Gentamicin reduces the self-renewal capacity of murine pluripotent hemopoietic stem cells.

This study pursues our initial observation of an association between prophylactic treatment of irradiated mice with gentamicin sulfate, and the subsequent low self-renewal capacity exhibited by transplanted marrow CFUS which they host. Either drug treatment of the host before engraftment, or exposure of marrow cells in vitro prior to their inoculation, produced suppressed CFUS self-renewal with respect to paired controls. Characteristics of primary spleen colonies (number, size, histology) were not altered, suggesting a specific deficit in secondary stem cell production or maintenance.

Merocyanine 540 alters the self-renewal capacity of murine pluripotent hemopoietic stem cells.

Merocyanine 540 (MC 540), an impermeant photoreactive dye with a high affinity for the plasma membrane of hemopoietic precursors, was examined for effects on the self-replicative capacity (SR) of CFUS from normal mouse marrow, and on various CFUS subpopulations fractionated by velocity sedimentation. Brief exposure (30 s) of whole marrow to MC 540 resulted in a reduction in overall CFUS self-renewal in primary recipient spleens. Reduced self-renewal was also observed when fractionated CFUS subpopulations were used. Reduced self-renewal was not accompanied by obvious changes in primary spleen colony number or composition. MC 540 may interact with specific superficial membrane sites relevant to the SR process. Upon longer exposure, further MC 540 effects appear restricted to a reactive subpopulation of large (low SR) CFUS. Self-renewal was enhanced in this fractionated pool, without evidence of primary colony reduction, by intermediate staining. This strongly suggests that under certain conditions the dye can alter a fundamental functional property of susceptible stem cells, without their inactivation. Still more prolonged staining apparently leads to the selective elimination of this reactive low SR CFUS subset. A marked reduction in whole marrow-derived spleen colonies was accompanied by an enhanced self-renewal capacity among the survivors. These two MC 540 effects--stem cell modification, and stem cell elimination--may reflect different stages in an ongoing membrane photo-oxidation process.

Use of ECT in the United States in 1975, 1980, and 1986.

OBJECTIVE: The objective was to analyze nationally representative data from the National Institute of Mental Health (NIMH) to update trends in the use of ECT in the United States. METHOD: The data are estimates from the NIMH Sample Survey Program for 1975, 1980, and 1986, which include representative samples of inpatients in psychiatric facilities in the United States. The authors' analyses use trend data from public general hospitals, private general hospitals, private psychiatric hospitals, and state and county mental hospitals. They report on 126,739 patients who received ECT in 1975, 1980, and 1986, focusing on data from 1980 and 1986. RESULTS: In 1986, 36,558 patients received ECT. This represents a decrease from the 1975 figure (58,667 patients) but no change from 1980 (31,514 patients). ECT was used primarily in private general hospitals (64%) and private psychiatric hospitals and much less often in public general hospitals and state and county mental hospitals. In 1986 over 90% of ECT recipients were white, and 84% had an affective disorder diagnosis. Although 71% of the patients who received ECT were women, hospital type and age were more important than gender in predicting ECT use. Individuals 65 years of age and older received ECT out of proportion to their numbers in inpatient care. CONCLUSIONS: The declining use of ECT in the United States ended in the 1980s. Few African Americans receive ECT, and its use is becoming more targeted toward patients with affective disorders. The amount of services research done on this modality is very small. Basic questions have yet to be answered, including who refers patients for ECT and why, and how ECT fits into the overall course of treatment.

Trends in the inpatient care of persons with schizophrenia.

This report analyzes nationally representative data to examine inpatient services provided to persons with schizophrenia. The data are for patients admitted to general hospitals, private psychiatric hospitals, and State and county mental hospitals between 1970 and 1986 (weighted n = 860,637). The proportion of admissions diagnosed as having schizophrenia decreased from 21 percent in 1970 to 16 percent in 1986; this proportion decreased in public general hospitals and increased in private general hospitals. The rate of admissions for schizophrenia decreased in public general hospitals and State and county mental hospitals and increased in private general hospitals. The overall admissions rate decreased for whites with schizophrenia and increased for African-Americans, owing entirely to increased admissions of African-American males. Private general hospitals and State and county mental hospitals relied less over time on private insurance; the use of Medicare increased in both public and private general hospitals; and Medicaid use increased in private general hospitals. Further research on services for this population is necessary as a baseline for health care reform.

Influence of psychoactive substance use on the reliability of psychiatric diagnosis.

The interrater reliability of diagnoses made on the basis of a structured interview for psychiatric patients with and without psychoactive substance use disorders (PSUDs) was examined. Forty-seven pairs of ratings by 9 different clinical interviewers were used. Results supported 3 major findings: (a) The interrater reliability for non-PSUD psychiatric diagnoses is quite high when a subject has no diagnosable PSUD; it is lower, though still substantial, when a PSUD is present. (b) Interviewers are not aware of this and are just as certain of the accuracy of their diagnoses when a PSUD is present as when one is not. (c) Interrater reliability is moderate to substantial as to the judgment of whether, when a non-PSUD diagnosis is present, it is caused by the use of psychoactive substances. The implications of these findings for the appropriate selection of treatments for dually diagnosed patients are discussed.

Bilateral tubal pregnancy. A report of an unusual case.

BACKGROUND: Bilateral tubal pregnancies are rare and are usually confirmed simultaneously during the same operation. We report a case in which the right salpingectomy was performed seven weeks before the left salpingectomy. When the right salpingectomy was done, the left uterine tube appeared entirely normal. CASE: A 38-year-old woman underwent laparoscopic surgery for suspected right tubal pregnancy. A right tubal pregnancy was found to have partially aborted into the peritoneal cavity. The left uterine tube was carefully inspected and appeared normal. Histopathology of the right tube showed products of conception and chorionic tissue. Seven weeks after surgery, the woman presented in hemorrhagic shock necessitating emergency laparotomy and left salpingectomy. Histopathology of the left tube confirmed the presence of chronic tissue. The patient did not have coitus between the two salpingectomies. CONCLUSION: The explanation of the presentation is uncertain. However, this case underscores the importance of careful follow-up of patients after laparoscopic surgery for ectopic pregnancies.

Effectiveness of outreach to homeless substance abusers.

Substance abuse is a frequent and complicating feature of homelessness. Barriers to service access have prevented homeless individuals from receiving substance abuse care. Outreach to homeless persons is a mechanism for identifying homeless substance abusers and engaging them in treatment. This study describes a program of substance abuse treatment conducted by a medical care provider for homeless persons in Baltimore, Maryland and compares characteristics of outreach recipients to those of walk-in clients. The study also examines the differences in drug abuse pathology and selected treatment outcomes among homeless and non-homeless clients and the extent to which homeless persons are unidentified in the drug abuse treatment reporting system of the state. Homelessness is about 5.5 times more prevalent in the clientele of drug abuse treatment programs than is reflected in the statewide substance abuse management information system of Maryland. Composite scores on the Addiction Severity Index for homeless individuals are significantly higher (reflecting more serious problems) on every measure in the interview, compared to non-homeless individuals. Except for residential treatment settings, homeless persons demonstrate a shorter length-of-stay in substance abuse treatment than housed clients. Our outreach effort successfully located its targets. Outreach clients reported significantly higher levels of substance abuse than walk-in clients. In addition 42.3% of outreach contacts became service recipients. These findings indicate that outreach can be a successful method of targeting and engaging a segment of homeless substance abusers who are otherwise difficult to engage in treatment.

Quality of life in alternative residential settings.

Central to policy revisions over the past forty years toward persons with psychiatric disabilities has been a change in where they live. Whereas forty years ago those patients needing assistance were generally housed in large public mental hospitals, today a myriad of alternative community housing settings are offered. A major impetus for this shift in housing, at least as currently articulated in most public forums, has been to improve their quality of life. Here we examine the quality of life experiences of psychiatrically disabled persons living in alternative settings: a state hospital, large residential care facilities, small group homes, and supervised apartments. Our central hypothesis, only partly supported, is that a quality of life gradient exists across these living settings. The results lend support to the value of quality of life assessments and point to the importance of more focused notions about how our various interventions may affect the persons whom we serve.

Assessment and classification of patients with psychiatric and substance abuse syndromes.

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical hypotheses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.

Implications of mental and substance use disorders. A comparison of single and dual diagnosis patients.

To understand better the implications of co-occurring mental and substance use disorders, we examined DSM-III-R diagnoses and life problems among a representative sample of 314 patients admitted to either a psychiatric hospital or a residential substance abuse treatment program from the same inner-city catchment area. Based upon the Structured Clinical Interview for DSM-III-R, the patients were divided into four groups. The first two groups had dual diagnoses, either: a) a primary axis I mental disorder (MD) and a comorbid psychoactive substance use disorder (PSUD); or b) a PSUD-related mental disorder and a PSUD, but no primary axis I MD. The third and fourth groups had a single diagnosis, either: c) a primary axis I MD, but no lifetime PSUD; or d) a PSUD, but no lifetime primary axis I MD. As expected, the two dual disorder groups had more cumulative problems than did either of the single disorder groups. Dually disordered patients with PSUD-related MD most resembled single-diagnosis PSUD patients in terms of substance use profile and life problems. Dually disordered patients with primary MD more resembled single-diagnosis MD patients, but had more severe life problems. Presence of a PSUD was associated with male gender, antisocial personality disorder, and more severe legal problems. Presence of a primary mental disorder was associated with more extensive prior hospitalizations and greater psychiatric severity.

Evaluation of expanded school mental health programs.

Expanded school mental health programs provide a full range of mental health services (assessment, treatment, case management, prevention) to youth in regular and special education, and typically involve close collaboration between schools and community agencies. A major challenge for these programs is documenting that provided services are of high quality and leading to enhanced outcomes for the youth and schools served by them. Dimensions of school mental health evaluations and a step-by-step process for conducting them are presented, using the example of a well established program in Baltimore. Challenges to such evaluation and strategies for overcoming challenges are also presented.

Severity of substance use disorders among psychiatric inpatients.

This study compares the severity of DSM-III-R psychoactive substance use disorders (PSUDs) among dually diagnosed psychiatric inpatients with independent axis I mental disorders (IMDs) with the severity of PSUDs among: a) patients from the same hospitals with PSUD-related organic mental syndromes (PSUD-OMD) and b) patients from a residential drug-treatment program with PSUDs but no axis I mental disorders. The drug-use disorders among the group 1 (IMD+PSUD) patients were less severe on multiple indicators from the Structured Clinical Interview for DSM-III-R (SCID) and the Addiction Severity Index compared with the drug-use disorders among the other two groups. This did not hold for alcohol disorders. These findings carry potential implications for treatment strategies for the mentally ill with drug use.

Prevalence and patterns of "dual diagnosis" among psychiatric inpatients.

Studies of patients admitted to public mental hospitals have consistently found high rates of comorbid substance use disorders. We sought a better understanding of this comorbidity among psychiatric inpatients, in particular differentiating two groups of "dual diagnosis" patients, (1) those with independent mental disorders complicated by substance use disorders, and (2) those with psychoactive substance use disorder-induced organic mental disorders (PSUD-induced OMD). The diagnoses of 435 consecutively admitted inpatients from an inner-city catchment area were ascertained with the Structured Clinical Interview for DSM-III-R (1987 Inpatient Version [SCID-P]), modified to describe more accurately the relationships between psychiatric syndromes and substance use. More than half (55.9%) of these psychiatric patients had current substance use disorders. Over half (53.6%) of these "dually diagnosed" patients had no lifetime history of an independent mental disorder, but rather had psychiatric syndromes related to psychoactive substance use. The dual diagnosis subgroups differed on treatment history, principal psychiatric diagnoses, and the types of substances used. The results underscore the heterogeneity of dual diagnosis patients admitted to psychiatric hospitals and the potential importance of differentiating among these subgroups.

Defining subgroups of dual diagnosis patients for service planning.

OBJECTIVE: The high proportion of persons presenting for treatment of psychiatric disorders who also have comorbid substance use problems severely challenges the capacity of mental health care programs to plan for patients' needs. One of the problems encountered in anticipating the treatment needs of these patients is the wide heterogeneity of their comorbidity, that is, the broadly varying types, severity, and time courses of psychiatric and substance disorders. This paper describes and evaluates a relatively simple conceptual framework for delineating the heterogeneity of patients who are dually diagnosed. METHODS: A typology of subgroups of patients was defined a priori based on whether patients are singly or dually diagnosed and whether their disorders are current or past. Patients admitted to three treatment facilities in an inner-city catchment area were assigned to one of the subgroups based on administration of the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). The subgroups were compared on clinical diagnoses and service needs as measured by the SCID-P and the Addiction Severity Index. RESULTS: A total of 461 patients were assigned to four mutually exclusive dual diagnosis subgroups--patients with current definite dual diagnoses, current possible dual diagnoses, current substance-induced organic mental disorder, and past definite dual diagnoses--and the two comparison groups. The subgroups differed significantly from each other and from two single-diagnosis comparison groups on axis I diagnoses, types of substance use disorders, and current problem areas. CONCLUSIONS: The framework developed has potential utility for distinguishing subgroups of dually diagnosed patients relevant for service planning.

Psychiatric hospital care and changes in insurance coverage strategies: a national study.

The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment.

Detection of substance use disorders among psychiatric inpatients.

This study examines the utility of the Addiction Severity Index (ASI) for detecting psychoactive substance use disorders (PSUDs) among psychiatric inpatients. Four hundred thirty-five inpatients at two inner-city psychiatric hospitals completed the ASI and the Structured Clinical Interview for DSM-III-R (SCID). Receiver operating characteristic (ROC) analysis assessed the optimal threshold ASI alcohol and drug composite scores to detect DSM-III-R PSUDs. The correlations of both the ASI alcohol and drug composite scores with their corresponding DSM-III-R PSUD categories were significant (p<.0001). However, the ROC analysis revealed that the ASI misses approximately 20% of SCID-positive PSUD cases. Specificity of the ASI, on the other hand, is quite good (95% to 98%), and optimal ASI threshold scores to rule out a PSUD among these patients are identified. The results also support the sensitivity of these patients to the toxic effects of illicit substance use.

Psychosocial functioning of youth receiving mental health services in the schools versus community mental health centers.

Evaluated psychosocial differences between youth receiving mental health services in Community Mental Health Centers (CMHCs; n = 79) as compared to youth receiving services from a program operating in 10 Baltimore schools (n = 186). Racial and gender differences were shown, with more African American youth and females in the School than CMHC sample. Multivariate analyses that controlled for these racial and gender differences failed to reveal significant effects, indicating comparable functioning on measures of life stress, violence exposure, family support, self-concept, and emotional/behavioral problems for youth from the two samples. However, particularly for those with internalizing disturbances, youth in the School sample were less likely to have received prior mental health services than youth from the CMHCs. Findings support the conclusion that school-based mental health programs are reaching youth who need mental health services, who otherwise may not receive them.