Psychometric properties of the Fletcher Recovery Housing Alliance Measure (FRHAM-12).

Background: Recovery Housing (RH), an important resource for substance use disorder (SUD) recovery, centers on shared lived experience. Program evaluation considers the contribution of environmental factors to outcomes, yet most research on outcomes has focused on patient factors and fidelity to protocols. Investigations of process measures reflecting the dynamic interplay between patient factors and the treatment program are limited. Alliance, one's perceived connection with others, is a process measure associated with mental health outcomes and includes domains "tasks," "goals," and "bonds." We posit that alliance serves as a proxy construct to measure the impact of shared experience in RH.Objectives: Develop and assess the psychometric properties of the Fletcher Recovery Housing Alliance Measure (FRHAM-12) for RH.Methods: A cross-sectional survey with the 12-item FRHAM-12 was administered to 271 individuals (60% men, 39% women, 1% other) within six RH centers in Kentucky. Item-total correlations, internal consistency reliability, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA) were conducted.Results: The FRHAM-12 was found to have a strong internal consistency (0.924 alpha coefficient) and the EFA yielded a single component (56.38% of cumulative scale variance). CFA indicated acceptable levels of absolute and relative fit of a unidimensional scale with values of 0.67 and 0.976 for the standardized root mean square residual and relative fit index.Conclusion: This study aimed to construct and validate an initial measure for RH alliance resulted in the brief, FRHAM-12; a tool with strong internal and factor validity. Future research should examine the measure's predictive and concurrent validity.

The relationship between the INTERMED patient complexity instrument and Level of Care Utilisation System (LOCUS).

OBJECTIVE: To investigate the concurrent and criterion validity of two independently developed measurement instruments, INTERMED and LOCUS, designed to improve the treatment and clinical management of patients with complex symptom manifestations. METHODS: Participants (N = 66) were selected from hospital records based on the complexity of presenting symptoms, with tripartite diagnoses across biological, psychiatric and addiction domains. Biopsychosocial information from hospital records were submitted to INTERMED and LOCUS grids. In addition, Global Assessment of Functioning (GAF) ratings were gathered for statistical analyses. RESULTS: The product moment correlation between INTERMED and LOCUS was 0.609 (p = .01). Inverse zero-order correlations for INTERMED and LOCUS total score and GAF were obtained. However, only the beta weight for LOCUS and GAF was significant. An exploratory principal components analysis further illuminated areas of convergence between the instruments. CONCLUSIONS: INTERMED and LOCUS demonstrated shared variance. INTERMED appeared more sensitive to complex medical conditions and severe physiological reactions, whereas LOCUS findings are more strongly related to psychiatric symptoms. Implications are discussed.

Depression and Liver Transplant Survival.

BACKGROUND: Patients who underwent liver transplantation and experienced clinical depression have heretofore evinced lower survival rates when compared to nondepressed counterparts. OBJECTIVE: To investigate the hypothesis that transplant patients who seek and obtain medical treatment for depression would circumvent the prior reduced survival findings. METHODS: A total of 765 patients with liver transplants were scrutinized for complications following transplantation. Further, 104 patients experienced posttransplant depression as manifested by diagnosis and treatment by medical personnel. Survival analyses were conducted comparing hazard and survival curves for these selected individuals and the remainder of transplant patients. RESULTS: Contrary to prior data and consistent with the aforementioned hypothesis, median survival durations, survival curves, and hazard functions (controlling for age and prolonged posttransplant survival for the depressed patients were better. CONCLUSION: The improved survival for the depressed patients may simply be related to an amelioration of depressed symptoms via antidepressant medications. However, this interpretation would only be congruent with reduced hazard, not elevated survival, beyond the norm (median) for other transplant participants. Assuming the reliability and generalization of our findings, perhaps a reasonable and compelling interpretation is that combined with the effectiveness of antidepressant medications, the seeking and receiving treatment for depression is a type of proxy measure of a more global pattern of adherence to recommended posttransplant medical regimens.

Childhood Enuresis: Current Diagnostic Formulations, Salient Findings, and Effective Treatment Modalities.

Enuresis constitutes a frequently encountered problem area for children that may adversely affect social and emotional adjustment. This type of incontinence has been of concern to the human family for centuries. A brief history of enuresis is presented followed by current conceptualizations, diagnostic criteria, prevalence rates and psychiatric comorbidities. Historic notions of causation together with ineffective, sometimes barbaric treatments are then discussed, ending with a presentation of evidence-based treatment modalities, with the urine alarm being an essential element of effective treatment. An intervention termed dry bed training combines the urine alarm with a series of procedures designed in part to reduce relapse potential and should be a primary consideration for implementation by treatment professionals. Finally, a brief case study is presented illustrating special etiological and treatment considerations with juvenile psychiatric patients.

Confirmatory Factor Analysis of the Delirium Rating Scale Revised-98 (DRS-R98).

Principal components analysis applied to the Delirium Rating Scale-Revised-98 contributes to understanding the delirium construct. Using a multisite pooled international delirium database, the authors applied confirmatory factor analysis to Delirium Rating Scale-Revised-98 scores from 859 adult patients evaluated by delirium experts (delirium, N=516; nondelirium, N=343). Confirmatory factor analysis found all diagnostic features and core symptoms (cognitive, language, thought process, sleep-wake cycle, motor retardation), except motor agitation, loaded onto factor 1. Motor agitation loaded onto factor 2 with noncore symptoms (delusions, affective lability, and perceptual disturbances). Factor 1 loading supports delirium as a single construct, but when accompanied by psychosis, motor agitation's role may not be solely as a circadian activity indicator.

Using the INTERMED complexity instrument for a retrospective analysis of patients presenting with medical illness, substance use disorder, and other psychiatric illnesses.

BACKGROUND: The financial and treatment challenges of complex patients must be addressed with adequate assessment and evaluation. The INTERMED complexity instrument (INTERMED) has been developed for this purpose, but to date has not been used retrospectively. The current study represents a retrospective validity investigation of INTERMED with patients with substance use disorder comorbid with other psychiatric and medical conditions (triple diagnoses). Such patients were expected to generate high complexity scores on the INTERMED instrument. METHODS: Information on 66 patients with triple diagnoses was submitted to the INTERMED complexity grid. These data were subjected to cluster analysis and other analytic procedures. RESULTS: Total INTERMED scores reflected elevated complexity for patients with triple diagnoses. As a group, they represented a single cluster of complex patients. CONCLUSIONS: The validity of the INTERMED complexity assessment was corroborated in relation to retrospective data. In addition to elevations in the biological domain that hospital personnel typically confront, findings related to coping deficiencies and problems in living conditions were noteworthy in requiring comprehensive interventions.

Treatment of delirium with risperidone in cancer patients.

AIM: Antipsychotic medications have frequently been regarded as the treatment of choice for delirium. This study examined the clinical efficacy of risperidone for the treatment of delirium in cancer patients, combined with a repeated assessment of underlying medical severity levels. METHODS: The study included consecutive referrals of 29 delirious cancer patients (mean age, 68.9 ± 12.5 years; male, 69%) to the psychiatric consultation service. Risperidone was given orally once per day (mean dosage, 1.4 ± 1.3 mg/day). Study participants were assessed using quantitative standardized scales of cognitive function, delirium, and physical impairment at baseline and at the end of the study (seventh day). RESULTS: Risperidone with routine clinical management was effective for the treatment of delirium: 48% of the patients responded and 38% achieved remission. The reduction of delirium severity occurred in 79% of the patients. Changes in delirium severity were unrelated to age, gender, general cognitive dysfunction, or to severity of attendant medical conditions. In addition to changes in agitation and perceptional disturbances, risperidone was also effective for other specific delirium symptoms. CONCLUSIONS: Risperidone with routine clinical management is effective in the treatment of delirium in advanced cancer patients, independent of changes in the underlying medical condition.

Patient complexity, depression, and quality of life in patients with epilepsy at an epilepsy center in Japan.

OBJECTIVE: The relationship between care complexity and quality of life among patients with epilepsy has not been assessed, especially in Japan. The aim of this study is to test the hypothesis that care complexity is associated with health-related quality of life (HRQOL) and mood disturbance. METHOD: This was an observational cross-sectional study. The study included a consecutive series of 49 patients who newly visited an epilepsy center. Study participants were administered standardized quantitative measures of HRQOL, case complexity, and depression. RESULTS: Patient complexity predicted lower HRQL scores. Data on the social and psychological complexity domains predicted patient HRQOL findings more accurately than data from the biological domain of the case complexity scale. Seizure frequency was unrelated to HRQOL findings in this study. Additionally, depression scores were also associated with lower HRQOL. SIGNIFICANCE: A patient complexity assessment, including psychological and social domains, may be one of the key tools in epilepsy treatment settings. Further studies using larger random selection from patients with epilepsy are necessary to generalize the findings to patients in other epilepsy programs.

More on Darwin's illness: comment on the final diagnosis of Charles Darwin.

Without the possibility of confirmatory exhumation, diagnostic inferences about Darwin's illness must remain speculative. A diagnosis of Darwin's aggregate symptoms must account for not only gastrointestinal distress but also his predominant and excessive retching and the conglomerate of other heterogeneous symptoms. We opine that Crohn's disease, posited as the 'final diagnosis', is not sufficient for subsuming his pleiomorphic symptomatology. An additional proposal is outlined that may help to explain his presentation with heterogeneous symptoms. It incorporates constitutional vulnerabilities, psychosomatic influences and Pavlovian conditioning as explanatory variables.

Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation.

OBJECTIVE: This study evaluates patient characteristics that might predict a missed diagnosis of delirium prior to being seen by a psychiatric consultant. METHOD: Study participants were assessed using quantitative standardized scales of cognitive function, delirium and physical impairment. RESULTS: Referring service personnel missed the diagnosis of delirium in 46% of psychiatric consultations. Two factors were associated with their failure to identify delirium accurately: use of a past psychiatric diagnosis to explain delirium symptoms and the presence of pain. Symptoms of delirium and quantitative scale scores did not distinguish between patients with whom diagnosis had been missed and those with accurate diagnoses. CONCLUSION: The consulting physicians of patients with delirium often incorrectly turn to past psychiatric diagnoses and/or are distracted by the presence of pain and, thus, fail to accurately diagnose delirium.

The Zung Self-Rating Depression Scale: convergent validity and diagnostic discrimination.

This study examined the concurrent validity of the Zung Self-Rating Depression Scale (SDS) in relation to the Depression (D) scale of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and addressed a gap in the literature with respect to diagnostic discrimination. The participants were persons on probation or parole. Although women were more depressed than men on the SDS, gender did not interact with SDS as a predictor in a logistic regression analysis. The SDS was found to be the primary discriminating variable in distinguishing depressed from nondepressed participants. In addition, the SDS contributed significant incremental validity over the D scale and showed greater accuracy in identifying nondepressed individuals.

An adolescent version of the Michigan Alcoholism Screening Test.

Item content of the Michigan Alcoholism Screening Test (MAST) was modified to make it more appropriate for young persons. The resulting test was found to have lower internal consistency than the adult MAST, but the elimination of five items with comparatively poor psychometric properties yielded an acceptable alpha coefficient of .73. A unitary factor model for the adolescent MAST was not confirmed; indeed, the revised test appeared to be factorially complex. Recommendations for further revisions are discussed.

Coefficient alpha and interculture test selection.

The internal consistency reliability of a measure can be a focal point in an evaluation of the potential adequacy of an instrument for adaptation to another cultural setting. Cronbach's alpha (α) coefficient is often used as the statistical index for such a determination. However, alpha presumes a tau-equivalent test and may constitute an inaccurate population estimate for multidimensional tests. These notions are expanded and examined with a Japanese version of a questionnaire on nursing attitudes toward suicidal patients, originally constructed in Sweden using the English language. The English measure was reported to have acceptable internal consistency (α) albeit the dimensionality of the questionnaire was not addressed. The Japanese scale was found to lack tau-equivalence. An alternative to alpha, "composite reliability," was computed and found to be below acceptable standards in magnitude and precision. Implications for research application of the Japanese instrument are discussed.

Effects of a training workshop on suicide prevention among emergency room nurses.

BACKGROUND: Suicide attempts are frequently encountered by emergency department nurses. Such encounters can potentially provide a foundation for secondary suicide prevention. AIMS: The aim of the present investigation was to evaluate the effect of a 7-hr training program for emergency room nursing personnel in Japan. METHOD: In all, 52 nurses completed the questionnaires before the workshop and 1 month after the workshop. The nurses' understanding of and willingness to care for suicidal patients positively changed. RESULTS: It is feasible to provide a 7-hr, relatively short, workshop on suicidal prevention aimed at emergency medical staff and to improve attitudes during a follow-up of 1 month. CONCLUSION: It is uncertain whether the positive attitudes of emergency nurses toward suicide and/or educational interventions could impact the outcomes of these interventions. Further studies are needed to address these important questions in this field.

Attitudes of Japanese nursing personnel toward patients who have attempted suicide.

OBJECTIVE: The aim of this study was to examine the attitudes among Japanese nurses together with their perceived need for training in relation to understanding the nature of suicidal behavior and preventive strategies. METHODS: The Understanding Suicidal Patients scale together with additional questions reflecting training and the psychiatric treatment of suicide attempters were administered. RESULTS: A total of 323 nurses attended this study. Overall, the nurses thought patients who attempted suicide were not treated well. The nurses who worked in the psychiatric unit or had the experience in psychiatric nursing had more favorable attitudes toward suicidal patients and viewed themselves as having more relevant skill training in dealing with suicidal patients than those who did not. The nurses who worked at emergency care/intensive care unit were less likely to understand suicidal patients, and were less inclined to be sympathetic and to verbally interact with suicidal patients concerning their problems. The nurses who have confidence in the psychiatric care of suicidal patients, confidence in their own skills, and have a need for more training had the more positive attitudes. CONCLUSIONS: The results suggest that less favorable attitudes may to some extent be the result of lack of knowledge regarding suicidal patients. Future studies should focus on the evaluation of educational experiences on attitudes and skill acquisition of nurses.

Functional neuro-imaging and post-traumatic olfactory impairment.

OBJECTIVE: To evaluate via a research literature survey the anterior neurological significance of decreased olfactory functioning following traumatic brain injuries. MATERIALS AND METHODS: A computer literature review was performed to locate all functional neuro-imaging studies on patients with post-traumatic anosmia and other olfactory deficits. RESULTS: A convergence of findings from nine functional neuro-imaging studies indicating evidence for reduced metabolic activity at rest or relative hypo-perfusion during olfactory activations. Hypo-activation of the prefrontal regions was apparent in all nine post-traumatic samples, with three samples yielding evidence of reduced activity in the temporal regions as well. CONCLUSIONS: The practical ramifications include the reasonable hypothesis that a total anosmic head trauma patient likely has frontal lobe involvement.

Psychiatric consultation and substance use disorders.

BACKGROUND: A substantial number of patients in general hospitals will evince substance abuse problems but a majority is unlikely to be adequately identified in the referral-consultation process. This failure may preclude patients from receiving effective interventions for substance use disorders. OBJECTIVES: 1. To evaluate all referred patients for possible substance use disorders. 2. To ascertain the degree of convergence between patients referred for chemical problems and the corresponding DSM diagnosis. 3. To compare demographic data for substance abusing patients and referrals not so classified. 4. To evaluate conditions concomitant with substance use disorders. METHOD: Consecutive one-year referrals (524) to consultation-liaison psychiatric services were scrutinized for chemically-related problems by psychiatric consultants. RESULTS: Of the referrals, 176 met criteria for substance use disorders (SUD) (57% alcohol; 25% other drugs; 18% both alcohol and other drugs). Persons diagnosed with SUD tended to be younger, male, non-Caucasian, unmarried, and unemployed. They were more likely to be depressed, have liver and other gastrointestinal problems, and to have experienced traumatic events; they also tended to have current financial difficulties. Most were referred for SUD evaluation by personnel in general medicine and family practice. Following psychiatric consultation, SUD designated patients were referred mainly to substance abuse treatment programs. The only variable related to recommended inpatient versus outpatient services for individuals with SUD was the Global Assessment of Functioning Axis (GAF) with persons having lower estimated functioning more likely to be referred for inpatient interventions. CONCLUSIONS: These data are similar to the results of past studies in this area. Unlike previous investigations in the domain of consultative-liaison psychiatry, financial stressors and specific consultant recommendations were included in data gathering. Although the results are encouraging in that individuals with SUD were identified and potentially sent for appropriate treatment, the likelihood is that many patients with SUD remain unrecognized and do not receive necessary consultative and treatment services.

Review of two years of experiences with SPECT among psychiatric patients in a rural hospital setting.

We summarize single proton emission computed tomography (SPECT) findings from 63 psychiatric patients in a small rural hospital in western Minnesota. SPECT scans were ordered only for patients in whom documentation of hypoperfusion and functional deficits might be helpful in clarifying diagnoses and treatment planning. The patients referred for SPECT scans had histories of traumatic brain injuries, atypical psychiatric symptom presentations, or conditions that were refractory to standard treatments. In the context of strict referral guidelines and close psychiatrist-radiologist collaboration, a much higher yield of significant findings was obtained compared with those noted in other reports in the literature.

Misdiagnosed delirium in patient referrals to a university-based hospital psychiatry department.

The authors examined the factors associated with referral errors in which the presence of delirium was ostensibly not recognized by medical staff personnel. Medical records of 541 university-hospital patients consecutively referred for psychiatric consultation were scrutinized for extant delirium. The data indicated that a greater likelihood of a missed diagnosis was associated with younger age; referrals outside of family practice service; orientation as to person, place, and time; and a history of bipolar affective disorder or psychosis. The ramifications of failure to diagnose existing delirium include increased morbidity and mortality, longer length of hospital stay, and increased healthcare costs.

A comparison of psychiatric consultation liaison services between hospitals in the United States and Japan.

The authors investigated psychiatric consultation in two hospitals, one in the United States, the other in Japan. They examined similarities and differences, and drew inferences on possible cross-cultural values and/or temporary cultural conditions. As compared with the Japanese consultation patients, the Americans had more mood disorders, including anxiety and chemical-dependency problems, in respective diagnostic classifications. Patients in the United States also showed more acute as well as more serious chronic conditions. These differences may relate to disorder base-rates in the respective countries. In general, psychosocial problems emerged as ascendant in Japan, as compared with chemical-dependency difficulties among American patients. The results are discussed in terms of current conditions in Japan that affect the mental health professions, together with attempts by Japanese clinicians to protect collective mores by ascribing causation for disorders to the individual, rather than the societal conditions often invoked in the United States.