Faculty Bibliography

OBJECTIVE: To describe mental health status and its correlates among clients of three palliative care programs targeting underserved populations. METHODS: Mental Health Inventory (MHI-5) scores of clients from programs in Alabama (n = 39), Baltimore (n = 57), and New York City (n = 84) were compared. RESULTS: Mean MHI-5 scores did not differ among sites and were indicative of poor mental health. Significant differences were noted among sites with regard to client sociodemographics, physical functioning, and perceptions of interpersonal relations. Results of multivariate regression models estimated for each site suggest variation in the relative importance of potential predictors among sites. Whereas poorer mental health was primarily associated with history of drug dependence at Baltimore and more physical symptomatology at New York, better mental health was most strongly correlated with more positive perceptions of interpersonal relationships at Baltimore and increasing age and more positive perceptions of meaning and purpose in life at New York. SIGNIFICANCE OF RESULTS: The data presented suggest the importance of assessing clients' history of and current need for mental health services. Evidence of a relationship between positive perceptions of meaning and purpose and better psychological function underscores the importance of existential issues for the overall well-being of those who are seriously ill.

Despite prolonged survival and improved quality of life as a result of treatment advances for HIV/AIDS, thousands still suffer with the disease and 15-16,000 a year die in the United States alone. Little is known about those patients with HIV/AIDS who still require palliative care services or the types of services needed. This paper describes the program elements and clients of three programs providing palliative care to persons with HIV/AIDS in Alabama (n = 41), Baltimore, Maryland, (n = 55), and New York City (n = 52). Also presented are the prevalence of need for 27 services as assessed by clients and staff, the level of agreement found between client and staff assessments at each site, and services for which prevalence of need varied among programs. Interviews were conducted between June 2000 and October 2002. The majority of clients at all programs were socioeconomically disadvantaged, persons of color, and had a history of substance abuse, although significant differences were noted in the distributions of clients at each program with regard to these characteristics. Greater differences were observed among programs in the prevalence of need reported than were found between reports of clients and staff at the same program. Despite these differences, a common set of medical (ambulatory/outpatient care, laboratory testing, pharmacy) and ancillary (nutritional counseling, transportation) services was identified by at least 25% of clients and staff at each program. These findings suggest that need, beyond a core of medical and ancillary services, is relative and best conceptualized as a mixture of need, demand, and supply. The need for a mix of "care" and "cure" services identified reflect the erratic disease trajectory experienced by some clients who move in and out of treatment as well as the vulnerability and marginalized lives of the clients served by these programs.

While HIV-patient education has emphasized the importance of adherence to antiviral combination therapies, the complexity of current multi-drug regimens, coupled with aversive sideeffects pose significant threats to adherence. Given that greater non-adherence among older adults is well documented in the general medication adherence literature, older HIV-infected adults may be at elevated risk for non-adherence. Patient accounts for non-adherence were explored as part of a psychosocial investigation of the experiences of HIV-infected late middle-age and older adults on protease inhibitors. Thematic classification of the 'accounts' offered for non-adherence according to Scott and Lyman's (1968) typology of justifications and excuses allowed for the identification of the perceived motives for intentional versus unintentional non-adherence. Excuses offered for non-adherence included: (1) intolerable side-effects, (2) unusually busy lives, (3) unavailability of food when needed, (4) tiredness, and (5) the need to conceal medications to avoid stigma/exposure of HIV status. Common justifications for non-adherence were: (1) some flexibility won't hurt me, (2) no one really knows the real impact of non-adherence, (3) if my viral load is 'undetectable' then strict adherence is not necessary, and (4) strict adherence is an unattainable standard. In contrast to expectations, few age-related reasons for non-adherence were identified. These understandings for their non-adherence provide a crucial basis for understanding new paths for promoting adherence to combination antiviral therapies

The features of a preventive mental health intervention developed to assist late middle-aged and older spouses' psychosocial adjustment to spousal death from cancer and facilitate their transition to widowhood are described. Beginning during the last few months of the patient's illness and continuing into the initial months of the post-death period, the program is designed to provide the well/surviving spouse with emotional support, facilitate grief work and enable open discussion. Program format and delivery are discussed and the pre- and post-death components are presented. High risk criteria are used to target spouses at risk for mor bid bereavement outcomes. The rationale for the risk profile is discussed. Implications of the program for social work practice are provided.

Psychosocial adjustment to living with HIV/AIDS was examined in a purposive sample of 146 New York City, African-American, Puerto Rican, and White non-Hispanic women using the Psychosocial Adjustment to Illness Scale, self-report version (PAIS-SR). Puerto Rican participants reported significantly more problems than African-Americans on the Summary Scale and the Domestic Environment and Psychological Distress domain subscales and significantly more problems than either Whites or African-Americans on the Social Environment domain subscale. Problematic sexual relationships were found to be significantly associated with race/ethnicity, although scores did not differ significantly between any two groups. On average, women in all three racial/ethnic groups reported high levels of psychosocial adjustment problems to their illness relative to normative data for cancer patients. These findings suggest that, while all HIV-infected women may be at risk for problematic psychosocial adjustment to living with HIV/AIDS, Puerto Rican women may be especially vulnerable