Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: results of a placebo-controlled trial.

OBJECTIVE: The opiate antagonist drug naltrexone has been shown in a few studies with limited sample sizes to be effective when combined with psychosocial therapies for the treatment of alcohol dependence. The goal of this study was to obtain additional information regarding its efficacy in pertinent alcoholic populations and with a well-defined therapy. METHOD: In this study, 131 recently abstinent alcohol-dependent outpatients were treated with 12 weekly sessions of manual-guided cognitive behavioral therapy and either 50 mg/day of naltrexone (N = 68) or placebo (N = 63) (with riboflavin added as a marker of compliance) in a double-blind, randomized clinical trial. Alcohol consumption, craving, adverse events, and urinary riboflavin levels were assessed weekly. Levels of blood markers of alcohol abuse were also ascertained during the trial. RESULTS: The study completion, therapy participation, and medication compliance rates in the trial were high, with no differences between treatment groups. Naltrexone-treated subjects drank less, took longer to relapse, and had more time between relapses. They also exhibited more resistance to and control over alcohol-related thoughts and urges, as measured by a subscale of the Obsessive Compulsive Drinking Scale. Over the study period, 62% of the naltrexone group did not relapse into heavy drinking, in comparison with 40% of the placebo group. CONCLUSIONS: Motivated individuals with moderate alcohol dependence can be treated with greater effectiveness when naltrexone is used in conjunction with weekly outpatient cognitive behavioral therapy. Naltrexone increases control over alcohol urges and improves cognitive resistance to thoughts about drinking. Thus, the therapeutic effects of cognitive behavioral therapy and naltrexone may be synergistic.

Dexamethasone for the treatment of depression: a randomized, placebo-controlled, double-blind trial.

OBJECTIVE: The authors' goal was to assess dexamethasone for the treatment of depression. METHOD: Thirty-seven outpatients (11 men and 26 women) meeting DSM-III-R criteria for major depressive disorder were randomly assigned to receive either placebo or 4 mg/day of oral dexamethasone for 4 days. Baseline Hamilton depression scale scores were compared with scores obtained 14 days after the first dose of study medication. Data were analyzed by using two-sample t tests, chi-square methods, and Fisher's exact test. RESULTS: Seven (37%) of the 19 patients given dexamethasone but only one (6%) of the 18 patients given placebo responded positively. No adverse events or side effects were reported, and all patients who entered the study completed it. CONCLUSIONS: A brief course of oral dexamethasone (4 days) was significantly more effective than placebo within 14 days for the treatment of depression in a randomized, double-blind study of depressed outpatients.

Physician communication with children and parents.

The way physicians communicate with patients has been shown to affect physiologic measurements, adherence to therapeutic regimens, and satisfaction with medical care. The purpose of this study was to document the content of medical interviews in routine pediatric visits and to identify demographic and situational characteristics that influenced the extent of communication between doctor and child. One hundred fifteen office visits to 49 physicians were videotaped and analyzed. Children studied were 4 to 14 years old with a mean age of 8.5 years. Verbal transactions were coded according to direction of communication, transaction type, and content category. Coder reliability for this system was 0.84. A considerable amount of the total communication, 45.5%, was between doctor and child. Doctors interacted differently with parents and children. More information about the current problem was obtained from children; physicians provided feedback primarily to parents. Parents received 4.4. times as much information as children about the nature and prognosis of a condition. The extent to which doctors talked to children in "substantive" areas was primarily associated with a child's age (r = .52, P less than .001) but was partly influenced by family size (r = .20, P less than .05) and family utilization (r = .22, P less than .02). Race, socioeconomic status, type of problem, and previous encounter with the examining physician did not alter communication patterns. Boys were given more information than girls (6.5% vs 4.0%, P less than .01). We suggest a theoretical framework for future investigation and teaching that identifies the child as an active participant in the medical process.

Dissemination of assertive community treatment programs.

OBJECTIVE: The study sought to estimate the number of programs in the U.S. for severely mentally ill adults that used the assertive community treatment model and to describe variations in characteristics of the intervention across programs. METHODS: Assertive community treatment programs identified by state mental health authorities completed a 12-item survey. The survey included questions on caseload, composition of the treatment team, nature of services, and structure of service provision. RESULTS: A total of 303 of 340 programs (89 percent) identified by states responded to the survey. More than 75 percent provided most of their services in the field, delivered medications, included medical staff on the assertive community treatment team, and had caseload ratios of less than 20 consumers for each provider. CONCLUSIONS: Assertive community treatment programs have disseminated quite unevenly across 33 states, with the highest concentrations of programs in midwestern and eastern states.

Fever in the first six months of life: risks of underlying serious infection.

The age-specific rate of elevated temperature over 37.8 C was evaluated in all infants less than 6 months of age (n = 1341) seen from July 1, 1974 to June 30, 1978 in a family practice clinic. Mild elevations (37.8 C-38.3 C) were common even in the first few months of life, and accounted for 20.7 per cent of infant visits. Temperatures greater than 38.3 C are uncommon in the first months of life but are seen more frequently with each succeeding month. Temperature elevation over 38.3 C was associated with a significantly higher rate of meningitis (p less than .01), otitis media (p less than .001) and lower respiratory infection (p less than .05). Significantly higher laboratory usage was documented in infants less than 3 months and for infants with temperature more than 38.3 C. The high rate of mild temperature elevations in young infants suggests that a selective diagnostic strategy directed at high-risk infants is important. Infants less than three months of age with a fever exceeding 38.3 C are calculated to have 21.5 times the risk of a serious underlying infection as infants older than three months with a similar temperature elevation. Clinical evaluation must remain an important tool in determining which febrile infants should be evaluated by further laboratory and diagnostic tests.

Children as patients: a communications process study in family practice.

To determine how family physicians divide their attention between children and parents, 115 videotaped pediatric encounters of children (aged 4 to 14 years) and parents with family physicians in a family medicine center were analyzed. It was learned that physicians tended to involve children actively in the diagnostic stages of interviews but much less so in discussions of treating or dealing with their problems. Physicians did not alter this pattern as they advanced in training. Older children were more likely to receive direct communication from physicians in all phases of office encounters. Though the family physicians in this sample had more direct communication with children than reported in previous research, it is argued that greater involvement of children in all phases of pediatric visits is warranted. A developmental framework indicates that children gradually evolve their attitudes, concepts, and behaviors around illness and health. Family physicians and family medicine programs are in an excellent position to explore and utilize the practice of actively incorporating a child in a medical interview.

Examining key variables in selected reminiscing modalities.

This study examined the underlying variables of selected reminiscing processes to determine those that contributed to well-being. Two hundred and forty subjects randomly selected from nursing homes and high-rises participated in one of 10 different reminiscing modalities for eight weeks. Measures of life satisfaction (LSI-A), psychological well being (ABS), self-esteem (SES), and depression (BDI) were given pre- and postintervention to determine the most therapeutic treatment modalities. Results showed the most therapeutic way to reminisce was through a structured, evaluative life review performed on an individual basis. Thus, three variables contributed to successful reminiscing: individuality (one-to-one reminiscing), evaluation (a personal valuing of events), and structure (covering the whole life span).

Does nursing education promote ageism?

The literature is replete with diverse studies about gerontological nursing education on the attitudes of nursing students. This study examined the effect of a 3-year curriculum on ageism over all 3 years. Students were exposed first to well elderly subjects, then hospitalized older subjects, then severely ill older subjects. They were tested with the Kogan's Old People Scale and a semantic differential scale to see how their attitudes towards older people changed according to their experiences. The Kogan scale was most sensitive and showed that older students and those with grandparent role models had better attitudes towards older adults. Also, there were great increases in positive attitudes towards ageing in year 1 that slowly decreased by the end of year 3.

Case-control study of etiologic factors in the development of severe pelvic organ prolapse.

The aim of this case-control study was to identify etiologic factors predictive for the development of severe pelvic organ prolapse. Three hundred and sixty-eight controls from a database describing pelvic organ support in the general population were identified as having known good pelvic organ support. Eighty-seven cases were identified from a urogynecology clinic with severe pelvic organ prolapse. The risk of severe prolapse was modeled using stepwise multiple logistic regression analysis. Additional analyses using chi2 and two-sample t-tests were conducted to determine differences in means for individual variables. Variables examined included age, gravidity, parity, number of vaginal deliveries, weight of largest infant delivered vaginally, menopause status, race, body mass index prior to pelvic surgery, and medical illnesses. The following four variables were selected in the regression analysis as predicting severe prolapse: age, weight of largest vaginal delivery, hysterectomy and previous prolapse surgery. Other variables that demonstrated statistically significant differences between groups by chi2 and two-sample t-tests were gravidity, parity, number of vaginal deliveries, menopausal status, race, history of incontinence surgery and the presence of hypertension. Variables that did not demonstrate any significant differences were body mass index, the presence of chronic obstructive pulmonous disease and diabetes mellitus. Advancing age, increasing weight of infants delivered vaginally, a history of hysterectomy and a history of previous prolapse surgery were found to be the strongest etiologic predictors of severe pelvic organ prolapse in our population.

Adjustment of gynecological and breast cancer patients to the cancer diagnosis: comparisons with males and females having other cancer sites.

Newly diagnosed cancer patients (N = 133) were studied to determine gender-based differences in initial adjustment and whether, within the female population, women with gynecological or breast cancer adjust differently. The Brief Symptom Inventory (BSI) and the Rand Health Insurance Study-General Well-Being Schedule (HIS-GWB) were used to measure anxiety, depression, hostility, somatization, and general psychological distress or psychological well-being. There were no gender differences on any of the measures when men were compared with women. However, when gynecological/breast cancer patients were analyzed separately from women with other forms of cancer, they were significantly less depressed, anxious, and hostile; they had less somatization, less psychological distress, and greater psychological well-being. These findings may be related to the perception of their illness as being less serious than that of other females with cancer.

Providing assertive community treatment for severely mentally ill patients in a rural area.

OBJECTIVE: The authors' goals were to describe an assertive community treatment program developed for patients in rural South Carolina and to evaluate the effect of the program on rates of hospital utilization and cost of care. METHODS: Twenty-three patients with chronic psychotic disorders living in rural areas of South Carolina were assigned to an assertive community treatment program. The patients' average number of days per year in the hospital, length of stay per admission, number of admissions per year, and estimated annual cost of care during the five years before assignment to the program and during a period from four to 26 months after assignment were compared. RESULTS: The intervention was associated with a 79 percent decrease in hospital days per year, a 64 percent decrease in the number of admissions per year, a 75 percent decrease in the average length of stay per admission, and a 52 percent reduction in estimated direct cost of care. CONCLUSIONS: Although the methods of assertive community treatment may need to be modified to suit the travel requirements and other characteristics of rural settings, the study results suggest that the model can be successfully used in rural areas.

Posttreatment results of combining naltrexone with cognitive-behavior therapy for the treatment of alcoholism.

Naltrexone, an opiate antagonist medication, has been reported to be efficacious in the treatment of alcohol dependence when added to psychosocial treatments. Although the within-treatment efficacy of naltrexone has received primary attention, there has been little published on the outcome of individuals once the medication is discontinued. Animal studies have led to concern regarding a quick rebound to heavy drinking. This report extends the data previously reported by evaluating the outcome in alcoholic subjects during the 14 weeks after a 12-week treatment with naltrexone or placebo in conjunction with cognitive behavioral therapy. Of the 131 subjects evaluated during the treatment phase, 124 (95%) had up to 14 weeks of posttreatment drinking data available for analysis. Measures of craving and blood markers of heavy drinking were also evaluated. By the end of treatment, naltrexone demonstrated significantly greater efficacy than placebo. However, once the medication was discontinued, there was a gradual increase in relapse rates, heavy drinking days, and drinks per drinking day, and fewer days of abstinence were reported. By the end of the 14-week follow-up period, although naltrexone-treated subjects were, on average, still doing better than control subjects, the effectiveness of naltrexone was no longer statistically significant. There was no evidence that naltrexone subjects had an immediate return to heavy alcohol use as suggested in animals. These data suggest that, for a number of alcoholic subjects, continued treatment with naltrexone, or perhaps psychosocial intervention, for longer than 3 months is indicated. Future research should identify which alcohol-dependent individuals may need prolonged treatment to improve treatment success in the long term.