A behavioral weight-loss intervention for persons with serious mental illness in psychiatric rehabilitation centers.

OBJECTIVE: Overweight and obesity are epidemic in populations with serious mental illnesses. We developed and pilot-tested a behavioral weight-loss intervention appropriately tailored for persons with serious mental disorders. METHODS: We conducted a single-arm pilot study in two psychiatric rehabilitation day programs in Maryland, and enrolled 63 overweight or obese adults. The 6-month intervention provided group and individual weight management and group physical activity classes. The primary outcome was weight change from baseline to 6 months. RESULTS: A total of 64% of those potentially eligible enrolled at the centers. The mean age was 43.7 years; 56% were women; 49% were white; and over half had schizophrenia or a schizoaffective disorder. One-third had hypertension and one-fifth had diabetes. In total, 52 (82%) completed the study; others were discharged from psychiatric centers before completion of the study. Average attendance across all weight management sessions was 70% (87% on days participants attended the center) and 59% for physical activity classes (74% on days participants attended the center). From a baseline mean of 210.9 lbs (s.d. 43.9), average weight loss for 52 participants was 4.5 lb (s.d. 12.8) (P<0.014). On average, participants lost 1.9% of body weight. Mean waist circumference change was 3.1 cm (s.d. 5.6). Participants on average increased the distance on the 6-minute walk test by 8%. CONCLUSION: This pilot study documents the feasibility and preliminary efficacy of a behavioral weight-loss intervention in adults with serious mental illness who were attendees at psychiatric rehabilitation centers. The results may have implications for developing weight-loss interventions in other institutional settings such as schools or nursing homes.

Alcohol drinking problems among New York City residents after the September 11 terrorist attacks.

Recent studies have shown an increase in alcohol use in New York City in the months after the September 11 terrorist attacks; thus far there have been no studies documenting changes in drinking problems. In 2002, a random digit dial phone survey was conducted of residents of New York City. This study provided us with estimates of the prevalence of alcohol drinking problems among residents of New York City 6 months after September 11 compared with the 6 months before September 11. Among 1,570 adults, the prevalence of drinking problems was 3.7% in the 6 months before September 11 and 4.2% in the 6 months after September 11. The incidence of drinking problems among those without drinking problems before September 11 was 2.2%. Persons with incident drinking problems were more likely than those without to report symptoms consistent with posttraumatic stress disorder (17.4% vs. 0.4% in those without drinking problems and 1.4% in nondrinkers), and depression (23.5% vs 5.6% vs. 4.9%, respectively) after September 11. After a disaster, a link between drinking problems and posttraumatic stress disorder or depression should be assessed.

Risk of heavy drinking and alcohol use disorders in social phobia: a prospective analysis.

OBJECTIVE: The risks of heavy drinking and alcohol abuse/dependence were prospectively assessed among individuals with DSM-III social phobia and individuals with subclinical social phobia (irrational fear of social situations without significant impairment or avoidance). METHOD: The baseline interview for the Baltimore site of the Epidemiologic Catchment Area program was completed in 1981. Between 1993 and 1996 the original cohort was traced. Among the 1,161 individuals who did not have episodes of heavy drinking or current or prior alcohol abuse/dependence at baseline, logistic regression was used to assess the association of social phobia and subclinical social phobia with incident alcohol abuse/dependence and incident episodic heavy drinking. RESULTS: Among the 33 individuals with a DSM-III diagnosis of social phobia at baseline, only one developed heavy drinking by follow-up, and none developed alcohol abuse or dependence. Among the 84 individuals with a history of subclinical social phobia, the cumulative incidence rates of heavy drinking and alcohol abuse/dependence were 119 per 1,000 and 95 per 1,000, respectively. After adjustment for sex, age, race, education level, marital status, age at first alcohol intoxication, and history of other psychiatric or illicit drug use disorder, the estimated relative risk for heavy drinking among respondents with subclinical social phobia was 2.41, and the estimated relative risk for alcohol abuse/dependence was 2.30, relative to respondents without social phobia or subclinical social fears. CONCLUSIONS: The data may improve our understanding of the relationship of social phobia and risk for alcohol conditions, which may have important implications for preventive measures.

The association of depression and problem drinking: analyses from the Baltimore ECA follow-up study. Epidemiologic Catchment Area.

In this study, we hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women. As part of the Epidemiologic Catchment Area (ECA) program, probability samples of area residents were selected and the baseline interview for the Baltimore site was completed in 1981. Between 1993 and 1996, 73% of the survivors (n = 2633) were reinterviewed. For the 334 problem drinkers identified, the occurrence of a depressive episode and level of alcohol consumption for each intervening year between the baseline and follow-up interviews were assessed. Generalized estimating equations (GEE) were used for logistic regression analyses to examine the association between the occurrence of depression in the prior year with transition to higher-level drinking in the subsequent year. The problem drinkers tended to have a bimodal association of transitioning to higher-level drinking; although the strength of the association was greater for men. Future research will need to assess the potential influences on this relationship of other sociodemographic and psychopathologic characteristics, including the effect of treatment for depression or substance use.

Alcohol consumption and subclinical findings on magnetic resonance imaging of the brain in older adults: the cardiovascular health study.

BACKGROUND AND PURPOSE: Subclinical findings on MRI of the brain are associated with poorer cognitive and neurological function among older adults. We sought to determine how alcohol consumption is related to these findings. METHODS: As part of the Cardiovascular Health Study, 3660 adults aged 65 years and older underwent MRI of the brain from 1992 to 1994. We excluded 284 participants with a confirmed history of cerebrovascular disease. We assessed self-reported intake of beer, wine, and liquor at the annual clinic visit closest to the date of the MRI and grouped participants into 6 categories: abstainers, former drinkers, <1 drink weekly, 1 to <7 drinks weekly, 7 to <15 drinks weekly, and >/=15 drinks weekly. Neuroradiologists assessed white matter grade, infarcts, ventricular size, and sulcal size in a standardized and blinded manner. We used multivariate regression to control for sociodemographic and clinical characteristics. RESULTS: We found a U-shaped relationship between alcohol consumption and white matter abnormalities. Compared with abstainers, individuals consuming 1 to <7 drinks had an OR of 0.68, and those consuming >/=15 drinks weekly had an OR of 0.95 (p for quadratic term=0.01). Heavier alcohol consumption was associated with a lower prevalence of infarcts (OR for >/=15 drinks weekly relative to abstainers 0.59; P for trend=0.004), but larger ventricular size (OR for >/=15 drinks weekly relative to abstainers 1.32; P for trend=0.006) and sulcal size (OR for >/=15 drinks weekly relative to abstainers 1.53; P for trend=0.007). CONCLUSIONS: Moderate alcohol consumption is associated with a lower prevalence of white matter abnormalities and infarcts, thought to be of vascular origin, but with a dose-dependent higher prevalence of brain atrophy on MRI among older adults. The extent to which these competing associations influence overall brain function will require further study.

Isolation of stable hemolysin and catalase variants of Staphylococcus aureus S6C includes one with an exoprotein-deficient phenotype.

Previous studies suggested that the exoprotein-deficient phenotype of a Delta 1058::Tn551 insertion/deletion mutant of Staphylococcus aureus S6C was not owing to the insertion/deletion event, but instead was owing to the inherent instability of the agrC gene during transduction of the Delta 1058::Tn551 region into S6C. The purpose of the following study was to examine S6C as a potential source of exoprotein-deficient mutants that would account for their appearance after transposition and transduction. Four stable variants of S6C were isolated that differed in their hemolysin and catalase activities. Surprisingly, the agr regulatory molecule, RNAIII, was undetectable in one of these variants, which most likely accounted for the exoprotein-deficient phenotype of this variant. When the original Delta 1058::Tn551 mutation was transduced into the hemolytic, catalase-positive variant of S6C, none of the transductants exhibited an exoprotein-deficient phenotype. These data suggest that, while the exoprotein-deficient phenotype of the S6C variant is most likely due to mutations in the agr regulatory system, these mutations are not caused by the transduction of the Delta 1058::Tn551 region into S6C, but instead already exist in an exoprotein-deficient variant of S6C.

Sensation seeking needs among 8th and 11th graders: characteristics associated with cigarette and marijuana use.

This cross-sectional school-based study explored the relationship between adolescent use of cigarettes and marijuana and the sensation seeking personality factors of (1) Disinhibition and (2) Thrill and Adventure Seeking. The study population included a representative sample of both male and female 8th and 11th graders in the state of Delaware. Analytic methods utilized included correlational analysis and multivariate logistic regression. In the multivariate logistic regression models, the Disinhibition personality factor accounted for cigarette and marijuana using behaviors with odds ratios ranging between 2 and 3. Thrill and Adventure Seeking was not a significant explanatory variable in any of the final multivariate models. Potential confounders (age, gender and race) were considered in all analyses. Of all the two-way interactions assessed, none was significant. The findings from this study utilizing a large general community sample indicate that sensation seeking needs are a potential risk factor for adolescent substance use.

A latent variable approach to studying risk factors for Alzheimer's disease.

The objective of this study is to investigate and to improve measurements for the study of suspected animal and occupational exposure risk factors for Alzheimer's disease (AD). A subsample (n = 200) of a longitudinal study sample from research on risk factors for Alzheimer's disease was selected by systematic probability sampling. Participants were men born between 1917 and 1927, selected from the National Academy of Sciences-National Research Council (NAS-NRC) Registry of white male twins who served in the United States Armed Forces during the World War II Korean Conflict era. A questionnaire was administered via telephone interview. A total of 25 animal exposure items and 28 occupational exposure items were selected from the risk factor questionnaire administered to the men. Measurement for animal or occupational exposure was ascertained based upon the participants' responses to the survey questions. Latent variable analyses extracted 3 animal exposure factor scales: pet, farm/livestock and exposure to wild animals (e.g. while hunting). The occupational exposure data led to extraction of 2 factor scales: medical exposures and manual work involving metal. Latent variable analysis revealed that many items (potential risk factors) are highly correlated with each other and can be conceptualized as correlated observable manifestations of more unitary underlying constructs. In future research, it may be advantageous to assess correlated items such as these in relation to an underlying dimension of exposure, rather than as discrete exposures.

Mental health versus substance abuse treatment programs for dually diagnosed patients.

The aim of this study was to assess the similarities and differences of patients with co-existing psychiatric and substance use disorders attending treatment in either a mental health setting or a substance abuse treatment setting. A total of 129 patients were assessed, including 65 individuals from the substance abuse treatment center and 64 individuals from the mental health program. Treatment records were reviewed for diagnoses and sociodemographic data. While the two groups were highly similar with regard to age and ethnicity, there were significant differences in psychiatric profile, with the substance abuse treatment group having less severe diagnoses and no patients with schizophrenia, while the mental health treatment group had a majority of patients with schizophrenia. Other differences in the two groups, such as marital and parental status, disability status, and medical problems appeared to be directly linked with the aforementioned diagnostic profile. These data suggest important differences in characteristics of patients with comorbid disorders that appear to be dependent on the type of treatment program they attend. For the most effective management, integrated treatment programs should be aware of these differences and tailor service provision accordingly.

Chronically mentally ill patients with and without substance use disorders: a pilot study.

The study was designed to assess characteristics of chronic mentally ill patients with and without a substance use disorder. Study patients (n=48) had either psychiatric illness alone (they received conventional psychiatric rehabilitation) or dual diagnoses (they received mental illness and substance abuse services). All patients were administered the Brief Symptom Inventory (BSI), the Client Satisfaction Questionnaire, the Perceived Social Support Scales, and the Composite International Diagnostic Interview. Higher proportions of dually diagnosed patients had schizophrenia, had higher scores on the BSI, and were less satisfied with treatment.

A description of precipitants of drug use among dually diagnosed patients with chronic mental illness.

In this report, we describe patients' perceptions of the chronological occurrence of their mental illness and substance abuse. The patients were enrolled in a community mental health center and received dual diagnosis treatment from an affiliated psychiatric rehabilitation program. Using a questionnaire designed to address this issue, we assessed patients' perceptions of support currently being received at the treatment program and how beneficial they perceived this support to be. In addition, we assessed why substance use was a coping strategy in times of perceived stress early in life and whether this behavior has changed to date. Assessing the perception of the sequence of co-occurring disorders among patients enables us to better understand the factors that precipitate substance use and exacerbate mental illness. This knowledge may aid in the design of effective treatment strategies for this population of patients.

Severely mentally ill patients with and without substance use disorders: characteristics associated with treatment attrition.

We aimed to describe characteristics associated with attrition for patients in community mental health treatment with chronic mental illness with and without substance use disorders. Baseline assessments included symptom severity, treatment satisfaction, social support, and a structured diagnostic interview. Treatment attrition was assessed at six months. At six months, 36% of the dual diagnosis group (n = 25), and 61% of the mental illness alone group (n = 23) were lost to follow-up. Attrition in the dually diagnosed group tended to be associated with less satisfaction with treatment, and higher mean symptom scores. There were no characteristics associated with attrition in the group of patients with mental illness alone. However, client satisfaction tended to increase among the mental illness alone patients that were successfully followed. The dually diagnosed group that remained in treatment had a significantly lower mean treatment satisfaction score than the mental illness alone group at six months. This type of investigation should aid in patient care and evaluation of treatment programs for persons with severe mental illness and co-occurring substance use disorders.

Depressive symptoms and metabolic control in African-Americans with type 2 diabetes.

OBJECTIVE: To determine the prevalence of depressive symptoms and the relationship between depressive symptoms and metabolic control. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study of 183 African-American adults aged 35-75 years with type 2 diabetes who were recruited from two primary care clinics in East Baltimore, Maryland. Depressive symptoms, using the Center for Epidemiological Studies Depression Scale (CES-D), HbA1c, fasting lipid profile, BMI, and blood pressure, were measured on each participant. Diabetes-related health behaviors were assessed by questionnaire. RESULTS: The prevalence of depressive symptoms (CES-D > or =22) was 30%. After adjustment for age, sex, income, social support, and duration of diabetes in linear regression models, there were significant graded relationships between greater depressive symptoms and higher serum levels of cholesterol and triglycerides (P<0.050). Similar, albeit less statistically significant, relationships were found with higher levels of HbA1c (P = 0.104), diastolic blood pressure (P = 0.073), and LDL cholesterol (P = 0.176). Unexpectedly, individuals who reported more depressive symptoms also had higher serum levels of HDL cholesterol (P = 0.047). The associations were not explained by differences in diabetes-related health behaviors. CONCLUSIONS: Depressive symptoms are marginally associated with suboptimal levels of HbA1c, diastolic blood pressure, and LDL cholesterol, and significantly associated with suboptimal levels of total cholesterol and triglyceride levels. Prospective studies are required to determine whether improved identification and management of depressive symptoms would enhance metabolic control in this population.

Prospective study of depression and the risk of heavy alcohol use in women.

OBJECTIVE: The authors' goal was to determine whether depression is associated with a greater risk of heavy alcohol consumption in women. METHOD: The study was based on a 1-year follow-up of the Baltimore cohort of the National Institute of Mental Health Epidemiologic Catchment Area project. The sample consisted of 1,383 women at risk for heavy alcohol use. History of depression and frequency of lifetime-experienced depressive symptoms were assessed at baseline, and incident cases of heavy drinking were identified 1 year later. After calculating descriptive statistics for the sample, the authors developed a series of logistic regression models to estimate the risk of heavy drinking at follow-up associated with depression status. RESULTS: The initial estimate of the risk for heavy drinking in women with a history of depressive disorder was 2.60 times greater than the risk in women with no history of depressive disorder. This estimate did not change markedly after adjustment for age, history of antisocial personality disorder, or father's history of heavy drinking (relative risk=2.2). A higher frequency of depressive symptoms was also found to be associated with an elevation in the risk for heavy alcohol use (relative risk=1.09). CONCLUSIONS: These results add to other evidence that depression must be considered in the assessment of vulnerability for heavy alcohol use in women. Further research is needed to clarify the mechanisms of the observed association and to discover whether detection and effective treatment of depression might reduce risk of later alcohol problems.

Educational level and risk for alcohol abuse and dependence: differences by race-ethnicity.

OBJECTIVE: Using prospective data, we extend and strengthen prior evidence on the relationship of educational level and the risk of alcohol abuse and dependence among adults. Hypothesizing that risk of alcohol disorders would be greater among individuals who dropped out of high school without getting a diploma, and among those who entered college but then failed to get a degree, relative to those with a college or higher degree, we examined these relationships by race-ethnicity. METHODS: Data are from the total of 18,571 adult participants selected for the Epidemiologic Catchment Area (ECA) program by probability sampling of households and census tracts between 1980 and 1984. To assess occurrence of psychiatric conditions over time, staff administered the Diagnostic Interview Schedule soon after sampling and again at followup approximately one year later. The final sample for this report was stratified: African Americans (N = 2856) and whites (N = 7889). RESULTS: In multiple logistic regression analyses, we found that dropping out of high school was associated with elevated risk for alcohol disorders, relative to those with an Associate of Arts degree or higher, among both African Americans (estimated relative risk [RR] = 4.0, 95% confidence interval [CI], 1.1-14.3, P = .03), and whites (RR = 4.7, 95% CI, 2.2-10.0, P = .0001). In contrast, entering college but failing to get a degree was associated with a significantly increased risk only for whites; however, African Americans were less numerous in the sample, causing attenuation of power. In order to assess whether this relationship was confounded by macrosocial factors of the neighborhood environment, cases were matched to non-cases by age and census tract, and initial conditional logistic regression analyses also were completed. CONCLUSIONS: If confirmed in other investigations, these findings may help to identify groups that are at higher risk for developing alcohol abuse and alcohol dependence in adulthood, and may aid in the development of prevention or early intervention programs.

Empirical examination of current depression categories in a population-based study: symptoms, course, and risk factors.

OBJECTIVE: Research studies on the validity of current diagnostic and subthreshold categories of depression that use a population-based follow-up design are rare. The authors examined the validity and utility of four current depression categories by examining subject transition between categories and the symptoms, course, and risk factors of each. METHOD: A general population sample of 1,920 adults from the Baltimore Epidemiologic Catchment Area 13-year follow-up study were examined. Data on diagnoses, symptoms, course, and risk factors were collected by using the National Institute of Mental Health Diagnostic Interview Schedule, the Life Chart Interview, and an office visit. Polychotomous regression was used to examine the heterogeneity of four diagnostic categories: major depressive disorder, depressive syndrome, dysthymia, and a comorbid depression condition (major depressive disorder and dysthymia). RESULTS: Transitions between the four depression categories occurred over the 13 years. Symptom profiles for the four categories were parallel but differed in severity. Course characteristics among the four categories slightly differed. Risk factor profiles showed significant differences. Family history was associated with both depressive syndrome and major depressive disorder. Stressful life events were most strongly associated with depressive syndrome. Female gender was most strongly associated with the comorbid depression category. CONCLUSIONS: The evidence suggests that except for dysthymia, the depression categories are genetically homogeneous and environmentally heterogeneous. Stress is associated with mild depression, and gender is associated with severe depression. The apparent familial transmission of the subthreshold entity, depressive syndrome, needs further investigation.

Cultural elements of postpartum depression. A study of 327 Jewish Jerusalem women.

OBJECTIVE: To examine the social, cultural and religious factors underlying postpartum depression within a cultural cross-section of Jewish Jerusalem women. STUDY DESIGN: A prospective, repeated-measures study of 327 women. The Edinburgh Postpartum Depression Scale (EPDS) was administered immediately postpartum and 6-10 weeks later. Detailed sociodemographic information included perceptions of the pregnancy, community supports and religious affiliation. Odds ratios, 95% confidence interval and P values were calculated for all covariates. Multiple logistic regression was performed to estimate the degree of independent association between religiosity and postpartum depression. RESULTS: Postpartum depressive symptoms significantly associated with secular affiliation (odds ratio [OR] 2.9 [1.3-6.3] and tended toward an inverse association with orthodox affiliation (OR 0.6 [0.3-1.3]). Across secular, traditional, religious and orthodox groups, there was a decreasing trend in EPDS mean scores. Other predictors of depressive symptoms were psychiatric history, immigrant status and poor support with newborn care. CONCLUSION: Our study sample was particularly suitable for the assessment of cultural and religious elements of postpartum depression. We found religiosity, with its associated social and community structuring and well-defined social roles, to be significantly associated with self-reported postpartum depressive symptoms. These findings suggest that cultural factors, including role definitions, community support and rituals, may explain discrepancies found in the incidence of postpartum depression.

The psychiatric profile of patients with chronic diseases who do not receive regular medical care.

OBJECTIVE: To assess the relationship between psychiatric disorders and lack of regular medical care in individuals with chronic medical diseases. METHODS: Nine hundred sixty-three respondents to the household-based Baltimore Epidemiologic Catchment Area (ECA) Follow-Up Study were interviewed in 1981, 1982, and 1993-1996. The main outcome measures were: 1) not receiving regular care from a health professional for an active chronic medical condition in 1981, 2) persistent lack of regular medical care, and 3) leaving regular medical care. RESULTS: In cross-sectional analyses, having a psychiatric disorder (OR 1.70, 95% CI 1.17-2.48) was associated with not receiving regular medical care. This was mostly due to individuals with phobic disorder (OR 1.57, 95% CI 1.02-2.43). In prospective analyses, depression (RR 2.4, p < 0.04) and alcohol abuse (RR 2.9, p < 0.001) predicted leaving regular medical care one year later. Phobic disorder (RR 2.8, p < 0.001) predicted leaving care thirteen years later. CONCLUSIONS: Psychiatric disorders appear to place an individual at risk for irregular medical care. Studies of the quality and continuity of care for patients with chronic medical conditions should include measures of common psychiatric conditions.

Detecting alcohol use disorders in the severely mentally ill.

The frequent co-occurrence of alcoholism with serious mental illnesses ("dual diagnosis") necessitates that clinicians are able to recognize its presence in people with disabling mental illnesses. This study demonstrates that professionals often miss the diagnosis, but that their ability to detect alcoholism can be greatly enhanced by the use of a simple screening tool. Members of an urban psychosocial rehabilitation program who received psychiatric treatment in an affiliated outpatient clinic were interviewed after their clinic therapists and rehabilitation counselors had been asked questions pertaining to their general health and substance use. The members were interviewed with two screening tests, the CAGE and the SMAST, and a clinical DSM-III-R diagnosis of alcohol use disorder was established. Both the SMAST and CAGE had good sensitivity and the addition of a screener enhanced the clinicians' ability to detect alcohol use disorders.

The association of educational achievement and school dropout with risk of alcoholism: a twenty-five-year prospective study of inner-city children.

OBJECTIVE: This prospective study is focused on the characteristics leading to alcohol use disorders in early adulthood among a cohort of black children. The principal aim of this work is to examine the impact of educational attainment, school dropout and early school adaptation on the development of alcohol abuse and dependence in adulthood. METHOD: From a population that consisted of 1,242 first graders in 1966-67, a total of 953 were interviewed at age 32-33 about their current alcohol and drug use, educational attainment, employment and family situation. RESULTS: Diagnoses of alcohol abuse and dependence were defined according to DSM-III-R criteria resulting in identification of 13.5% as having a lifetime alcohol use disorder. Early predictions of an alcohol use disorder in adulthood included early reports of underachievement in first grade by the child's teacher, dropping out of high school, whether the family set definite rules about school during adolescence, and how often the adolescent worked on homework with his/her family. CONCLUSIONS: The results suggest that educational achievement and some early adaptive behaviors in school are associated with risk for alcohol use disorders. The public health importance of the findings are discussed.