The effect of post-injury depression on return to pre-injury function: a prospective cohort study.

BACKGROUND: Millions of people seek emergency department (ED) care for injuries each year, the majority for minor injuries. Little is known about the effect of psychiatric co-morbid disorders that emerge after minor injury on functional recovery. This study examined the effect of post-injury depression on return to pre-injury levels of function. METHOD: This was a longitudinal cohort study with follow-up at 3, 6 and 12 months post-injury: 275 adults were randomly selected from those presenting to the ED with minor injury; 248 were retained over the post-injury year. Function was measured with the Functional Status Questionnaire (FSQ). Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR disorders (SCID). RESULTS: During the post-injury year, 18.1% [95% confidence interval (CI) 13.3-22.9] were diagnosed with depression. Adjusting for clinical and demographic covariates, the depressed group was less likely to return to pre-injury levels of activities of daily living [odds ratio (OR) 8.37, 95% CI 3.78-18.53] and instrumental activities of daily living (OR 3.25, 95% CI 1.44-7.31), less likely to return to pre-injury work status (OR 2.37, 95% CI 1.04-5.38), and more likely to spend days in bed because of health (OR 2.41, 95% CI 1.15-5.07). CONCLUSIONS: Depression was the most frequent psychiatric diagnosis in the year after minor injury requiring emergency care. Individuals with depression did not return to pre-injury levels of function during the post-injury year.

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial behavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems.

The below-the-knee amputation for vascular disease.

Of 190 consecutive patients with below-the-knee amputation done for diabetic or arteriosclerotic vascular disease, 167 were successfully fitted with a prosthesis and used the prosthesis in some or all of the activities of daily living. The surgical failure rate was 4.2 per cent; only eight patients required surgical revision to a higher level of amputation. The technique of rigid plaster dressing followed by delayed application of a plaster cast and pylon was not detrimental to wound healing and did not increase the interval between surgery and the use of the prosthesis, nor did it depress the eventual level of function. When compared with our own previous experience with other flaps, the long posterior flap offered a significant advantage in healing rate.

Evaluating use of continuous treatment teams for persons with mental illness and substance abuse.

OBJECTIVE: Continuous treatment teams serving persons with co-occurring severe mental disorders and substance abuse disorders at seven sites in New Hampshire were evaluated to determine their fidelity to a model based on the Program for Assertive Community Treatment. METHODS: Continuous treatment teams and standard case management programs at the seven sites were evaluated on 13 criteria for fidelity to the continuous treatment team model over a 27-month period. Data sources included clinicians' activity logs, agencies' management information systems, interviews, observation of staff activity and practices, and clinical records and other documents. RESULTS: The continuous treatment teams scored significantly higher than the case management programs on ten of the 13 criteria. The teams were more effective than the case management programs in implementing substance abuse treatment. CONCLUSIONS: Evaluation of the programs' fidelity to the model criteria allowed differentiation of successfully implemented continuous treatment teams from standard case management and from an unsuccessfully implemented team. The results confirm the need for careful measurement of model implementation and for investigation of organizational issues such as administrative support and clarity of program mission.

Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial.

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.

A scale for assessing the stage of substance abuse treatment in persons with severe mental illness.

Substance abuse is common among persons with severe mental illness, but few measures exist for clinicians to evaluate treatment progress. The Substance Abuse Treatment Scale (SATS) combines a motivational hierarchy with explicit substance use criteria to form an eight-stage model of the recovery process. Data are presented supporting the reliability and validity of the SATS, based on its use in a community-based sample of persons with dual disorders. The SATS can be used as either a process or an outcome measure, for individuals or for groups, and its value in making explicit the stages of substance abuse treatment is discussed.

Incentives for community treatment. Mental illness management services.

Serving people with mental and other chronic illnesses in community settings may improve compliance and satisfaction with treatment, but existing payment mechanisms often favor office-based treatment. This study examines the effect of a change in Medicaid payment on the location and amount of service provided by case managers. Amounts of service given by treatment providers to 185 of their clients in community settings and in mental health centers were compared before and after reimbursement changed from an all-inclusive prospective rate to a mixed prospective/retrospective payment. Clients were enrolled in two different treatment programs: continuous treatment teams with extensive training in in vivo treatment, and a case management program that emphasized office-based treatment. In-community service increased, and the amount of office-based treatment decreased. Continuous treatment teams increased in-community services more than case managers did; case managers decreased office-based treatment more. There was no change in total amount of services provided. It was concluded that mixed prospective and retrospective reimbursement can remove financial barriers to in-community treatment, but it works best in combination with a training program. Additional research is needed to determine the precise financial impact of such changes.

Screening for hypothermia in the ambulatory elderly. The Maine experience.

This study investigated the prevalence of low body temperatures in 97 elderly and 20 nonelderly subjects. To the best of our knowledge, no earlier survey has been conducted with a North American population. To ensure comparability with the British National Survey performed in 1973, urine temperatures were collected as a proxy measure of core temperatures. The urine-collecting funnel was modified to minimize cooling artifact introduced by the device. Study subjects were selected from an internal medicine clinic that serves the poor, a federally subsidized housing project, and a subsidized housing project in northernmost Maine. A youthful population (mean age, 32.3 years) was chosen to provide a comparative population to elderly participants (mean age, 73.9 years). Based on the British National Survey, the expected prevalence of low body temperatures (less than 35.5 degrees C) was 10%. The present study detected no low body temperatures, and the average urine and mouth temperatures were 0.3 and 0.19 degree C warmer, respectively, than those in the British National Survey. Youthful subjects were not significantly different from elderly participants. There appears to be no evidence from this study that low early-morning basal body temperature (less than 35.5 degrees C) is a common geriatric occurrence in ambient room temperature.