Faculty Bibliography

This column describes the nonproprietary software Talker, used to adapt screening instruments to audio computer-assisted self-interviewing (ACASI) systems for low-literacy populations and other populations. Talker supports ease of programming, multiple languages, on-site scoring, and the ability to update a central research database. Key features include highly readable text display, audio presentation of questions and audio prompting of answers, and optional touch screen input. The scripting language for adapting instruments is briefly described as well as two studies in which respondents provided positive feedback on its use

In recent years, an increasing awareness of comorbid disorders with schizophrenia has largely overlooked posttraumatic stress disorder (PTSD) as a co-occurring disorder. PTSD and schizophrenia may express themselves in symptoms that are difficult to distinguish. The hallmark symptoms of PTSD are re-experiencing the event, hyperarousal, and avoidance, particularly of trauma-related stimuli. Flat affect may be part of the deficit syndrome of schizophrenia or may be indicative of the emotional numbing often seen in PTSD sufferers to combat overwhelming anxiety. A comprehensive treatment approach that includes different modalities is key in treating people with SCZ-PTSD. Individual treatment, group treatment, family therapy, and milieu therapy, combined with psychotherapy, cognitive behavioral therapy, social support, and pharmacotherapy are important therapeutic tools. In the United States, treatment for schizophrenia has relied primarily on the use of antipsychotic drugs, with a deemphasis on psychotherapy. The treatment of PTSD and schizophrenia remains complex and understudied.

OBJECTIVE: This paper compares the prevalence of mental illnesses and alcohol and drug abuse and the residential histories of homeless individuals identified as having a mental illness and individuals who are not so identified. The cohort consisted of single persons applying for shelter over a 12-week period in Westchester County, a suburban county in New York State. METHODS: The sample of 201 persons (89 percent male, with a mean age of 37) represented 77 percent of consecutive single shelter applicants in a single-point-of-entry system over the study period. Information from an intake assessment was augmented by a semistructured interview to reconstruct subjects' residential history for the last five years, including periods of homelessness and time in institutions. RESULTS: Twenty-one percent of the cohort was classified as having mental illness. Seventy-two percent had a diagnosis of drug abuse or dependence, and 51 percent had alcohol abuse or dependence. For individuals with a mental illness, the use of cocaine and heroin was significantly lower, but alcohol use was somewhat greater, compared with other homeless persons. Persons with mental illness also experienced homelessness of some kind over a significantly longer period (a mean of seven years versus a mean of three years for other subjects), and they spent almost twice as many weeks during the previous five years literally homeless. Institutional time, most of which consisted of time in jail or prison, was equivalent for both groups. CONCLUSIONS: Not only is residential instability heightened among shelter users with mental illness, but over time public institutions play a critical role in their accommodations. For some homeless persons with mental illness, the circuit of shelters, rehabilitation programs, jails, and prisons may function as a makeshift alternative to inpatient care or supportive housing and may reinforce the marginalization of this population

Why do some people suffer from becoming a parent, whereas others do not? New parents' actual selves were related to their own hopes for themselves (ideal self) and to their spouse's sense of their responsibilities (ought self). Prebirth actual-ideal discrepancies predicted increased sadness or dejection after birth (especially for couples in longer marriages), whereas prebirth actual-ought discrepancies predicted decreased nervousness or agitation after birth (especially for mothers and couples with a less 'easy' child). Becoming a parent introduces new demands that both interfere with attaining one's own hopes (increasing dejection in parents high in ideal [own] discrepancy) and shift attention to the new parenting role (decreasing agitation in parents high in ought [spouse] discrepancy)

In this double.blind controlled study, 143 opioid.dependent male subjects were detoxified and randomly assigned to etrafon (amitriptyline 25 mg and perphenazine 2 mg), methadone, or placebo. Subjects were treated, monitored, and evaluated frequently for 1 year. Reported here are assessments carried out at 3.month intervals after hospital discharge. Treatment effectiveness was defined in terms of improvement of clinical symptoms, employment, and reduction in drug abuse. Data were analyzed on subjects who remained in treatment for at least 3 months (73%). Data analysis used a random regression model. Overall, type of treatment did not significantly affect outcome. An unexpected but significant effect on outcome seemed due to adherence to drug regimen. Those who adhered to their medication, whether etrafon, methadone, or placebo, improved more than noncompliers on most outcome measures regardless of type of drug treatment. 1993 American Academy of Addiction Psychiatry

Eighty-eight of 143 hospitals in New York State providing psychiatric inpatient treatment responded to a mailed questionnaire designed to determine the size of three subgroups of chemical abusers--alcohol abusers, drug abusers, and polychemical abusers--among inpatients with psychiatric diagnoses, as well as the availability of services for these patients. Data for New York City and its metropolitan area were analyzed separately. In 1987 almost one-third of psychiatric admissions both in and outside the metropolitan area had comorbid chemical abuse disorders. Seventy-five percent of patients in the metropolitan area with comorbid chemical abuse had a drug abuse disorder; in rural areas 88 percent of patients with chemical abuse disorders abused alcohol. Both hospital- and community-based aftercare services, especially in the metropolitan area, were less available to psychiatric patients with chemical abuse than to patients without these disorders

A statistical methodology based on the Cox proportional hazards model (a survival time analysis method), an alternative to the approach underlying DRGs, is presented. The method is used to obtain an estimate of the length-of-stay (LOS) distribution of a patient incorporating either patient-specific or hospital variables. A percentile of the distribution chosen to minimize prediction error serves as the assigned LOS. Absolute deviation is used as the loss function both to determine the choice of a predicted LOS and to examine how well the scheme works. Multiple assignment schemes may also be developed from this approach. The results of the method, tested on a national probability sample of 4,608 psychiatric patients treated in psychiatric units of general hospitals, suggest that with respect to average absolute deviation, the proposed methodology may provide a scheme that is superior to the present DRG scheme. For the sample, the average percent improvement obtained using the median of the estimated LOS distribution as the predicted LOS over the sample mean of the DRG group is 19%. A two assignment strategy results in average improvements over DRGs of 43%

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century. In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency