Inability of single resting arterial blood gas to predict significant hypoxaemia in chronic obstructive pulmonary disease.

BACKGROUND: While point measurement of resting arterial partial pressure of oxygen (P(a)O(2)) is the traditional gold-standard for assessment of oxygenation in chronic obstructive pulmonary disease (COPD), 24-h oximetry may identify further patients with clinically significant hypoxaemia. We aimed to describe the relationship between these two parameters and identify other correlated variables. METHODS: All patients registered with the Barwon Health Hospital Admission Risk Program from 1 March to 31 October 2008 for the diagnosis of COPD were identified. The main inclusion criteria were obstructive spirometry, clinical stability and moderate resting hypoxaemia (P(a)O(2) 56-70 mmHg). All patients underwent 24-h oximetry, arterial blood gas, spirometry, anthropometry and telephone questionnaire, and 23 patients also completed polysomnography. RESULTS: Inclusion criteria were met in 35 of 287 patients. Mean recording time was 23.5 h, representing 97% of intended oximetry time. Nineteen patients (54%) spent greater than 30% of recorded oximetry time below 90%. There was a moderate inverse correlation between time below 90% saturations and P(a)O(2) (r=-0.40, P= 0.02), with body mass index (BMI) the only other independent predictor of the primary outcome identified (r= 0.39, P= 0.02). Correlations were similar for waking hours considered separately. However, for sleeping oximetry, BMI and age were the only independent predictors of time below 90%. Polysomnography demonstrated a high prevalence of rapid eye movement-related hypoventilation and obstructive sleep apnoea syndrome. CONCLUSIONS: Many patients with moderate hypoxaemia on resting P(a)O(2) desaturate significantly on ambulatory oximetry. The correlation between P(a)O(2) and proportion of saturations below 90% is moderate and similar to BMI, but this pattern does not hold during sleeping hours.

The relationship between social networks and occupational and self-care functioning in people with psychosis.

BACKGROUND: Relatively few studies have examined relationships between the social networks of people with psychotic disorder and other aspects of their functioning. The aim of this paper is to describe the social networks of people with psychosis and to investigate relationships between social networks and personal and occupational functioning, taking account of illness course. METHODS: A two-phase epidemiological survey of persons with psychosis was conducted in four predominantly urban areas of Australia. A census and screen for psychosis was followed by a semi-structured interview of a stratified random sample of participants to assess their functioning. Data relating to functioning and social networks from 908 individuals (most with a diagnosis of schizophrenia) were analysed using structural equation modelling (SEM). RESULTS: The majority of people with psychosis (67 %) had a network comprising of family and friends, 15 % were defined as having a family-dominated network, 11 % a friends-dominated network and 7 % of participants were defined as socially isolated (no family or friends). Participants who had friends and family in their network (12 %) or who had a family-dominated network (7 %) were more likely to be in full-time employment compared with those with a friends-dominated network (4 %) or those who were socially isolated (5 %). Dysfunction in self-care was more frequently reported among socially isolated people (50 %) and those with family-dominated networks (47 %) than among those with friends-dominated networks (35 %) and those who had friends and family in their social network (23 %). SEM revealed a strong association between social integration and functioning (r = 0.71), even after controlling for illness course. Social integration was defined as having contact with family and/or friends and functioning was defined as having employment and no difficulties in self-care. Male gender was associated with poorer self-care, and female gender was slightly, but significantly, associated with a greater likelihood of having friends. CONCLUSION: There is a strong relationship between social networks and functioning after taking account of course of illness. That is, the presence of family and friends is generally associated with better self-care and employment. Interventions that are targeted at improving social relationships are likely to have a positive impact on self-care and occupational functioning (and vice versa).

Prevalence of psychiatric disorder in a methadone maintenance population.

OBJECTIVE: The objective of this study was to examine the prevalence of psychiatric disorders in a group of patients who had recently entered a methadone maintenance programme. METHOD: A total of 62 patients were interviewed using the Composite International Diagnostic Interview (CIDI) within 6 months of commencing methadone maintenance. The CIDI was used to establish symptoms of psychiatric illness at interview and in the 12 months prior. RESULTS: In the 12 months prior to interview, 76% of the sample fulfilled ICD-10 criteria for a psychiatric disorder other than substance-use disorder. Over half of the group interviewed fulfilled ICD-10 criteria for an affective disorder, two-thirds fulfilled criteria for an anxiety disorder and just under half fulfilled diagnostic criteria for both an affective disorder and an anxiety disorder in the 12 months prior to interview. At the time of interview, 19% fulfilled ICD-10 diagnostic criteria for a moderate or severe affective disorder. Seventy per cent of males and 89% of females interviewed had a comorbid psychiatric illness. In 71% of the group who had a comorbid psychiatric illness, the onset of psychiatric symptomatology was reported to predate the use of heroin. CONCLUSION: The prevalence of psychiatric disorder is up to 10 times higher in the population on methadone maintenance than in the general population and is two to three times higher than that found in community surveys of those with a substance-use disorder. These results are consistent with earlier findings and have implications for service planning.

Development of a brief form of the Life Skills Profile: the LSP-20.

OBJECTIVE: To develop a brief form of the Life Skills Profile (LSP) that incorporates all five subscales of the full form. METHOD: A new short form of the LSP (LSP-20) was developed to incorporate all five subscales of the full form. The LSP-20 development was based on a reanalysis of data from previously published studies. These data sets were also reanalysed to determine any differential effects of numbers and percentages of items in the LSP-39, LSP-16 and LSP-20, comparability of scores of the different forms, of test-retest and interrater reliability, and validity of the LSP-20 by comparison with the Positive and Negative Syndrome Scale (PANSS). RESULTS: A twenty-item short form of the LSP-39 (LSP-20) is described which retains 16 items of an earlier short form but which also reproduces the subscale concerned with disability associated with positive psychotic phenomena. The subscales correlated highly with their counterparts in the full form, interrater and test-retest reliabilities were comparable, and concurrent validity was good. CONCLUSIONS: The LSP-20 is a brief form of a widely used instrument that offers equivalent coverage to the full form with sound empirical properties, though unlike the LSP-39, it can be scored in the direction of impairments or strengths. Therefore the LSP-20 may be more suited to routine service disability and aggregated outcome assessments, but less suited than the LSP-39 to detailed research, or to interactive use as part of service user's individual care planning and review.

Symptom severity and personal functioning among patients with schizophrenia discharged from long-term hospital care into the community.

Twenty recently deinstitutionalized residents of a 24-hour staffed community residential unit were assessed using measures of symptoms and functioning on two occasions one year apart. Overall inter-clinician agreements in ratings were good, but clinicians agreed more in their ratings of positive than of negative symptoms of schizophrenia. Levels of symptoms (measured with the Positive and Negative Syndrome Scale) and functioning (measured with the Multnomah Community Ability Scale) were similar to those of comparable groups of patients, and were moderately related, sharing approximately 50% of variance. For the whole group, mean measures of symptoms and functioning were generally unchanged at one year, with retest measures of symptoms more stable than measures of functioning.

From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year.

BACKGROUND: In the context of deinstitutionalization of psychiatric services, Community Care Units (CCUs) were developed to provide accommodation, clinical care and rehabilitation for patients discharged from the long-stay open wards of a large psychiatric hospital that was in the process of closing. CCUs are 20-bed units built in suburban locations and staffed on a 24-h basis by multidisciplinary clinical teams. METHOD: An initial group of 125 hospital patients was assessed at 1 month pre-move, 1 month post-move, and again at 1 year, on range of measures covering clinical status, personal functioning, quality of life, residential preferences, aggressive behaviour, and social networks. Staff attitudes, relative and carer perceptions and preferences, and residential environments were also assessed. RESULTS: Most of the transferred patients were still resident in their CCU at 1 year. The clearest result was that patients showed improved quality of life in relation to their living environment. Comparison of the hospital and CCU environments showed that the latter were significantly less restrictive and regimented. Most relatives and carers also preferred the CCU. On average, symptom and disability levels were little changed at 1 year. CONCLUSIONS: Our results suggest that the CCU is an appropriate form of service delivery for most long-stay hospital inpatients, but that both more and less supervised settings are also required. While symptoms and disability were little changed at 1 year, it is possible that further follow-up may detect delayed or slow changes. Given the widespread replacement of psychiatric hospitals with community-based services, the future role of the CCU needs to be reviewed.

Defining disability in psychosis: performance of the diagnostic interview for psychosis-disability module (DIP-DIS) in the Australian National Survey of Psychotic Disorders.

OBJECTIVE: We aimed to use data from the Australian Survey of Mental Health and Wellbeing to examine the psychometric properties of the Diagnostic Interview for Psychosis-Disability Module (DIP-DIS). The DIP-DIS is a semi-structured questionnaire specially designed to assess disability associated with psychotic disorders. METHOD: The psychometric properties of the instrument were determined by examining its inter-rater reliability, internal structure, as well as its criterion and discriminant validities. RESULTS: Analysis shows: (1) that it can be rated reliably by trained interviewers, (2) that the items are complementary but tap a number of different domains, (3) that four factors account for over 66% of the variance, and (4) that it is sensitive to differing clinical populations with expected differences in level of disability. Ratings on the DIP-DIS bore significant relationships with a criterion measure of quality of life. CONCLUSIONS: The DIP-DIS has encouraging psychometric properties for cross-sectional assessment of disability and may be useful in future studies of disablement associated with psychosis. Future work should examine its sensitivity to change.

Why are we weighting? The role of importance ratings in quality of life measurement.

Many Quality of Life (QoL) instruments ask respondents to rate a number of life domains in terms of satisfaction and personal importance, and derive weighted satisfaction scores by multiplying the two ratings. This paper demonstrates that this practice is both undesirable and unnecessary. QoL domains are selected on the basis of their inherent importance, rendering separate importance rating partially redundant. Weighted scores present difficulties in interpretation. Further, we show that multiplicative composites have undesirable psychometric properties. There is evidence that multiplicative composites have little or no advantage over unweighted ratings in correlational or predictive studies. Apart from the face validity and the intuitive appeal of multiplying satisfaction ratings by importance ratings, there appear to be no sound reasons for doing so, and several good reasons not to do so.

The relationship between insight and medication adherence in severely mentally ill clients treated in the community.

OBJECTIVE: To study the relationship between aspects of insight and medication adherence and elements of psychopathology. METHOD: Clients completed insight and adherence measures in interview; doctors and case managers independently completed ratings of adherence and psychopathology. Other client information was obtained from the clinical file. RESULTS: The subscale structure of the insight scale was well reproduced. Clients endorsed items relating to need for treatment more than items relating to relabelling of symptoms and awareness of illness. Self-reported insight was lower in those clients for whom either the treating doctor or the case manager or both thought the client was non-adherent. Insight was related positively to clinician ratings of depressed mood, and negatively to clinician ratings of personal functioning. CONCLUSION: Our data support the subscale structure of the insight questionnaire used, and previous suggestions that insight is positively related to depressive affect, and inversely related to impaired psychosocial functioning.

The measurement of improvement during hospitalisation for acute psychiatric illness.

OBJECTIVE: The aim of this paper is to compare clinical changes and lengths of stay of patients with schizophrenic and affective disorders in public and private hospital settings. METHOD: Recently published Australian work using the Health of the Nation Outcome Scales (HoNOS) was compared with new data collected in a public setting. Changes in HoNOS scores between admission and discharge were analysed against length of stay. Individual HoNOS items were also examined. RESULTS: Public facilities tended to show greater improvements, owing to higher admission severities, and their lengths of stay tended to be shorter. Certain HoNOS items, notably the self-harm item, were significantly more severe in both diagnostic groups on admission in the public facilities. CONCLUSIONS: The findings are discussed in terms of the fact that self-harm is a criterion for involuntary hospitalisation, and private facilities do not treat involuntary patients. Certain problems assessed by the HoNOS are more amenable to rapid reduction than others, and this may contribute to differences in length of stay. Implications for outcome measurement are discussed.

Schizophrenia, mental state, and mother-infant interaction: examining the relationship.

OBJECTIVE: The aim of this study is to examine the role that disturbance of mental state of hospitalised mothers with a postpartum schizophrenic illness plays in determining the quality of mother-infant interactions. METHOD: We examined the relationship between the nature and severity of symptomatology in mothers with schizophrenia and the quality of her interactions with her infant in a sample of 15 mother-infant dyads admitted to a psychiatric Mother-Baby Unit. Data were obtained at admission and discharge. RESULTS: Mothers with florid positive symptoms and prominent negative symptoms of schizophrenia and their infants were identified as being at particular risk of displaying disturbed interactions. The adverse contribution of negative symptoms was often not evident until after the positive symptoms had resolved. CONCLUSIONS: Given that negative symptoms are often treatment resistant, optimal care of mothers with schizophrenia and their infants needs to involve ongoing therapeutic intervention which specifically addresses disturbances of mother-infant interaction. Further research is required to identify which interventions are likely to be of greatest benefit.

Health of the Nation Outcome Scales. Results of the Victorian field trial.

BACKGROUND: In Victoria, Australia, systematic assessment of outcomes in mental health services are being instituted. AIMS: To carry out a large-scale field trial of the Health of the Nation Outcome Scales (HoNOS). METHOD: 2137 clients were rated by mental health workers on the HoNOS, and about half were rated again within a few months. RESULTS: While interrater reliability of the total score was satisfactory, that of some individual items was unacceptable. Significant associations with age and gender were found, and clients with non-psychotic disorders obtained higher (i.e. worse) ratings than those with psychotic disorders. There were relationships between service use and HoNOS total score. For the group as a whole, total scores had not changed at the second rating, but admissions and discharges were associated with increases and decreases in total score. Among clients in the community, there was no relationship between change in HoNOS total score and frequency of contacts. CONCLUSIONS: Certain items, notably 11 and 12, were unreliable. The absence of evidence of sensitivity to change may be due to the short re-rating interval, little real change in the clients, or the characteristics of the scale itself.

Issues in the assessment of outcome in mental health.

OBJECTIVE: The purpose of this paper is to examine a number of issues in the assessment of outcome in mental health. METHOD: Issues are considered in terms of a number of dichotomies or choices. These include: intervention-dependent versus intervention-independent definitions of outcome, focusing on inputs or processes versus outcomes; individual versus organisational outcomes; outcomes for patients versus outcomes for significant others; pure versus mixed outcomes; care versus cure; direct versus indirect measures; objective versus subjective measures; descriptive versus prescriptive measures; global versus specific assessment; and assessing at significant times points versus assessing at fixed intervals. CONCLUSIONS: Guiding principles are formulated in terms of the foregoing issues.

A study of the quality of life of the severely mentally ill.

As part of a larger study, the Lehman Quality of Life Interview (QOLI) was conducted a total of 85 times with 55 clients with serious mental illness. Results revealed widespread adverse objective circumstances (unemployment, poverty and social isolation) despite which most clients rated their satisfaction levels about average (about equally satisfied and dissatisfied). As expected, subjective quality of life indicators were generally better predictors of global well-being (GWB) (itself based on subjective ratings) than were objective indicators. Correlations between objective and subjective indicators were very low and insignificant. Moderate relationships were found between GWB and levels of personal functioning, and changes in levels of personal functioning, as rated by mental health workers. Retests showed that subjective quality of life was relatively stable over intervals of several months. The findings suggest that leisure and social relations would be suitable areas for interventions that might improve clients' quality of life.

The assessment of clinically significant change using the Life Skills Profile.

OBJECTIVE: In the context of the need to develop practical outcome measures, the present study aimed to assess the sensitivity of the Life Skills Profile (LSP) in terms of differences between hospital-based and community-based clients, and to assess the sensitivity of the LSP to changes over time. In this way, criteria could be established whereby the LSP could be used to determine appropriate changes in locus of care, both in terms of the "cut-off' for hospital-based and community-based tenure, and the level of "clinically significant change' in functioning. METHOD: The LSP was administered at 3-monthly intervals to 200 clients of an area public mental health service with serious mental illness over a 21-month period. Locus of care (hospital or community) was noted at each administration. RESULTS: Clients in the community scored significantly better than those in hospital, however there was a great deal of overlap. Using hospital or community tenure as the variable of interest, a measure of reliable and clinically significant change over a 3-month period based on the LSP was developed. A total LSP score of 116.5 or above best discriminated clients in the community from those in hospital, and a difference of 18 points or more in two LSP obtained 3 months apart was unlikely to have arisen by chance. A simple, two-part criterion of significant change based on these results showed 89% accuracy in matching transition (or lack of transition) between hospital and community with changes in LSP scores. CONCLUSIONS: The results need to be understood within the methodological limitations of the present study. The findings provide users of the LSP with guidelines for the interpretation of repeat assessments. This may encourage more services to use formal reassessment methods to monitor the progress of their clients.

Ethnic differences in the utilisation of public psychiatric services in an area of suburban Melbourne.

OBJECTIVE: The main aim of this study was to compare levels of service use by English and non-English speaking background people. METHOD: A comparison of service use in 1991/1992 between clients of English speaking (ESB) and non English-speaking (NESB) background was undertaken using hospital inpatient statistics, community mental health centre contact data, interpreter usage figures, and the 1991 Australian census. RESULTS: The main findings indicated: (a) longer median lengths of stay of NESB than ESB inpatients; (b) roughly equal involuntary hospitalisation rates between ESB and NESB residents, but significantly lower rates of voluntary hospitalisation for NESB residents; (c) NESB face-to-face clinic contacts significantly shorter (by between five to ten minutes) than ESB; and (d) variable and generally low use of interpreters. No significant associations between ethnicity, legal status and gender were found. There were limitations in the available data and conclusions could be drawn only with caution. CONCLUSIONS: Recommendations include better routine collection of ethnically relevant information, and measures designed to improve the acceptability and accessibility of inpatient services.