Relationship quality among HIV patients and their caregivers.

Despite the increasing attention to caregivers of HIV patients, no previous study has systematically investigated the effects of the relationship quality between an HIV patient and their caregiver. The present study assessed 176 dyads consisting of an HIV-infected patient and their self-identified 'caregiver'. Relationship quality was measured by the Family Assessment Device (FAD). Dependent measures included the Beck Depression Inventory, SF-36 Physical Functioning Scale, Caregiver Strain Index and 4-day HIV treatment adherence. A substantial proportion of HIV patient-caregiver dyads reported difficulties in their relationships (17-66% depending upon FAD scale). The level of relationship difficulties was not strongly related to the type of patient-caregiver relationship. However, the quality of the HIV patient-caregiver relationship was significantly associated (p<0.05) with caregiver depression and burden as well as HIV patient depression, physical functioning and HIV medication adherence, even when the potential effects of length of HIV infection and social support were controlled. These results suggest that relationship quality is impaired in many patient-caregiver dyads and is uniquely associated with levels of depression, caregiver burden and treatment adherence.

Why fix what isn't broken? A rejoinder to Ridenour, Daley, & Reich.

Ridenour, Daley, & Reich (2000) suggest that the Family Assessment Device should be reorganized. We disagree and provide further reasons why such a reorganization is unwise.

"Factor analyses of the family assessment device," by Ridenour, Daley, & Reich.

Ridenour, Daley, and Reich conducted a series of factor analyses using the correlational matrix of the subscale scores of the Family Assessment Device (FAD), published in Family Process, December, 1999. They conclude that "the FAD subscales be reorganized from their current seven-subscale format" (p. 507). We propose that this suggestion for reorganization is premature and based on the inappropriate application of an "internal consistency" model of scale construction to the FAD. We further suggest that the most important criteria regarding an assessment instrument are those of reliability, validity, and clinical utility. In the absence of this kind of data regarding alternative organizations of the FAD, we believe that the original subscales remain the best choice.

Pathological crying and laughing: treatment with sertraline.

OBJECTIVE: To evaluate the efficacy of sertraline for treating pathological laughing and crying after stroke. DESIGN: Case series. SETTING: Inpatient rehabilitation units of a community and a tertiary-care hospital. PATIENTS: One patient was a 62-year-old right-handed man who had two strokes approximately 2 years apart and had computed tomography consistent with a cerebral infarct involving the left middle cerebral artery branches in the left parietal lobe. A second patient was a 72-year-old right-handed man who had a right middle cerebral artery infarct. He had a questionable history of depression prior to the stroke. INTERVENTION: Both patients had poststroke labile affect that was interfering with their rehabilitation. Sertraline was prescribed. MAIN OUTCOME MEASURES: Pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. RESULTS: Both patients showed significant improvement after taking sertraline-improvement that was reflected in their pretreatment and posttreatment scores on the Pathological Crying and Laughing Scale and Functional Independent Measure. The staff noted improvements in sleeping, eating, social interaction, and therapy participation. Both patients tolerated the sertraline well and had no significant side effects.

Role of the family in recovery and major depression.

OBJECTIVE: Major depression is significantly influenced by the family environment of the depressed patient. In order to explore how family functioning relates to this illness, the authors examined changes in family functioning over a 1-year course of major depression. METHOD: Subjective (Family Assessment Device) and objective (McMaster Clinical Rating Scale) assessments of family functioning were collected at hospitalization and 6 and 12 months after discharge for 45 inpatients diagnosed with major depression and their family members. Patterns of family functioning were examined by subjective and objective perspectives, initial levels of functioning, and reports of patients and other family members. RESULTS: Approximately 50% of families with a depressed member perceived their own family functioning as unhealthy; clinicians rated 70% of the families as unhealthy. While family functioning improved significantly from hospitalization through 12 months after discharge, the improvement was not uniform across all areas of functioning. Further, patients with good family functioning at hospitalization generally maintained their healthy functioning and were more likely to recover by 12 months than patients with poor family functioning. Although steady improvement in family functioning characterized the subjective ratings, objective assessments of family functioning suggested initial improvement followed by a decline from month 6 to month 12. CONCLUSIONS: Results show a clear association between family functioning and recovery from major depression. Different aspects of family life respond differently to the depressive illness; no one family dimension was uniquely related to outcome.

Stroke: a family dilemma.

Research studying the clinical effectiveness of stroke rehabilitation has focused on managing acute stages and on evaluating short-term treatment programmes. However, many studies suggest that stroke affects long-term quality of life and the well-being of the family. This article reviews the stroke literature relative to aging, disability, and rehabilitation. The social effects of stroke in terms of clinical problems which make rehabilitation a family dilemma are discussed. Issues identified include the need for family assessment, education, advocacy, and counselling to foster treatment compliance and social support.

The development of a clinical rating scale for the McMaster model of family functioning.

This article describes the development and validation of the McMaster Clinical Rating Scale (MCRS). The MCRS is a 7-item scale designed to be completed by a trained rater after completion of an in-depth interview of the family. We present data from four new studies and review previously published articles concerning the reliability, validity, and clinical utility of the MCRS. Adequate interrater reliability and rater stability were obtained. The MCRS was found to correlate significantly with the self-report Family Assessment Device and to discriminate between families in different phases of a depressive disorder.

Depressed patients with dysfunctional families: description and course of illness.

Sixty-eight depressed patients were subdivided according to their family's level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels of neuroticism. A 12-month follow-up of these patients indicated that depressed patients with dysfunctional families had a significantly poorer course of illness, as manifested by higher levels of depression, lower levels of overall adjustment, and a lower proportion of recovered patients. Thus, impaired family functioning appears to be an important prognostic factor in major depression.

The family's role in stroke rehabilitation. A review of the literature.

Clinical and research attention in stroke care has been on managing the acute stage of stroke recovery and on evaluating the effectiveness of relatively short-term rehabilitation programs. However, studies suggest that stroke can diminish quality of life and the well-being of patients' families. This article reviews the literature pertaining to the effects of stroke on family functioning and discusses stroke in terms of clinical problems that make rehabilitation a family dilemma. Issues identified in the literature include the need for family assessment, education, advocacy and counseling to foster treatment compliance and social support after stroke.

Providing care to persons with physical disability. Effect on family caregivers.

Studies on caregiving often assume that outcomes will be problematic and assess negative factors, such as burden or stress. Results may be biased by detailing only the problems encountered. The current study assessed positive, neutral and negative aspects of caregiving and evaluated the impact of caregiving using criteria based on an accepted model of family functioning. Of 942 consecutive hospital admissions, 217 subjects required assistance in personal care and returned home with a primary caregiver. Caregivers reported moderately more anxious, depressive and somatic symptoms than expected from standardized tests, but these findings were not clinically or statistically significant. Family functioning was related to the duration of the caregiving experience. Family relations seemed to be a source of strength for caregivers, regardless of disability type. Further research is needed to determine if family functioning can be used to buffer against unfavorable aspects of caregiving or to enhance positive aspects of the situation.

Poststroke family function: an evaluation of the family's role in rehabilitation.

Stroke affects long-term quality of life and well-being for not only the patients themselves but also their families. However, the focus of most rehabilitation programs has been on managing the acute stage of stroke and evaluating the effectiveness of short-term treatments. Families usually share in treatment, especially in the long term, and they are ultimately responsible for the patient's welfare. This article reviews the literature as it relates to the clinical problems that make rehabilitation a family issue.

Characteristics of hospital patients receiving medical rehabilitation: an exploratory outcome comparison.

This study classified consecutive hospital admissions to acute medical and surgical wards (n = 3,170) into clinical subgroups based on diagnostic, prognostic, and functional criteria. The groups were (1) independent, (2) terminal, (3) medical, (4) dementia, and (5) rehabilitation candidate. Medical record data from hospital admission, discharge, and nine-month follow-up were collected. The groups had unique patterns of survival, residence, and use of health care services during follow-up. Rehabilitation participants were compared with a group similar in age, major diagnostic category, and functional ability, who did not receive rehabilitation. Only 21% of persons meeting the study criteria for rehabilitation actually received rehabilitation services. At follow-up, participants in rehabilitation had lower mortality, spent less time in skilled nursing care, and were less frequently hospitalized. Although exploratory in nature, this study supports previously observed benefits of rehabilitation. In combination with clinical assessment, the process of identifying patient subgroups may be useful in planning interventions more uniformly and in developing measures to reduce selection bias in rehabilitation admission decisions.

A cross-cultural study of major depression and family functioning.

Patterns of family functioning in families with a depressed member from two cultures (North America and Hungary) were compared. In both cultural settings, families with a depressed member reported poorer family functioning than the control families. Comparisons between the two depressed groups, however, showed that the response to family dysfunction by the two cultures differed. While depressed families in Hungary reported difficulties in setting family rules and boundaries, those in North America experienced impaired functioning in solving problems, communicating, being involved with each other, and in overall functioning. These results are discussed in terms of the interplay between culture, depression and family functioning.

Factors predicting satisfactory home care after stroke.

This study prospectively investigated factors predicting optimal poststroke home care. One hundred and thirty-five first occurrence stroke patients and their primary support persons were evaluated during the initial hospitalization after stroke and again one year poststroke. Discriminant function analysis was used to identify two groups from the baseline data: home care situations which were rated optimal and those which were not. Group membership was predicted and validated with 72.6% accuracy. Patients at risk for less than optimal home care had caregivers who were (1) more likely to be depressed, (2) less likely to be married to the patient, (3) below average in knowledge about stroke care, and (4) reporting more family dysfunction. Our findings suggest that caregiver-related problems can have a collective effect on rehabilitation outcome and that treatment should reduce caregiver depression, minimize family dysfunction, and increase the family's knowledge about stroke care.

Factors influencing the decision to rehabilitate: an initial comparison of rehabilitation candidates.

This study classified consecutive admissions to a U.S. Department of Veteran Affairs Medical Center. Patients on acute medical and surgical wards (n = 3170) were divided into clinical subgroups based on diagnostic, prognostic and functional criteria. The groups were: (1) independent; (2) terminal; (3) medical; (4) dementia; and (5) rehabilitation candidate. Medical record data from hospital admission, discharge and 9 month follow-up were collected. The groups had unique patterns of survival, residence and use of health care services during follow-up. Subsequently, rehabilitation participants were compared with a group similar in age, major diagnostic category and functional ability, who did not receive rehabilitation. Twenty-one percent of persons meeting study criteria for rehabilitation received rehabilitation services. At follow-up, participants in rehabilitation had lower mortality, spent less time in skilled care and were less frequently hospitalized. Although exploratory in nature, this study supports previously observed benefits of rehabilitation. In combination with clinical assessment, the process of identifying patient subgroups may be useful in planning interventions more uniformly and in developing measures to reduce selection bias in rehabilitation admission decisions.

Prospective payment for rehabilitation: effects on hospital readmission, home care, and placement.

Suspected benefits of a prospective payment system (PPS) in which hospitals are paid by diagnosis-related groups (DRGs) are that hospital lengths of stay and costs may be reduced. The US Department of Veterans Affairs is one of the first agencies to adopt PPS funding for rehabilitation; this early adoption of PPS provides a unique opportunity to test for both beneficial and adverse outcomes. This study compared hospital stay, readmission rate, and incidence of nursing home placement before and after introduction of PPS on a 22-bed rehabilitation service. Hospital stay decreased from 29.3 days to 26.4 days, but 64% more patients were discharged to nursing homes. Findings suggest that PPS may overlook home care in favor of placement, which neutralizes the cost benefits of the proposed reimbursement system. Further research on the effects of PPS is needed to determine (1) impact on clinical aspects of rehabilitation and (2) whether other funding mechanisms are more appropriate.

Family functioning, social adjustment, and recurrence of suicidality.

We examined suicidal and nonsuicidal patients with major depression during and subsequent to their hospitalization. Factors associated with suicidality at the index episode included psychosocial variables as well as measures of family functioning. Previous suicidality, inter-episodic adjustment, changes in family constellation, and perception of family functioning were instrumental in separating nonsuicidal patients at follow-up from patients exhibiting recurrent suicidal behavior. These results indicate that when assessing patients with major depression for suicidality, particular attention should be paid both to the social environment and to family functioning as perceived by the patient.