Sustained outcomes of a peer-taught family education program on mental illness.

OBJECTIVE: This study examines 6-month follow-up data from participants in a randomized trial of a peer-driven 12-session family support and education program, called family-to-family (FTF) and offered by the US National Alliance on Mental Illness, to determine whether improvements in distress, family functioning, coping and empowerment were sustained. METHOD: Individuals randomized to the FTF condition were assessed after program completion and then 3 months later on measures of distress, family functioning, coping, and empowerment. We used a multilevel regression model (sas proc mixed) to test for significant changes over time (baseline, 3 and 9 months). RESULTS: All significant benefits that FTF participants gained between baseline and immediately post-FTF were sustained at 9 months including reduced anxiety, improved family problem-solving, increased positive coping, and increased knowledge. Greater class attendance was associated with larger increases in empowerment and reductions in depression and displeasure with ill relative. CONCLUSION: Evidence suggests that benefits of the FTF program were sustained for at least 6 months without any additional boosters or supports. Peer-based programs may produce sustained benefits for individuals seeking help in addressing challenges and stresses related to having a family member with a mental illness.

Weight changes and their associations with demographic and clinical characteristics in risperidone maintenance treatment for schizophrenia.

OBJECTIVE: This study aimed to characterize weight changes in schizophrenia patients taking risperidone as part of a randomized, controlled, open-label clinical trial. METHODS: A total of 374 patients with schizophrenia who had been clinically stabilized following an acute episode were randomly assigned to a 'no-dose-reduction' group (initial optimal therapeutic doses continued throughout the study), a '4-week group' (initial optimal therapeutic doses continued for 4 weeks followed by a half dose reduction that was maintained until the end of the study) or a '26-week group' (initial optimal therapeutic doses continued for 26 weeks followed by a half dose reduction until the end of the study). Participants were assessed monthly using standardized assessment instruments during the first 6 months, and then every 2 months until the last recruited patient completed the 1-year follow-up. Weight gain was defined as gaining at least 7% of initial body weight, weight loss as losing at least 7% of initial body weight. A BMI <18.5 kg m⁻² was defined as underweight, 18.5-24.9 kg m⁻² as normal range, and ≥ 25 kg m⁻² as overweight or obese. RESULTS: At the end of follow-up, of the patients who started within the underweight range (n=22), 77.3% gained weight, whereas 4.5% lost weight. The corresponding figures were 39.6% and 4.8% in patients who started at normal weight (n=273), respectively, and 17.7% and 17.7% in patients who started at overweight (n=79), respectively. At the same time, 59.1% of the patients who started at underweight range went into the normal weight and 13.6% into the overweight/obese range, respectively, while 24.5% of those who started at normal weight went into the overweight/obese range, and 1.1% into underweight range, respectively; 20.3% of those who started at overweight range went into normal weight at the end of the follow-up. Multiple logistic regression analyses revealed that being underweight or normal weight at study entry predicted weight gain compared to being overweight, whereas being overweight at entry was associated with a higher likelihood of weight loss compared to being normal weight. No correlation was found between weight change and dose reduction. CONCLUSIONS: Weight change is a common, long-term, but heterogeneous side effect in risperidone maintenance treatment for stable schizophrenia patients. Special attention should be paid to fluctuations in weight that may occur throughout the course of treatment with risperidone.

A randomized trial of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses. METHODS: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations. RESULTS: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status. CONCLUSIONS: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.

Effects of family history of heart disease, apolipoprotein E phenotype, and lipoprotein(a) on the response of children's plasma lipids to change in dietary lipids.

We examined the effects of family history of coronary artery disease (CAD), apolipoprotein E (apo E) phenotype, and lipoprotein(a) [Lp(a)] on the response of plasma lipids to change in dietary lipid intake after 3 mo of nutrition education in 125 children aged 4-10 y. The subjects were healthy children with elevated low-density-lipoprotein (LDL)-cholesterol concentrations who participated in the Children's Health Project, a nutrition-education program designed to lower plasma cholesterol by means of dietary modifications in accordance with recommendations of the National Cholesterol Education Program. Dietary and plasma lipids were measured by three 24-h recalls and assessments of two fasting plasma samples collected before and 3 mo after the start of intervention. Family history of CAD was determined by questionnaires administered to parents at baseline. Apo E phenotyping was done with isoelectric focusing followed by immunostaining; Lp(a) was measured with two-site immunoradiometric assays of frozen aliquots of plasma samples collected at baseline and 3 mo. After adjustment for intervention group, age, sex, and body mass index, analysis of covariance showed that baseline plasma lipid concentrations were the strongest independent predictors of change in plasma lipids after 3 mo. Plasma total and LDL-cholesterol concentrations in children with less family history of CAD were significantly more responsive to change in dietary cholesterol than concentrations in children with a stronger family history of CAD. Neither apo E phenotype nor Lp(a) significantly influenced change in plasma lipids independently or interactively with change in dietary lipids.

The Pathways study: a model for lowering the fat in school meals.

We describe the development and implementation of the Pathways school food service intervention during the feasibility phase of the Pathways study. The purpose of the intervention was to lower the amount of fat in school meals to 30% of energy to promote obesity prevention in third- through fifth-grade students. The Pathways nutrition staff and the food service intervention staff worked together to develop 5 interrelated components to implement the intervention. These components were nutrient guidelines, 8 skill-building behavioral guidelines, hands-on materials, twice yearly trainings, and monthly visits to the kitchens by the Pathways nutrition staff. The components were developed and implemented over 18 mo in a pilot intervention in 4 schools. The results of an initial process evaluation showed that 3 of the 4 schools had implemented 6 of the 8 behavioral guidelines. In an analysis of 5 d of school menus from 3 control schools, the lunch menus averaged from 34% to 40% of energy from fat; when the menus were analyzed by using the food preparation and serving methods in the behavioral guidelines, they averaged 31% of energy from total fat. This unique approach of 5 interrelated food service intervention components was accepted in the schools and is now being implemented in the full-scale phase of the Pathways study in 40 schools for 5 y.

Alterations in adipocyte adenylate cyclase activity in morbidly obese and formerly morbidly obese humans.

Studies examining animal models of genetic obesity have identified defects in adipocyte hormone-stimulated lipolysis that involve the adenylate cyclase transmembrane signaling system, specifically those components that decrease adenylate cyclase activity. To determine whether obese people demonstrate alterations in adenylate cyclase activity that could contribute to the maintenance of obesity by inhibiting lipolysis, we examined human adipocytes from patients who were lean, obese, or formerly obese. Fat samples were obtained from the lower abdomen of 14 women who were morbidly obese (obese group), from 10 women who were formerly morbidly obese and had lost weight after gastric stapling (postobese group), and from 10 similarly aged women of normal weight (controls). Adipocyte adenylate cyclase activity was determined under ligand-free (no stimulatory or inhibitory influences present), hormone-stimulated (isoproterenol, 10(-6) mmol/L), and maximal (cells stimulated with 10 mumol/L forskolin) conditions by measuring cyclic adenosine monophosphate (cAMP) levels by radioimmunoassay. The activity of adenylate cyclase was significantly different (p less than 0.01) in the three groups. Adipocytes from obese women had lower levels of cyclase activity under both ligand-free (5% vs 16% of maximal) and hormone-stimulated conditions (76% vs 100% of maximal) than adipocytes from normal women. Postobese women had levels of hormone-stimulated cAMP identical to those of normal women but still had abnormal ligand-free levels (under 5%). These results suggest the presence of an alteration in adipocyte adenylate cyclase regulation in morbidly obese women that is not entirely corrected when weight is lost after food intake is reduced by gastric stapling. This alteration in ligand-free cAMP activity may contribute to the development and maintenance of obesity.

Psychological interventions for schizophrenia.

This review examines the impact of dynamic and supportive psychotherapies (both individual and group) and psychosocial skills training on clinical and social outcomes for individuals with schizophrenia. The relatively few controlled trials of individual or group psychotherapies for persons with schizophrenia exhibit serious methodological problems that limit their generalizability. Reality-oriented approaches appear to be superior to dynamic, insight-oriented psychotherapies, but further research is needed to identify and evaluate disorder-specific models that target specific deficits and disabilities in schizophrenia. Research on psychosocial skills training models shows that target skills can be trained and maintained over time. Further work is needed to determine the extent to which trained skills generalize from the original training setting to "real life" environments.

Family interventions for schizophrenia.

This article reviews the existing evidence for the efficacy and effectiveness of psychoeducational family interventions in the treatment of persons with schizophrenia. There is substantial evidence that psychoeducational family interventions reduce the rate of patient relapse. There is suggestive, though not conclusive, evidence that these interventions improve patient functioning and family well-being. Interventions with multifamily groups that include the patient may be of superior benefit for subgroups of patients. More research is necessary to determine the critical ingredients of family interventions, to expand the groups of patients included in these studies, and to evaluate a broader range of outcomes.

Assertive community treatment and case management for schizophrenia.

This review examines the impact of assertive community treatment (ACT) and case management models on the use of inpatient hospitalization and other community mental health services, costs, and other clinical and social outcomes. ACT programs have been found to reduce hospitalization and increase use of community mental health services at an equivalent or reduced cost. Greater fidelity to the ACT model produced better outcomes. The impact of case management models is less consistent, but intensive case management programs also have been found to reduce hospitalization. We discuss limitations in past research and recommend future directions.

Conventional antipsychotic medications for schizophrenia.

This article reviews the existing evidence for the efficacy and effectiveness of conventional antipsychotic medications in the treatment of schizophrenia. Among the issues reviewed are their efficacy for acute symptom episodes and for long-term maintenance therapy, differential efficacy among medications, the gap between research-based efficacy rates and effectiveness rates in practice, dosing strategies, and the treatment of first-episode cases. Evidence for efficacy is overwhelming for reduction of positive symptoms but quite limited for other outcomes. Effectiveness in practice may be substantially less than efficacy in clinical trials, perhaps owing to patient heterogeneity, prescribing practices, and noncompliance. First-episode patients should be treated with antipsychotic medication, but perhaps at lower dosages, with consideration of a gradual decrease or discontinuation at 6 months to 1 year.

Schizophrenia: treatment outcomes research--editors' introduction.

Considerable research over the past few decades on the nature and treatment of schizophrenia has yielded important advances to improve the outcomes of this disorder. Recent action plans, including the "Decade of the Brain," the National Institute of Mental Health (NIMH) A National Plan for Schizophrenia Research, and NIMH's report, Caring for People With Severe Mental Disorders: A National Plan of Research to Improve Services, promise major new advances over the next several years. As research advances, it is critical to ensure that patients in everyday practice receive the most effective treatments being developed. This issue of the Schizophrenia Bulletin reviews the research on outcomes of treatments for schizophrenia and lays out an agenda for available research knowledge to be translated into practice and for future research to improve outcomes.

Change in nutrient intakes, number of servings, and contributions of total fat from food groups in 4- to 10-year-old children enrolled in a nutrition education study.

OBJECTIVE: To determine change in nutrient intakes, number of servings, and contributions of total fat from food groups in children who lowered their dietary fat intake. DESIGN: A research and demonstration study designed to lower plasma low-density lipoprotein cholesterol level. There were four study groups: two intervention and two control groups. All children had hypercholesterolemia except for those in one control group. There 24-hour dietary recalls were collected on randomly assigned days over a 2-week period at baseline and 3 months after the intervention. SUBJECTS: Three hundred three 4-to 10-year old children from suburbs north of Philadelphia, Pa. INTERVENTIONS: One intervention involved a home-based, parent-child autotutorial program (PCAT group) with audiotaped stories and print materials for the children and their families; the other intervention involved one face-to-face counseling session with a registered dietitian (counseling group). OUTCOME MEASURES: Change in mean nutrient intakes compared with the Recommended Dietary Allowance (RDA); change in number of servings and mean grams of total fat contributed from 10 different food groups. STATISTICAL ANALYSES PERFORMED: Analyses of variance and chi 3 analyses. RESULTS: Children in every study group had mean intakes of all nutrients (except vitamin D) greater than 67% of the RDA 3 months after the baseline measurement. Several food groups (ie, meats, dairy products, fats/oils, and desserts) provided less total fat to the diets of children who reduced their dietary lipid intake after 3 months (i.e., PCAT and counseling groups). These children also reduced the mean number of servings selected from these food groups. Within these same food groups, some children consumed fewer servings of higher fat foods and more servings of lower fat foods. APPLICATIONS/CONCLUSIONS: Children who lowered their dietary fat intake after intervention reported both quantitative and qualitative changes in food choices from several food groups. These choices did not significantly reduce their nutrient intakes.

A focus group pilot study of tobacco smoking among psychosocial rehabilitation clients.

OBJECTIVE: The study explored the perceived advantages and disadvantages of tobacco smoking and quitting among clients in psychosocial rehabilitation programs. Deeper understanding of such perceptions may be useful in creating maximally effective cessation and prevention interventions for this population. METHODS: Five focus groups of six to ten persons were formed with a total of 40 clients from two programs. Participants included smokers and nonsmokers-including former smokers and smokers who explicitly were not interested in quitting smoking. The semistructured, researcher-facilitated discussions covered pros and cons of smoking and not smoking, barriers to and facilitators of abstinence, and other issues. Audiotapes of the group discussions were transcribed and analyzed qualitatively. RESULTS: Participants emphasized their reasons for smoking, reasons for quitting or wanting to quit, views on smoking-related health concerns, perceived social costs and benefits of smoking, and strategies for quitting and maintaining abstinence. Many similarities between the focus groups' views and those of the general population were noted, along with some issues that are specific to having a mental illness or attending a psychosocial rehabilitation program, such as coping with psychiatric symptoms and limited access to information, support, and other coping methods. All of these views influenced participants' motivations and perceived readiness to smoke or to abstain, or to struggle between the two alternatives. CONCLUSIONS: Issues and needs that are specific to smokers who use mental health services must be addressed in the development of smoking prevention and cessation interventions in psychosocial rehabilitation and other mental health programs. The importance of messages about smoking that clients receive from program rules, program staff, and other sources is highlighted, as is the possibility that the regulation of affect and stress provided by tobacco use is especially important for people experiencing psychiatric symptoms.

Modifying the PACT model to serve homeless persons with severe mental illness.

The success of the Program for Assertive Community Treatment (PACT) has led to its replication with different client populations, especially those who are underserved by the traditional treatment system. This paper describes a program in Baltimore that has adapted the PACT model to serve homeless persons with severe mental illness. Although the essential ingredients and philosophy of the original model were maintained, the original team approach has been modified by the use of "miniteams." All staff share knowledge of all program clients through formal mechanisms such as daily meetings; however, each client is assigned to a miniteam composed of a clinical case manager, a psychiatrist, and a consumer advocate. Another deviation from the PACT model is that services can be time limited. The authors describe four phases of treatment and problems, including interventions characteristic of each phase.

Fifty years of progress in community mental health in US: the growth of evidence-based practices.

Fifty years have elapsed since the passage of the Community Mental Health Centers (CMHC) Act in 1963 that reflected the legislative peak of the community mental healthcare movement in the US Progress of the last 10 years is represented both by expansions of evidence-based practices (EBPs) and the development of emerging practices and fundamental shifts in the orientation of the system stimulated by the consumer-driven recovery movement. Established EBPs have accumulated expanded evidence, new EBPs have been developed and emerging EBPs are gaining increased acceptance. While the lack of widespread implementation of EBPs as well as the limitations of these technologies produces unnecessary suffering and disability, we believe that the growth of evidence for treatments and services justifies optimism for the future.

Promotion of healthy eating through public policy: a controlled experiment.

BACKGROUND: To induce consumers to purchase healthier foods and beverages, some policymakers have suggested special taxes or labels on unhealthy products. The potential of such policies is unknown. PURPOSE: In a controlled field experiment, researchers tested whether consumers were more likely to purchase healthy products under such policies. METHODS: From October to December 2011, researchers opened a store at a large hospital that sold a variety of healthier and less-healthy foods and beverages. Purchases (N=3680) were analyzed under five conditions: a baseline with no special labeling or taxation, a 30% tax, highlighting the phrase "less healthy" on the price tag, and combinations of taxation and labeling. Purchases were analyzed in January-July 2012, at the single-item and transaction levels. RESULTS: There was no significant difference between the various taxation conditions. Consumers were 11 percentage points more likely to purchase a healthier item under a 30% tax (95% CI=7%, 16%, p<0.001) and 6 percentage points more likely under labeling (95% CI=0%, 12%, p=0.04). By product type, consumers switched away from the purchase of less-healthy food under taxation (9 percentage point decrease, p<0.001) and into healthier beverages (6 percentage point increase, p=0.001); there were no effects for labeling. Conditions were associated with the purchase of 11-14 fewer calories (9%-11% in relative terms) and 2 fewer grams of sugar. Results remained significant controlling for all items purchased in a single transaction. CONCLUSIONS: Taxation may induce consumers to purchase healthier foods and beverages. However, it is unclear whether the 15%-20% tax rates proposed in public policy discussions would be more effective than labeling products as less healthy.

Radiographic texture analysis of densitometer-generated calcaneus images differentiates postmenopausal women with and without fractures.

INTRODUCTION: Bone fragility is determined by bone mass, measured as bone mineral density (BMD), and by trabecular structure, which cannot be easily measured using currently available noninvasive methods. In previous studies, radiographic texture analysis (RTA) performed on the radiographic images of the spine, proximal femur, and os calcis differentiated subjects with and without osteoporotic fractures. The present cross-sectional study was undertaken to determine whether such differentiation could also be made using high-resolution os calcis images obtained on a peripheral densitometer. METHODS: In 170 postmenopausal women (42 with and 128 without prevalent vertebral fractures) who had no secondary causes of osteoporosis and were not receiving treatment for osteoporosis, BMD of the lumbar spine, proximal femur, and os calcis was measured using dual energy x-ray absorptiometry. Vertebral fractures were diagnosed on densitometric spine images. RTA, including Fourier-based and fractal analyses, was performed on densitometric images of os calcis. RESULTS: BMD at all three sites and all texture features was significantly different in subjects with and without fractures, with the most significant differences observed for the femoral neck and total hip measurements and for the RTA feature Minkowski fractal (p<0.001). In univariate logistic regression analysis, Minkowski fractal predicted the presence of vertebral fractures as well as femoral neck BMD (p<0.001). In multivariate logistic regression analysis, both femoral neck BMD and Minkowski fractal yielded significant predictive effects (p=0.001), and when age was added to the model, the effect of RTA remained significant (p=0.002), suggesting that RTA reflects an aspect of bone fragility that is not captured by age or BMD. Finally, when RTA was compared in 42 fracture patients and 42 nonfracture patients matched for age and BMD, the RTA features were significantly different between the groups (p=0.003 to p=0.04), although BMD and age were not. CONCLUSION: This study suggests that RTA of densitometer-generated calcaneus images provides an estimate of bone fragility independent of and complementary to BMD measurement and age.

Obesity among individuals with serious mental illness.

OBJECTIVE: To study the distribution and correlates of body mass index (BMI) among individuals with serious mental illness. METHOD: A total of 169 participants were recruited from randomly selected out-patients receiving community-based psychiatric care and were interviewed with items from the National Health and Nutrition Examination Survey (NHANES) III. Their BMI was compared with that of 2404 matched individuals from the NHANES data set. RESULTS: The distribution of BMI in the psychiatric sample significantly differed from that of the comparison group; 50% of women and 41% of men were obese compared with 27% and 20% in the comparison group. Within the psychiatric sample, higher BMI was associated with current hypertension and diabetes, a wish to weigh less, and reduced health-related functioning. CONCLUSION: Obesity is more prevalent among individuals with serious mental illness than in demographically matched individuals from the US general population. Among persons with mental illness, obesity is associated with co-occurring health problems.

Housing for persons with co-occurring mental and addictive disorders.

Homelessness is a far too common outcome for persons with dual diagnoses. This chapter discusses existing housing barriers and suggests housing, treatment, and support services responsive to population need.

Choose a diet that is low in saturated fat and cholesterol and moderate in total fat: subtle changes to a familiar message.

"Choose a diet that is low in saturated fat and cholesterol and moderate in total fat," issued in Nutrition and Your Health: Dietary Guidelines for Americans in the year 2000, has an interesting and lengthy history. The first guideline, for which there was extensive scientific data to show that dietary excess increased chronic disease risk, prompted much scientific discussion and debate when implemented as dietary guidance. Three major changes in the guideline are noted since it was issued in 1980, i.e., numerical goals for dietary fats; the applicability of recommended fat intakes for all individuals > or =2 y old; and rewording to emphasize reducing saturated fat and cholesterol intakes. The shift in emphasis includes the terminology moderate fat, which replaces the phrasing low fat. National data about the food supply, the population's dietary intake, knowledge, attitudes and behaviors, and nutritional status indicators (e.g., serum cholesterol levels) related to dietary fats help to monitor nutrition and health in the population. Experts consider that national data, although not without limitations, are sufficient to conclude that U.S. intakes of fats, as a proportion of energy, have decreased. The lower intakes of saturated fat and cholesterol are consistent with decreases in blood cholesterol levels and lower rates of coronary mortality over the past 30 years. Strategies are needed and some are suggested, to further encourage the population to achieve a dietary pattern that is low in saturated fat and cholesterol and moderate in total fat. Other suggestions are offered to improve national nutrition monitoring and surveillance related to the guideline.