Bradley J. Dain

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis.

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

Job Terminations Among Persons with Severe Mental Illness Participating in Supported Employment

For persons with psychiatric disabilities, maintaining a job is often more difficult than acquiring a job. A large proportion of jobs end unsatisfactorily. This study explored job terminations among 63 persons with severe mental illness who participated in competitive jobs through supported employment programs. More than half of the job terminations were unsatisfactory, defined as the client quitting without having other job plans or being fired. Baseline ratings of demographic and clinical characteristics, preemployment skills training, and early ratings of job satisfaction and work environment did not predict unsatisfactory terminations. Clients with better work histories were less likely to experience unsatisfactory terminations. In addition, unsatisfactory terminations were associated retrospectively with multiple problems on the job that were related to interpersonal functioning, mental illness, dissatisfaction with jobs, quality of work, medical illnesses, dependability, and substance abuse. These results suggest that supported employment programs need to address job maintenance with interventions that identify and address different types of difficulties as they arise on the job.

Thermal enhancement of low dose rate irradiation in a murine tumour system

The effects of localized hyperthermia (HT) in combination with low dose rate irradiation (brachytherapy) have been investigated in vivo using a murine mammary adenocarcinoma. Flank tumours were grown to 0.45-0.70 cm3 in volume, at which time their treatment course was initiated. Tumours were locally heated in a water bath for 15 min at either 44 or 45 degrees C. For tumour irradiations a non-invasive cap was devised to permanently house three iodine-125 sealed sources located at 120 degree intervals around the circumference of the hemispherical cap. During treatment, mice were secured in a modified syringe tube allowing mobility while restricting access to the cap which was placed over the tumour. Calculated dose rates ranged from 15 to 40 cGy/h. Brachytherapy (BT) was delivered for 48 or 72 h to obtain a dose range of 830-2378 cGy. Mice were randomized into one of 10 treatment protocols: BT alone, HT-BT, BT-HT, HT-BT-HT, 1/2BT-HT-1/2BT, four control groups of HT alone and a sham treatment group. Normalized tumour doubling volume growth delays (GDDv) were used to calculate the thermal enhancement ratios (TER). In the 44 degrees C experiments, HT before BT (TER = 1.33 +/- 0.071) was more efficacious than HT after BT (TER = 1.07 +/- 0.042). Two HT treatments, one given before and one after BT (TER = 1.38 +/- 0.152), were not different from a single HT treatment given before BT. However, a single HT treatment given in the middle of an interrupted course of BT resulted in the greatest thermal enhancement (TER = 1.64 +/- 0.072) compared to any other treatment sequence. These data suggest that potentiation of low dose rate irradiation by a single heat treatment may be maximized if the HT is given either in the middle of, or simultaneously with, the BT.

The economic benefits of supported employment for persons with mental illness

BACKGROUND: Policies and programs that emphasize employment for persons with mental illness are often promoted with the goals of improving economic self-sufficiency and reducing dependence on public welfare programs. At present, there is little empirical evidence about the actual effect of vocational interventions on economic self-sufficiency or on use of public benefits by persons with mental illness. STUDY AIMS: This study provides a preliminary look at how participating in supported employment, a form of vocational rehabilitation emphasizing ongoing support in competitive jobs, affects the amount that participants earn from work and the total amount of income they receive from all sources. Further, we examine the extent to which receiving public benefits affects the amount earned from private employment, taking into consideration other factors that might be associated with benefit status. METHODS: Data are from a randomized trial of supported employment interventions. This analysis followed 137 of those study participants with severe mental illness for 18 months after they enrolled in either of two supported employment programs. Income from various sources was estimated based on interviews with study participants upon study entry and at six-month intervals thereafter. Changes in income from work, government and other sources were analyzed using paired Wilcoxon matched-pairs signed-ranks tests and t-tests. Using ordinary least-squares regression, we analyzed the effect of benefit status on changes in earnings, taking into account diagnosis, work history, education, program type, site of program, psychiatric symptoms, global functioning and previous earnings. RESULTS: Estimated total income increased by an average of

Response of a brachytherapy model using 125I in a murine tumor system

134 (US) per month after enrolling in supported employment. More than three-quarters of this increase was from government sources, such as Social Security and educational grants. The increase in government income was largely due to participants applying for and getting cash benefits for the first time. Social Security payments for those receiving benefits before enrollment did not change significantly. A small group of persons (n = 22) who did not receive Social Security benefits before or after enrolment earned significantly more from competitive employment after enrolling than did those who received benefits. This finding persisted after taking into acount differences in work history, clinical and functional variables and education. LIMITATIONS: Because of the relatively small sample size and the lack of continuous measures of income these results should be considered preliminary. CONCLUSIONS: Supported employment, one of the more effective forms of vocational rehabilitation for persons with mental illness, did not reduce dependence on government support. Receiving government benefits was associated with lower earnings from work. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These findings suggest that most persons in treatment for severe mental illness need continued public financial support even after enrolling in vocational rehabilitation programs. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Undoubtedly increased labor force participation can benefit persons with mental illness in a number of ways. However, policy makers should be careful about justifying increased access to vocational programs on the basis of reduced spending for income support. Further, targeting such programs only to persons receiving income support may overlook the clients who can benefit most: those who are not currently receiving benefits. IMPLICATIONS FOR FURTHER RESEARCH: Policy makers need a better understanding of how vocational interventions and income support programs affect the income and well-being of persons with mental illness. Studies similar to this one should be repeated with larger, more diverse samples that will allow use of instrumental variables statistical techniques.

Laryngeal Complications of Prolonged Intubation

The effects of low-dose-rate irradiation (brachytherapy) were investigated in vivo using a murine mammary adenocarcinoma (MTG-B) growing in the flank of C3H mice. For local tumor irradiations, a noninvasive cap was devised to cover the tumor and house three 125I seeds (average apparent activity 5.2 mCi each) located at 120 degree intervals around the circumference of the hemispherical cap (13 mm i.d.). Mice were secured during treatment in a tube allowing limited mobility while restricting access to the seeds. Tumors were exposed to a series of dose rates ranging from 14-40 cGy/h, and the total dose over the treatment interval (48 or 72 h) ranged from 830 to 2378 cGy. A total of nine experiments were conducted using the caps over a 10-week interval. In each experiment three groups (irradiated tumors, sham controls, and untreated controls) were analyzed, each containing 8-15 mice (N = 34, untreated control; N = 46, sham control; N = 91, brachytherapy irradiation). The brachytherapy results are compared to the effects of external beam irradiation in the same tumor system. A linear relationship was observed between the total radiation dose and doubling volume growth delay (GDDV) or treatment volume growth delay (GDTV) for the brachytherapy and external beam irradiation. The slopes of the dose-response curves are steeper for the acute dose (517 cGy/min) external beam irradiation (0.0072 day/cGy, GDDV; 0.00695 day/cGy, GDTV) than for the brachytherapy (0.0050 day/cGy, GDDV; 0.0057 day/cGy, GDTV) using both GDTV and GDDV end points. Comparison of the tumor volume regrowth slopes indicates that the tumor bed effect is larger for external beam irradiation than for brachytherapy, suggesting that the tumor bed effect may be dose-rate dependent.