Effects of substance dependence on outcomes of patients in a randomized trial of two case management models.

OBJECTIVE: The effectiveness of a community-based intensive clinical case management program was compared with that of a hospital-based expanded brokerage case management program for seriously mentally ill adults with and without substance dependence. METHODS: The sample of 268 frequently hospitalized psychiatric patients was recruited during acute psychiatric hospitalization. More than half of the sample (53 percent) was diagnosed as having at least one current DSM-III-R substance dependence disorder co-occurring with their primary major mental disorder. Subjects were stratified by substance dependence status and randomly assigned to one of the case management programs. They were interviewed before hospital discharge and at one, two, and six months after discharge to assess psychosocial and drug use variables. Subjects' service use was examined for the six months before and after hospitalization. RESULTS: The hypothesis that substance-dependent subjects would benefit more from intensive clinical case management was not supported. Substance dependence predicted negative outcomes independent of the case management intervention. The hypothesis that the two case management approaches would be equally effective for subjects not dependent on substances was also not borne out. Intensive clinical case management was the superior treatment for subjects who were not dependent on substances. Fewer of them required psychiatric hospitalization in the six-month postdischarge period than in the six-month period before hospital admission. CONCLUSIONS: The negative outcomes for substance-dependent subjects in both programs suggest that the two case management models were relatively ineffective for these patients. Results suggest that intensive clinical case management can be effective within the first six months for nondependent adults with serious mental illness.

Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.

This randomized controlled trial evaluated the efficacy of a brief intervention designed to reduce the harmful consequences of heavy drinking among high-risk college students. Students screened for risk while in their senior year of high school (188 women and 160 men) were randomly assigned to receive an individualized motivational brief intervention in their freshman year of college or to a no-treatment control condition. A normative group selected from the entire screening pool provided a natural history comparison. Follow-up assessments over a 2-year period showed significant reductions in both drinking rates and harmful consequences, favoring students receiving the intervention. Although high-risk students continued to experience more alcohol problems than the natural history comparison group over the 2-year period, most showed a decline in problems over time, suggesting a developmental maturational effect.

Expression of major histocompatibility complex (MHC) class I genes in astrocytes correlates with the presence of nuclear factors that bind to constitutive and inducible enhancers.

The molecular basis of constitutive and inducible major histocompatibility complex (MHC) class I gene expression was studied in murine astrocytes in primary culture. Astrocytes constitutively expressed MHC class I molecules and treatment of these cells with interferon-gamma (IFN-gamma) further induced expression. The conserved region containing the upstream MHC class I regulatory element (MHC-CRE) and juxtaposed interferon consensus sequence (ICS) enhanced constitutive MHC class I promoter activity. As seen with cell surface expression of MHC molecules, treatment of astrocytes with IFN-gamma increased MHC class I promoter activity. Inducible expression required the presence of the MHC-CRE/ICS enhancer region. Nuclear factors that bind to the MHC-CRE and ICS were constitutively expressed in cultured astrocytes and IFN-gamma treatment further induced binding activity both to the MHC-CRE and ICS and correlated with induction of MHC class I gene expression. This study identifies the MHC-CRE and ICS as the major cis elements in controlling MHC class I promoter activity and suggests that the expression of nuclear factor binding activities to these enhancer elements is a basic transactivating mechanism for the expression of MHC class I genes in astrocytes.