Psychiatric rehabilitation: efficacy of four models.

This paper is a critical review of four major rehabilitation programs: assertive community treatment, case management, vocational rehabilitation, and educational rehabilitation. Reported outcomes are reviewed in the context of study design, service characteristics, client characteristics, and operationalization of outcomes. Findings from the four programs are compared with one another. The authors concluded that clients are able to learn most of the skills taught, independently of the rehabilitation model. Furthermore, skills learned in one life domain generalized to a moderate extent to other areas. The four rehabilitation programs had varied effects on the outcome variables, and part of the variability in the findings appears to be related to client characteristics. Limitations of the studies reviewed are identified and a set of recommendations was suggested for the future practice of research into psychiatric rehabilitation.

Damage induced by systemic kainic acid in rats is dependent upon seizure activity--a behavioral and morphological study.

Kainic acid (KA) was injected intraperitoneally into rats at a dose (9 mg/kg) which produced status epilepticus in approximately 50% of the animals. Rats were categorized into groups that displayed status epilepticus, partial seizures or no effect in the 4 hr following kainic acid injection. Behavioral and morphological changes were characterized for each group. Rats that were not affected by kainic acid were indistinguishable from a saline-injected control group. When sacrificed 4 hr after treatment, rats displaying partial seizures showed morphological changes similar to, but less severe than, those exhibiting status epilepticus. Additional groups were tested and sacrificed 7 days (d) after treatment. Rats from the limited seizure group showed little behavioral or morphological response, while animals from the status epilepticus group had marked behavioral deficits and severe lesions. The tissue damage and its distribution were similar to lesions observed after seizures induced by other convulsants, and in spontaneously epileptic dogs. These results suggest that the extent of damage resulting from systemic administration of KA is dependent on the extent of seizure activity, which may in turn be related to the influence of kainic acid and other excitatory amino acids on the limbic system.

Pharmacological regulation of intravenous cocaine and heroin self-administration in rats: a variable dose paradigm.

Rats were trained to intravenously self-administer unit doses of cocaine or heroin. Constant supplemental infusion of a portion of each rat's mean hourly intake increased the mean time between successive infusions, but the effect was not statistically reliable from the data of a small sample of animals. A variable dose per infusion (VDI) paradigm was developed which enabled testing of several unit doses of cocaine or heroin within single test sessions. Unit doses of 0.5, 1.0, and 2.0 mg/kg of cocaine or 0.025, 0.05, and 0.1 mg/kg of heroin were made available with equal frequency but in unpredictable sequence to independent groups of rats. The mean time between successive infusions was linearly related to the log dose of the preceding infusion in each case. Pimozide, a drug thought to attenuate the reinforcing effects of both cocaine and heroin, shifted the functions without disturbing the dose-response relations; pimozide reliably decreased the time between successive cocaine infusions across a 4-fold range of pimozide doses. The effect of pimozide on heroin self-administration was not statistically significant and disrupted responding at the highest dose tested. This paradigm thus offers a within-session assessment of the dose-dependent duration of reinforcing actions of cocaine and heroin, and this assessment is sensitive to at least one challenge of intravenous drug reinforcement.

Drug-induced reinstatement of extinguished self-administration behavior in monkeys.

Responding was established in squirrel monkeys under a modified progressive ratio schedule of IV d-amphetamine or cocaine self-administration. Subsituation of saline for the drug solutions resulted in extinction of the self-administration behavior. IV injections of certain doses of d-amphetamine or cocaine, immediately prior to test sessions in which response-contingent saline infusions were delivered, reinstated the rate and pattern of responding observed during sessions in which drug was self-administered. Presession IV injections of several doses of pentobarbital or chlorpromazine failed to consistently reinstate responding. These results were interpreted in terms of the discriminative control of drug self-administration behavior by the current drug state of the subject.

Pimozide attenuates lever pressing for water reinforcement in rats.

Rats were trained to lever-press for water on a schedule of continuous reinforcement, then tested every fourth session on five occasions either under conditions of non-reinforcement or following injections of the dopamine receptor blocker pimozide (0.5 or 1.0 mg/kg) or the injection vehicle. The low dose of pimozide did not significantly attenuate responding until the fifth session. The high dose attenuated responding on all occasions, with residual responding decreasing progressively across repeated drug sessions. Responding in the pimozide conditions was never less than that of the non-reinforced control group. Responding in each condition was strongest in the early minutes of a session. After five sessions, rats were switched from the pimozide condition to the non-reinforced condition (or vice-versa) for one additional test day. Decreased responding continued for rats transferred from non-reinforcement to pimozide though not for rats transferred from pimozide to non-reinforcement. These data suggest a role for brain dopamine in behavior; they reflect the same patterns as have been seen with food reinforcement and with several centrally-acting reinforcers.

Concurrent heroin self-administration and intracranial self-stimulation in rats.

In a two-lever testing chamber, rats lever pressed for lateral hypothalamic brain stimulation or intravenous heroin reinforcers on a concurrent FR1 FR1 schedule of reinforcement. Responding for stimulation did not alter the rate of heroin self-administration, and responding for heroin caused increased responding for stimulation. Discontinuing heroin injections, or administering 3 mg/kg of naloxone, disrupted responding for both reinforcers, while changing the unit dose of heroin did not appreciably affect response rates for stimulation. This experiment demonstrates that rats are able to lever press during the period between successive self-administered heroin infusions, suggesting that the pausing normally seen between infusions is not due to debilitation, stereotyping, or sedation.

Concurrent intracranial self-stimulation and amphetamine self-administration in rats.

In a two-lever testing chamber, rats had concurrent access to intravenous amphetamine and brain stimulation reinforcers. Responding for each reinforcer was generally increased above baseline rates taken when only one reinforcer was available. Amphetamine stereotypy was observed, but did not interfere with rapid lever-pressing for brain stimulation.

Measuring client satisfaction with assertive community treatment.

OBJECTIVE: A mailed survey was used to measure satisfaction of seriously mentally ill clients with services provided by an assertive community treatment team. METHODS: A detailed 35-item questionnaire was mailed in 1995 to all 174 clients of the Brockville (Ontario) Psychiatric Hospital's assertive community rehabilitation program. RESULTS: The rate of return was 51 percent. Compared with clients who did not return the survey, the respondent group had significantly fewer males and fewer clients with a diagnosis of schizophrenia; respondents had been associated with the program for less time. Factor analysis of the survey responses revealed three principal components accounting for 46 percent of the total variance in responses. The factors were interpersonal aspects of care, client involvement in treatment, and medication and treatment issues. Respondents were generally satisfied with service from the program, but they were dissatisfied with side effects of medication and the amount of medication they were taking. CONCLUSIONS: A mailed survey appears to be an efficient and nonintrusive way to collect satisfaction data anonymously from persons with serious mental illness who are clients of an assertive community treatment team. The results highlight areas of need that the team can address.

Assertive community treatment of severe mental illness: a Canadian experience.

The study assessed one-year outcomes for 110 clients with serious mental illness who were randomly assigned to an assertive community rehabilitation program that provides psychiatric rehabilitation services in community settings or to hospital-based rehabilitation programs. Key elements of the community program include a multidisciplinary team on call 24 hours a day, in vivo treatment, and instruction and assistance in basic living skills. Data from client interviews after one year of service were used to assess clients' quality of life, satisfaction with services, and psychopathology. Clients in the assertive community rehabilitation program were more likely to be maintained in community settings and reported better quality of life than clients in the hospital-based programs.

Partnerships for people with serious mental illness who live below the poverty line.

Fifty-four persons with serious mental illness who were living below the poverty line were randomly divided into two groups. Members of one group received allowances and forgivable loans to raise them above the poverty line for one year. The others received some funds, but not enough to raise them above the poverty line. All participants selected one staff member from a consortium of supporting agencies to serve as a sponsor and another person to serve as an adviser to help them function better. For both groups hospitalization rates were significantly reduced, and quality of life in some domains improved.

'Idiopathic' neonatal cerebral infarction.

Neonatal cerebral infarction is infrequently reported in the living newborn and is usually associated with perinatal risk factors, trauma, and asphyxia. This report describes two cases of full-term newborns with no predisposing problems who had unequivocal left cerebral infarctions associated with seizures in the first 24 hours of life. Radiological studies suggested an embolic cause in one case.

Comparison of the behavioral effects of neurotoxic and systemically toxic agents: how discriminatory are behavioral tests of neurotoxicity?

The behavioral effects of carbon tetrachloride-produced impairment of liver function, insulin-produced reduction of plasma glucose levels, and the reduction of food and water intake have been evaluated. Considerable similarity was found among the behavioral effects of systemically toxic agents, three neurotoxicants (triethyltin, acrylamide, and 2,5-hexanedione), and the neuroleptic drug haloperidol. Measure of motor strength differentiated neurotoxic from non-neurotoxic compounds, while measures of motor activity were equally sensitive to neurotoxic, systemically toxic, and non-neurotoxic agents. These findings demonstrate the importance of assessing systemic toxicity before drawing conclusions about the neurotoxicity of a behaviorally active compound.

Measuring subjective quality of life in people with serious mental illness using the SEIqoL-DW.

In response to suggestions that available measures may not adequately reflect the idiosyncratic nature of subjective quality of life, the schedule for the evaluation of individual quality of life (SEIQoL) was developed to allow individuals first to select and define their own dimensions of quality of life, and then to assign a relative weight to each of the dimensions they have chosen. A simplified version of the instrument, the SEIQoL-direct weighting (SEIQoL-DW), can be used to elicit similar information from subjects with impaired cognitive functioning. The present study explored the feasibility of using this technique with a sample of 35 clients with serious mental illness served by assertive community treatment (ACT) teams. The SEIQoL-DW was well accepted by the study cohort. The SEIQoL-DW's global index was correlated with the satisfaction with life scale (SWLS), and with the quality of life inventory (QOLI). The SEIQoL-DW may have potential as a clinical planning tool that allows respondents to define personally relevant quality of life dimensions upon which attainable goals can be based.

Discrete-trial control of morphine self-injection behaviour in monkeys: effects of injection dose and trials per session.

Responding for intravenous injections of morphine was studied using a discrete-trials procedure in squirrel monkeys. For one group, each session consisted of 10 trials at an inter-trial interval of 15 min; for the second group, each session consisted of 100 trials at an inter-trial interval of 1.5 min. When different injection doses of morphine (1-1000 mug/kg per injection), including saline as a control procedure, were substituted at random for blocks of five consecutive sessions, the frequency of morphine self-administration was found to be an inverted U-shaped function of the injection dose. This relationship was observed in each group of monkeys, despite a 10-fold difference in the total amount of the drug which was available for self-administration per session when a given injection dose was substituted for both groups. The results show that the injection dose of morphine acted as a primary determinant of response probability, even under circumstances in which trial spacing imposed a significant delay between consecutive opportunities for drug self-administration,

Defining the role of pet animals in psychotherapy.

The literature now contains more than 1000 references to the use of a variety of animals in therapy. The terms used include Pet Therapy, Pet Assisted Therapy, Pet Facilitated Therapy. They reflect lack of agreement as to the role and effectiveness of animal use. Most are anecdotal descriptive studies lacking in scientific methodology. There are almost none in the psychiatric literature despite repeated claims of effectiveness in treating mental and emotional illness. This paper provides a review for the psychiatrist. It describes the development and use of rating scales to generate numerical values for statistical analysis, from videotaped observations of pet therapy sessions. Blind ratings yielded high inter-rater correlations. Although a pilot study, the results indicate the feasibility of designing definitive studies to evaluate the claims of animal enthusiasts. Valuable insights were gained which help to clarify the respective roles of animals and therapists.

Program outcome and QA: a new approach to evaluation.

Health care providers and managers are familiar with the limitations of current quality assurance (QA) practices, which do little to indicate the overall effectiveness of health care programs. This article discusses a comprehensive method of evaluating program effectiveness, efficiency, cost, client satisfaction, and adherence to standards. The authors present the Brockville Psychiatric Hospital's experience in evaluating a new program with data collected from a multi-faceted QA perspective, and suggest that combining program evaluation with QA could become the standard for future program assessments.

Program evaluation as a measure of the quality of a new approach to community psychiatric care.

The effectiveness of a new approach to providing psychiatric rehabilitation services in community settings will be assessed using a combination of quality assurance principles and program evaluation techniques. A new Assertive Community Rehabilitation Program (ACRP) is evaluated and compared with existing hospital rehabilitation programs. Measures of service efficiency, admission, discharge and readmission rates, and service costs are made for 100 new referrals, 99 inpatients and 117 outpatients. Follow-up interviews use standardized measures of clients' quality of life, clinical status, client and staff satisfaction, and community resource utilization. After 19 weeks of operation, the ACRP has prevented more admissions, and discharged more inpatients than the comparison programs. Readmission rates have not differed. Results at the end of the one-year project using this program-based quality assurance approach will facilitate managerial decisions about the future of rehabilitation services.

Quality of life after psychiatric rehabilitation: the clients' perspective.

Fifty-five people discharged from inpatient psychiatric rehabilitation programs were interviewed 1 year after leaving hospital using the Client's Quality of Life Instrument. Following long periods of psychiatric hospitalization, these former patients had adapted to living in the larger community with considerable success. Ninety-six percent felt that their quality of life had improved as a consequence of leaving hospital. Most people had the necessary maintenance skills to live in community settings. They showed appropriate behaviors and blended into the larger community without difficulty. They used outreach support services provided by the hospital to help them in the transition to community living.