Dose response effects of cognitive-behavioral therapy in a school mental health program.

School mental health (SMH) programs have been shown to be effective in providing evidence-based interventions to underserved youth. However, limitations of SMH programs are that they can entail holiday breaks, typically do not operate through summer, and often require pulling students from class to receive therapy. These limitations suggest that treatment must be expeditious and potent. Although researchers have investigated dose response to treatment, no studies were located that addressed dose response to treatment in SMH programs. The present study addressed this gap by evaluating the dose response to SMH treatment in a sample of 133 adolescents. Adolescents were assessed at baseline, post-treatment, and at multiple time points throughout treatment. An average treatment response of a 26.81-point decrease in Youth Outcome Questionnaire (YOQ-30) score was found across 14 sessions of cognitive-behavioral therapy (CBT). Further, adolescents exhibited reliable change in YOQ-30 score within an average of 2.91 sessions. Finally, it was found that baseline scores on the Depression and Hyperactivity subscales of the Behavior Assessment System for Children, 2nd Edition, along with YOQ-30 score, predicted treatment response. These findings advance our understanding of dose response to CBT in SMH settings, and create opportunities to better inform effective treatment strategies in similar contexts.

CALM gatekeeper training is associated with increased confidence in utilizing means reduction approaches to suicide prevention among college resident assistants.

BACKGROUND: Most suicide prevention programs focus on increasing knowledge regarding the problem of suicide, yet many fail to include information on the science and application of means reduction approaches. In an attempt to address this gap in practice, the Counseling on Access to Lethal Means (CALM) program was developed to educate clinicians on the importance of means reduction interventions. METHODS: In the current study, a gatekeeper CALM training was delivered to 167 resident assistants. Confidence levels regarding suicide prevention and means reduction skills were assessed at baseline, post-training, and after a 6-week follow-up. RESULTS: Results were suggestive of medium to large training effects. Though there was a small decay of training effects at follow-up, the effects were durable when compared to baseline levels. CONCLUSION: Given these findings, future gatekeeper trainings should be provided more consistently to help sustain the effects and data on the implementation of CALM principles should be measured during follow-up assessments.

Theophylline pharmacokinetics in black Zimbabwean males.

Theophylline pharmacokinetics were studied in 16 black Zimbabwean volunteers aged 20-41 years. Following a single intravenous dose of 5 mg/kg, four serum levels were collected over 24 h. Data were analyzed using a one-compartment open model. The correlation coefficient was 0.995 +/- 0.004. The mean extrapolated peak level was 8.5 +/- 0.9 mg/L. The mean half-life and volume of distribution were 10.1 +/- 3.1 h and 0.55 +/- 0.7 L/kg, respectively. The mean clearance was 0.62 +/- 0.17 ml/kg/min. The mean weight was 7 kg less than the calculated ideal body weight. These data suggest a larger volume of distribution and longer half-life than in other reported populations. The clearance is on the low end of previously reported values. We postulate that the primary cause of the large volume is the decreased body fat and consequent increase in body water per kilogram. The slightly decreased clearance may have been partially due to the high carbohydrate, low protein diet of our subjects. The long half-life is simply a reflection of a large volume and a moderately low clearance. We suggest that standard per kilogram maintenance doses can be employed in this population. A larger loading dose of 8 mg/kg aminophylline is recommended. Finally, the lack of sustained release theophylline in Zimbabwe may not be a problem, given the longer half lives observed in this study.

Three-point versus two-point method for early individualization of aminoglycoside doses.

An approach using two serum concentrations following the initial dose of an aminoglycoside was retrospectively evaluated using the first and third samples from all three-point studies conducted by the pharmacokinetic consult service in 1988. The same Sawchuk and Zaske method was used for the three-point and two-point studies. Although the predicted peaks and troughs from the two-point study were statistically different from those of the three-point study, it is the authors' opinion that the root mean squared error of 0.38 mg/L (95% confidence interval [CI] 0.31-0.45) for the peaks and 0.09 mg/L (95% CI 0.06-0.11) for troughs is well within the limits of acceptable clinical error for gentamicin and tobramycin. Eliminating one-third of initial aminoglycoside concentrations could result in significant time and cost savings.

Pharmacotherapy consultation on polypharmacy patients in ambulatory care.

OBJECTIVE: To investigate actual cost and adverse effect outcomes associated with a phamacotherapy consultation in ambulatory care patients receiving polypharmacy. METHODS: Patients receiving five or more chronic medications were randomized to receive pharmacotherapy consultation or usual medical care. Outcomes measured were changes in drug costs, medical costs, and drug-related symptoms six months after the consultation. Data were analyzed with unpaired Student's t-test for continuous data. Chi2 Analysis was used for categorical data. Patients and physicians were surveyed about their perceptions of the consultations after the study period. RESULTS: Drug and medical costs did not differ before and after the consultation. More patients in the consultation group had adverse symptom scores improve by two or more points, and fewer had symptom scores worsen by two or more points than in the control group. Seventy percent of patients and 76% of physicians believed that the consult was beneficial. CONCLUSIONS: Polypharmacy patients are the most likely to have drug-related problems and require intervention. Of all the interventions performed in this study, 73% of the original problems were recognized only through a patient interview, suggesting that an interpersonal relationship remains critical to the provision of pharmaceutical care. Although patients and physicians see intuitive value in pharmaceutical care, pharmacists need to exert more energy in the direction of marketing the profession. Finally, there are numerous difficulties in measuring the benefits of these interventions, possibly making broad-based interventions in complicated patients too difficult to assess accurately. Future studies should focus on patients with limited, specific problems or on interventions with narrow goals.

Comparison of four single-point phenytoin dosage prediction techniques using computer-simulated pharmacokinetic values.

The predictive abilities of the following four single-point phenytoin dosage adjustment methods were compared using computer-simulated data: the Bayesian feedback method of Vozeh et al. (B), a linearized version of the Bayesian method (LB), the population-clearance method of Graves et al. (G), and the Rambeck nomogram (R). A series of 512 "subjects" with normally distributed values for volume of distribution, weight, and the Michaelis-Menten variables Vmax and Km were simulated. The steady-state serum concentration (SSSC) resulting from the administration of a standard dose of phenytoin sodium (5 mg/kg/day) was calculated, and "subjects" with SSSCs less than or equal to 12 mg/L or greater than or equal to 17 mg/L were entered in the study. If the concentration was greater than 50 mg/L or the standard dosage exceeded Vmax, the dosage was reduced empirically by 25%. Normally distributed random errors were introduced into the SSSC values to simulate actual patient data. The pharmacokinetic values, dosages, and SSSCs were used for predicting the dosage required to attain an SSSC of 14.9 mg/L. In the unstratified population, the mean error and mean-squared error were lowest for methods G and B, followed by methods LB and R. Methods B and LB gave the highest percentages of satisfactory dosage predictions based on the resultant SSSC value. The performance of all methods was superior at initial SSSCs greater than 8 mg/L.(ABSTRACT TRUNCATED AT 250 WORDS)

The profession of pharmacy in Zimbabwe.

Zimbabwe (formerly Rhodesia) is a developing country in central southern Africa where great strides have been made in healthcare since black-majority rule began in 1980. Shortages of personnel, equipment, and drugs continue to be a problem. Challenges facing the pharmacy profession include improving drug supply, promoting rational use of essential drugs, and educating healthcare professionals and the public. Persuading pharmacists to practice in the government sector of healthcare rather than to serve the small percentage of the public that can afford private healthcare should be a major priority. Zimbabwe is a land of opportunity for pharmacy practice but the financial constraints are formidable.

Water handling in patients receiving haloperidol decanoate.

OBJECTIVE: To determine whether water handling in patients receiving haloperidol decanoate (HD) was impaired. DESIGN: Prospective, controlled trial of water handling in patients without symptomatic hyponatremia receiving HD. Eligibility for study inclusion required that patients had received HD for at least 4 months, were not taking any medication reported to cause inappropriate antidiuretic hormone secretion or hyponatremia (excluding haloperidol), and would agree to participate in the study. An age- and gender-matched healthy control subject was enrolled for each study patient. Baseline laboratory values were obtained within 48 hours prior to the standard water-loading test to screen for abnormalities in electrolytes, kidney function, and liver function. A 20-mL/kg water-load test was administered to each patient. Urine volume and osmolality were measured every hour for 4 hours. SETTING: A community mental health (CMH) outpatient psychiatric facility for the patients receiving HD and Saint Mary's Health Services for the controls. PARTICIPANTS: Fifteen patients receiving HD from the CMH facility and 15 age- and gender-matched control subjects were enrolled. MAIN OUTCOMES MEASURES: Impaired water handling was defined as a failure to dilute urine to less than 100 mmol/kg or a failure to excrete more than 65% of a water load in 4 hours. RESULTS: Five patients receiving HD were excluded because of protocol refusal or violation. Five of 10 evaluable patients receiving HD had abnormal water handling. Two of these could not lower their urine osmolality to less than 100 mmol/kg, 2 could not excrete more than 65% of the water load, and 1 did not meet either criteria. None of the healthy volunteers had abnormal free water handling. The difference between the study patients and the control subjects was statistically significant (p = 0.0097). CONCLUSIONS: Fifty percent of our study patients receiving HD had abnormal free water handling. This finding, combined with our clinical observations of symptomatic hyponatremia in other patients receiving the drug, suggests the need to investigate the incidence of hyponatremia and to design a useful screening tool to identify patients at risk. In the meantime, clinicians should be aware of the potential for impaired water handling in patients receiving HD.