Housing Instability, Structural Vulnerability, and Non-Fatal Opioid Overdoses Among People Who Use Heroin in Washington Heights, New York City.

Nationally, opioid overdose remains strikingly persistent among people experiencing homelessness and housing instability. Limited information is available about the characteristics of this phenomenon in economically disadvantaged communities of color. This study sought to evaluate the association between key contextual factors and experiencing a non-fatal opioid overdose among people who use heroin in Washington Heights, New York City. We conducted a cross-sectional survey (N = 101) among participants seeking harm reduction services who reported heroin use in the last three months. Binary logistic regression models examined the association between key social and structural factors and the likelihood of ever experiencing a non-fatal opioid overdose and recently experiencing a non-fatal opioid overdose. The majority of the sample reported housing instability and lived in poverty; almost 42% were homeless. After adjustment, participants who injected heroin were more likely to have ever experienced a non-fatal opioid overdose. Also, younger participants who reported hunger in the last six months were more likely to have experienced a non-fatal opioid overdose in the last three months. Findings suggest the role of structural vulnerability in shaping overdose risk among the participants. Overdose prevention strategies should consider factors of the social and economic environment to mitigate barriers to accessing health and social services within the context of the current opioid crisis.

Compatibility of Medical-Grade Polymers with Dense CO(2).

This study reports the effect of exposure to liquid carbon dioxide on the mechanical properties of selected medical polymers. The tensile strengths and moduli of fourteen polymers are reported. Materials were exposed to liquid CO(2), or CO(2) + trace amounts of aqueous H(2)O(2), at 6.5 MPa and ambient temperature. Carbon dioxide uptake, swelling, and distortion were observed for the more amorphous polymers while polymers with higher crystallinity showed little effect from CO(2) exposure. Changes in tensile strength were not statistically significant for most plastics, and most indicated good tolerance to liquid CO(2). These results are relevant to evaluating the potential of liquid CO(2)-based sterilization technology.

Patterns of mental health service utilization.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.

Dissociation as a mediator of psychopathology among sexually abused children and adolescents.

OBJECTIVE: This study investigated the role of dissociation as a mediator of mental health outcomes in children with a history of sexual abuse. METHOD: The study group consisted of 114 children and adolescents (ages 10-18 years) who were wards of the Illinois Department of Children and Family Services and were living in residential treatment centers. Interviews, provider ratings, and chart reviews were used to assess the relationship of childhood abuse history, dissociative responses, and psychopathology. RESULTS: Sexual abuse history was significantly associated with dissociation, whereas a history of physical abuse was not. Both sexual abuse and dissociation were independently associated with several indicators of mental health disturbance, including risk-taking behavior (suicidality, self-mutilation, and sexual aggression). Severity of sexual abuse was not associated with dissociation or psychopathology. Analysis of covariance indicated that dissociation had an important mediating role between sexual abuse and psychiatric disturbance. These results were replicated across several assessment sources and varied perspectives. CONCLUSIONS: The findings suggest a unique relationship between sexual abuse and dissociation. Dissociation may be a critical mediator of psychiatric symptoms and risk-taking behavior among sexually abused children. The assessment of dissociation among children may be an important aspect of treatment.

Religious belief, depression, and ambulation status in elderly women with broken hips.

The authors studied the relationship between religious belief and psychiatric and medical status in 30 elderly women recovering from the surgical repair of broken hips. Religious belief was associated with lower levels of depressive symptoms and better ambulation status.

Expenditures for psychotropic medications in the United States in 1985.

OBJECTIVE: Psychotropic medications have seldom been included in estimates of the costs of mental health services. In the infrequent case that these costs have been assessed, they have been estimated by using national surveys of consumers of health services. The objective of this study was to estimate the costs of prescriptions for psychotropic medications in the United States in 1985 and to assess the difference with the most recent cost estimate from a health services survey (1977). METHOD: Study data were based on retail costs of psychotropic medications reported to the Pharmaceutical Data Service Alpha National Prescription and Sales Audit. The data come from a computerized survey panel of 2,250 pharmacies representative of the more than 14,000 pharmacies nationwide. The database includes all medication prescriptions filled, whether paid with cash or Medicaid or reimbursed by third-party payment. Analyses were limited to psychotropic medication prescriptions. RESULTS: In 1985, $1.45 billion was spent on outpatient psychotropic medications. Nearly $868 million (60% of the total) was spent on antianxiety and sedative-hypnotic medications, while approximately $263 million (18%) was spent on antipsychotic medications, $240 million (17%) on antidepressants, and $84 million (5%) on combination psychotropic medications. These expenditures were much higher than would have been expected given the most recent health services estimate of $513 million. CONCLUSIONS: These results demonstrate the substantial cost of psychotropic medications in 1985. The finding that the cost of psychotropic medications was so high, in contrast to the lower estimate from the 1977 survey, demonstrates the importance of obtaining more frequent cost estimates and basing future estimates on medication databases.

Treatment opportunities on a consultation/liaison service.

The amount of time consultation psychiatrists in a large metropolitan teaching hospital spent providing direct services was studied over 1,104 consecutive consultation cases. Although the majority of cases required less than 5 hours of psychiatric time apiece, more than 10% of these cases each received more than 10 hours of direct services. This finding has important implications for understanding the types of psychiatric services provided to hospitalized medical/surgical patients.

Impact of psychiatric comorbidity on length of hospital stay for medical/surgical patients: a preliminary report.

The impact of psychiatric comorbidity on the length of hospital stay was addressed in a study of all medical/surgical patients discharged in 1984 from the Mount Sinai Hospital in New York City (N = 37,370) and Northwestern Memorial Hospital in Chicago (N = 21,889). At both hospitals the mean +/- SD length of stay of the patients with psychiatric comorbidity was significantly longer than that of the other patients: 19.8 +/- 33.3 versus 9.2 +/- 15.3 days at Mount Sinai Hospital and 13.7 +/- 27.7 versus 8.3 +/- 13.2 days at Northwestern Memorial Hospital. Early identification of patients with psychiatric comorbidity would permit appropriate psychosocial intervention, which might shorten their hospital stays.

A comparison of manual and MEDLARS reviews of the literature on consultation-liaison psychiatry.

A systematic manual search for articles related to consultation-liaison psychiatry was compared to a computerized search of the same journals during the same period that was done with the Medical Literature Analysis and Retrieval System (MEDLARS). More articles were located with the manual method (94%) than with MEDLARS (65%).

Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators.

OBJECTIVE: This study examined predictors of hospital readmission to determine whether readmissions can serve as a quality indicator for an inpatient psychiatric service. METHOD: A series of 255 patients consecutively admitted to any of seven psychiatric hospitals in a regional managed care program were followed to determine whether they were readmitted within 6 months of discharge. Case managers assessed patients with the use of a reliable outcome management/decision support system designed for acute psychiatric services. RESULTS: Patients with greater impairment in self-care, more severe symptoms, and more persistent illnesses were more likely to be readmitted than other patients. Suicidal patients were less likely to be readmitted. There was no evidence to suggest that poor hospital outcome or premature discharge was associated with readmission either within 30 days or within 6 months. CONCLUSIONS: Although patients at risk for hospital admission can be identified, it does not appear that the success of the hospital intervention per se influences the likelihood of readmission. Use of readmission rates as quality indicators for hospital care providers is not recommended.

Religious content in the DSM-III-R glossary of technical terms.

The authors reviewed Appendix C of DSM-III-R, Glossary of Technical Terms, for its references to religion. Religion was referred to more frequently in this glossary than it is in psychiatric research. The authors conclude that although the Glossary uses religion in constructive or cautionary reminders, the high rate of illustrative case examples of psychopathology that involve religion in the Glossary indicates cultural insensitivity in interpreting religion.

Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients.

OBJECTIVE: The authors hypothesized that psychiatric liaison screening of elderly patients with hip fractures would shorten the average length of hospital stay and increase the proportion of patients who returned home after discharge. METHOD: The study was performed at Mount Sinai Medical Center in New York and Northwestern Memorial Hospital in Chicago. The subjects were 452 patients 65 years or older who were consecutively admitted for surgical repair of fractured hips. During a baseline year the patients received traditional referral for psychiatric consultation. During the experimental year all the patients at Mount Sinai and the patients on one Northwestern Unit were screened for psychiatric consultation. RESULTS: The patients who received psychiatric liaison screening had a higher consultation rate than those who received traditional consultation. The rates of DSM-III disorders in the experimental year were 56% at Mount Sinai and 60% at Northwestern. The mean length of stay was reduced from 20.7 to 18.5 days at Mount Sinai and from 15.5 to 13.8 days at Northwestern, resulting in reductions in hospital costs ($647/day) of $166,926 and $97,361, respectively. Fees generated from Medicare service delivery could have paid for the $20,000 psychiatric intervention cost at each site. There was no difference, however, between the two years in the discharge placement of patients. CONCLUSIONS: Admission psychiatric liaison screening of elderly patients with hip fractures results in early detection of psychiatric morbidity, better psychiatric care, earlier discharge, and substantial cost savings to the hospital.

Associations between dimensions of religious commitment and mental health reported in the American Journal of Psychiatry and Archives of General Psychiatry: 1978-1989.

The authors assessed all measures of religious commitment (N = 139) reported in research studies published in the American Journal of Psychiatry and Archives of General Psychiatry in 1978 through 1989 (N less than 35). For nearly two-thirds of the measures, the studies either made no hypotheses or reported no results concerning the relationship of religious commitment to mental health status. For the great majority of the measures assessed, the studies reported a positive relationship between religious commitment and mental health.

Effect of a psychiatric liaison program on consultation rates and on detection of minor psychiatric disorders in cancer patients.

Because only 2% of the 47% of cancer patients with psychiatric disorders receive psychiatric consultations, the authors investigated the impact of a psychiatric liaison program on improving consultation rates on a gynecologic oncology unit. Consultation rates for gynecologic cancer patients before and after introduction of the program were compared to rates from other cancer patients in the same hospital during the same 7-year period. Rates for the gynecologic patients were higher after the program (9%) than before (4%), as were rates for follow-up consultations, and the detection of minor DSM-III disorders improved. The authors conclude that liaison improves access to psychiatric treatments that often enhance the quality of life for seriously ill patients.

A brief agitation rating scale (BARS) for nursing home elderly.

OBJECTIVE: To determine the effectiveness of a brief agitation rating scale (BARS) derived from the Cohen-Mansfield Agitation Inventory (CMAI). DESIGN: Test of reliability and validity of a new test. SETTING: The Lieberman Geriatric Health Centre, a skilled nursing facility. PARTICIPANTS: Forty members of the Lieberman Geriatric Health Centre nursing staff, 232 residents, and a sample of 40 randomly selected residents. MEASUREMENTS: Observational agitation ratings by registered nurses and certified nurses' assistants; item to total correlations for the CMAI on each of the three shifts; Pearson correlations between the 10-item BARS and the BEHAVE-AD and the BSSAD scales. RESULTS: Internal consistency reliability for the BARS was .74 (for the day shift), .82 (evening shift), and .80 (night shift), compared with .86, .91, and .87 for the full CMAI. Each of the 232 residents' scores on the BARS was correlated with a total score from the CMAI separately on each shift. Correlations were of .95, .94, and .95. Thus, across all shifts, the BARS accounted for approximately 90 percent of the variance of the total score of the CMAI. Concurrent validity of the BARS was supported by significant correlation with BEHAVE-AD and BSSD. CONCLUSIONS: The BARS represents a brief and effective mechanism to assess the presence and severity of physically aggressive, physically non-aggressive, and verbally agitated behaviors in elderly nursing home residents.

Patterned dystrophies of the retinal pigment epithelium.

Three varieties of patterned dystrophies of the retinal pigment epithelium have been described in the literature: They are reticular dystrophy, macroreticular dystrophy, and butterfly-shaped pigment dystrophy of the fovea (macula). They are all inherited and are bilateral and symmetric. Results of retinal-function tests in all three varieties were essentially normal, except for the electro-oculogram in the butterfly-shaped pigment dystrophy. We have observed within a single family one member manifesting butterfly-shaped pigment dystrophy, one member with macroreticular dystrophy, and one member with probable reticular dystrophy. Electrophysiologic studies of the retina in these patients were in accord with those already reported, except for supernormal scotopic responses in the latter two patients. This family demonstrates the linkage necessary to tie together a number of entities heretofore considered as separate.

Evaluating the use of psychiatric hospitalization by residential treatment centers.

OBJECTIVE: To examine differences in risk levels of psychiatric hospital referrals received from residential treatment centers (RTCs) as a measure of service quality. METHOD: This prospective study used the Childhood Severity of Psychiatric Illness (CSPI), a reliable measure of psychiatric severity and factors thought to affect decision-making. Psychiatric referrals were wards of the state from the 10 largest RTCs in one metropolitan county and were screened by mobile crisis workers for admission appropriateness. After interviewing clients, the independent crisis workers completed the CSPI. RESULTS: Referrals were placed into 1 of 2 categories based on CSPI ratings: high-risk or low-risk. Referrals were deemed high-risk if they displayed moderate or severe levels of suicidality, dangerousness to others, or psychotic symptoms on the CSPI. Results showed statistically significant variation in the level of risk of referrals received from the 10 RTCs. In addition, RTCs that had high rates of low-risk referrals were rated by crisis workers as demonstrating poorer supervision of their clients. CONCLUSIONS: The residential treatment providers in our sample are expected to provide intensive treatment to children and adolescents with serious emotional and behavioral problems. Our finding that some RTCs are making low-risk referrals suggests that they are struggling to meet the needs of some of their clients. Our findings can be used to inform quality improvement efforts at RTCs that are currently struggling.

Strengths of children and adolescents in residential settings: prevalence and associations with psychopathology and discharge placement.

OBJECTIVE: During the past few years there has been growing interest in developing strength-based approaches to services, particularly for children and adolescents. METHOD: This study assesses the prevalence of 30 strengths for a random sample of children and adolescents in residential placements in Florida. In addition, the relationship between strengths and clinical and functional characteristics is studied. RESULTS: Results suggest that there is substantial variation across individuals on the presence of strengths and the potential for development. Strengths were associated with symptoms, risk behaviors, and functioning. Level of strengths predicted success in the reduction of risk behaviors during the child/adolescent's stay. In addition, the level of strengths was independently associated with good dispositional outcomes. CONCLUSIONS: The findings provide further empirical support for the importance of strengths and the utility of an integrated model that considers both psychopathology and strengths in planning for children's services.

Psychiatric hospital service utilization of children and adolescents in state custody.

OBJECTIVE: To examine factors related to psychiatric hospitalization decision and length of stay of wards of the illinois Department of Child and Family Services. METHOD: A prospective design was implemented using the Childhood Severity of Psychiatric Illness (CSPI), a reliable, quantitative measure of psychiatric severity and its mediating factors. The CSPI was completed by hospital screeners upon conclusion of their crisis interviews. In addition to completing the CSPI, workers reported on demographic information, DSM-IV diagnoses, prescreening living arrangements, and length of hospital stay. RESULTS: CSPI variables could effectively predict decision to admit versus deflect. The overall accuracy of this statistically significant prediction model was 77.9%, which was replicated on a new sample. Factors associated with decision to hospitalize are clinical in nature; ratings of suicidality, dangerousness, and impulsivity contributed the most to the model. Predicting length of stay was only moderately successful. Despite achieving significance, the model accounted for just 15.1% of length of stay variance using a multiple regression. Factors associated with length of stay were largely nonclinical in nature: living arrangement stability, region of the hospitalization, and age. CONCLUSIONS: These results can be used to assess how decisions regarding level and duration of care are currently being made as a point of departure for quality improvement efforts.

Main effects analysis in clinical research: statistical guidelines for disaggregating treatment groups.

Treatment outcome research generally relies on main effects analysis of variance to determine whether treatments are differentially effective. Bryk and Raudenbush (1988) developed a decision strategy for disaggregating treatment groups under conditions of heterogeneity of variance. There is, however, reason to consider disaggregating main effects even when this assumption is not violated. The potential statistical significance of disaggregation can be shown to be a function of the reliability of the dependent measure. With this reliability, residual variance can be partitioned into a systematic (individual differences) component and a random error component. It is then possible to calculate an F test of the ratio of these variances. When this F is statistically significant and the proportion of within-cell systematic variance to total variance is large, disaggregation should be undertaken to search for important individual or treatment difference variables (i.e., interactions).