is most sensitively detected by ventricular wall motion abnormality.

Influence of isoflurane on renal and intestinal vascular responses to stress.

Renal and intestinal vasoconstrictor responses elicited by either hypothalamic defence alarm area activation or stimulation of somatic and visceral afferents were studied in 17 cats. In part I, the circulatory adjustments during 2% (end-tidal) isoflurane plus 70% nitrous oxide in oxygen were compared with a medium-dose fentanyl in 70% nitrous oxide-oxygen sequence which was supplemented by diazepam. In part II, three end-tidal concentrations of isoflurane (1.4%, 2% and 3%) plus nitrous oxide in oxygen were evaluated before and after pre-treatment with droperidol 200 micrograms kg-1. During fentanyl-diazepam anaesthesia, intense vasoconstrictor responses with associated decreases in renal and intestinal blood flows were observed. Isoflurane 2% counteracted this reflex vasoconstriction, particularly in the renal vascular bed. The pressor and vasoconstrictor responses were suppressed by isoflurane in a dose-dependent fashion. After the administration of droperidol, the vascular beds were unaffected by noxious stimulation. It is concluded that isoflurane blunts stress-related vasoconstriction in a dose-dependent fashion, especially in the renal, but also in the intestinal, circulation. Droperidol adds to the vasodilatory effect of isoflurane.

Isoflurane--a study of its adrenoceptor interaction in the isolated rat parotid gland.

Adrenergic receptor interaction with isoflurane was studied in an in vitro rat parotid gland model in which beta-adrenoceptor agonists evoke amylase release and alpha-adrenoceptor agonists induce potassium secretion from parotid cells. The amylase secretory studies were performed using a batch-incubation technique, and potassium efflux was evaluated using 86Rb+ as a probe for K+. Isoflurane was dissolved in a fat emulsion, which of its own had no secretory effect. Isoflurane induced a dose-dependent amylase release that was unaffected by beta-adrenergic blockade with propranolol and metoprolol. Isoflurane also induced a significant efflux of 86Rb+ that could not be inhibited by the alpha-adrenoceptor antagonist, phentolamine. Dinitrophenol, an uncoupler of oxidative phosphorylation, had no effect on the isoflurane-induced enzyme release, indicating that amylase secretion occurred by passive leakage. It is suggested that isoflurane has no direct action on alpha- or beta-adrenoceptors. Isoflurane, however, induces potent cellular events that might be due to an unspecific effect on the cell membrane, thereby causing changes in membrane permeability.

The effects of naloxone on central hemodynamics and myocardial metabolism in experimental propoxyphene-induced circulatory shock.

The courses of the hemodynamic and cardiometabolic effects of naloxone were evaluated in propoxyphene-induced shock in eight pentobarbital-anesthetized pigs. Circulatory shock was induced by an infusion of propoxyphene chloride 15 mg . min-1 i.v. At shock, i.e. MAP less than 60 mmHg and/or CI less than 2.0 l . min-1 . m-2, naloxone was administered at 0.75, 1.5 and 3.0 mg . kg-1 with an interval between increments of 8 min. The propoxyphene infusion of 15 mg . min-1 was continued throughout the study. Following the injection of naloxone 0.75 mg . kg-1, increases were observed (% of baseline value) in MAP (41%), i.e. deficit to baseline 59%, HR (66%), CI (67%) and SVI (108%), whereas MPAP and MPAOP were unchanged. dP/dt increased (34%). In the coronary circulation naloxone initiated the following changes: CSF increased (69%) as did MVO2 (48%) with unchanged MO2-extraction, but CVR decreased further (36%). The maximum effects of naloxone were registered 2-3 min after 0.75 mg . kg-1. Following 1.5 and 3.0 mg . kg-1, no changes in hemodynamics were observed other than those caused by progressing propoxyphene intoxication.

Regional coronary hemodynamics during isoflurane-nitrous oxide anesthesia in patients with ischemic heart disease.

The effects of 1.5 MAC isoflurane-nitrous oxide anesthesia on central hemodynamics, regional coronary blood flow, myocardial oxygenation, and lactate balance were investigated in 13 patients with coronary artery disease. Mean arterial pressure was reduced 45% mainly because of systemic vasodilation. Great cardiac venous flow (GCVF) decreased, whereas total coronary sinus blood flow (CSF) was unchanged. Total coronary resistance and resistance in the area drained by the GCVF decreased as did myocardial oxygen extraction, demonstrating coronary vasodilation. The GCVF/CSF ratio did not decrease despite the reduction in resistance to left ventricular ejection. Seven patients had ECG and metabolic indications of myocardial ischemia (lactate extraction reduced from 22 +/- 5% to 7 +/- 3%, P less than 0.02 for the group). Changes in GCVF and oxygen consumption in the corresponding area correlated closely (r = 0.943). However, the regression line was shifted to the left and three patients, who became ischemic, had an increase in GCVF despite unchanged or decreased myocardial oxygen demand. It is concluded that isoflurane may cause coronary blood flow redistribution with regional myocardial ischemia in patients with coronary artery disease.