Ellen P. Fischer

Use, quality, and outcomes of care for mental health: the rural perspective.

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.

Awareness of Illness in Schizophrenia and Outpatient Treatment Adherence

We present a brief measure of awareness of illness in schizophrenia and test whether awareness is related to perceived need for and adherence to outpatient psychiatric treatment. A prospective design assessed treatment adherence, awareness of the signs and symptoms of schizophrenia, symptoms, neurocognitive status, and substance abuse at baseline and 6-month follow-up in 89 persons with schizophrenia. Results indicate that persons with greater awareness perceived greater need for outpatient treatment and evidenced better adherence to outpatient treatment when adherence and awareness were measured concurrently. Awareness was not related to adherence at 6-month follow-up. In addition, neurocognitive impairment was associated with lower overall adherence to treatment when reported by collaterals at baseline and 6-month follow-up. Neurocognitive impairment was, however, associated with higher self-reported adherence to medication, which suggests that neurocognitive status may bias adherence reporting in persons with schizophrenia.

Low sensitivity of the anion gap as a screen to detect hyperlactatemia in critically ill patients.

The anion gap is commonly used as a screening test for the presence of lactic acidosis. Analysis of the distribution of anion gaps for 56 adult surgical ICU patients with peak blood lactate levels greater than or equal to 2.5 mmol/L showed the anion gap to be an insensitive screen for elevated lactate in a critically ill, hospitalized population. All patients (11/11) with a peak lactate greater than or equal to 10 mmol/L had an anion gap greater than or equal to 16 mmol/L; however, 50% (6/12) of patients with lactates between 5.0 and 9.9 mmol/L and 79% (26/33) of those with lactates between 2.5 and 4.9 mmol/L had anion gaps less than 16 mmol/L. Hyperlactatemia was associated with considerable mortality at all levels: 100% among patients with lactate levels greater than or equal to 10 mmol/L, 75% between 5.0 and 9.9 mmol/L, and 36.4% between 2.5 and 4.9 mmol/L. Acidosis (pH less than 7.30) did not significantly alter mortality by lactate level. The observation that, for 57% of patients in this study, an elevated lactate level was not accompanied by an elevated anion gap suggests that hyperlactatemia should be included in the differential diagnosis of nonanion gap acidosis.

The Family Forum: Directions for the Implementation of Family Psychoeducation for Severe Mental Illness

It is well documented that family psychoeducation decreases relapse rates of individuals with schizophrenia. Despite the evidence, surveys indicate that families have minimal contact with their relatives treatment team, let alone participate in the evidence-based practice of family psychoeducation. The Department of Veterans Affairs (VA) sponsored a conference, the Family Forum, to assess the state of the art regarding family psychoeducation and to form a consensus regarding the next steps to increase family involvement. The forum reached consensus on these issues: family psychoeducation treatment models should be optimized by efforts to identify the factors mediating their success in order to maximize dissemination; leadership support, training in family psychoeducation models for managers and clinicians, and adequate resources are necessary to successfully implement family psychoeducation; because family psychoeducation may not be appropriate, indicated, or acceptable for all families, additional complementary strategies are needed that involve families in the mental health care of the patient; and work is required to develop and validate instruments that appropriately assess the intervention process and consumer and family outcomes. A treatment heuristic for working with families of persons with severe mental illness is also offered and provides a match of interventions at varying levels of intensity, tailored to family and consumer needs and circumstances. The article describes opportunities for the research and clinical communities to expand the proportion of families served.

Abnormal coagulation profile in brain tumor patients during surgery

Neurosurgical patients are at high risk for the development of thrombosis and thromboembolism. We compared the perioperative clotting factor and coagulation parameters of 20 patients undergoing elective craniotomy for brain tumors to those of 20 patients undergoing elective abdominal surgery. We also measured the levels of plasma arginine vasopressin to determine if changes in this hormone might be associated with changes in clotting factors, activated partial thromboplastin times, or bleeding times. The results demonstrated a significant reduction in partial thromboplastin times and bleeding times in the neurosurgery group, which began at the initiation of surgery and lasted to the end of the study (12 h postoperatively). Elevations in factor assays and plasma arginine vasopressin occurred in both groups during surgery, but there were no differences between the neurosurgical and abdominal surgical patients, except with Factor IX levels, which were elevated only in the neurosurgical patients. Serum osmolality and hemoglobin levels were significantly higher in the neurosurgical cohort. These results suggest that there are hemostatic differences between neurosurgical patients with brain tumors and abdominal surgery patients that cannot be explained solely by elevations in plasma arginine vasopressin or the clotting factors measured; these differences may be the consequence of perioperative variables such as dehydration and hyperosmolality.

An Instrument for Measurement of Outcomes of Care for Schizophrenia Issues in Development and Implementation

To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrumentfor monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panels deliberations and determined the modules content and characteristics are described Initialfield testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Healths Plan for Research on the Severely Mentally Ill. As such, it is a promising toolfor effectiveness research in schizophrenia.

Effects of acid-base correction on hemodynamics, oxygen dynamics, and resuscitability in severe canine hemorrhagic shock

Objective: To compare the effects of hypertonic saline, sodium bicarbonate, and Carbicarb® resuscitation on acid‐base balance, hemodynamics, and oxygen dynamics in a reperfused, canine hemorrhagic shock model. Design: Prospective, randomized trial. Setting: Laboratory at a university medical center. Subjects: Thirty‐five anesthetized, mongrel dogs. Interventions: After the administration of anesthesia, the dogs were intubated and mechanically ventilated. Vascular catheters were inserted into each femoral artery, for continuous blood pressure monitoring, intermittent blood sampling, and for establishing controlled hemorrhage. A pulmonary artery catheter was inserted via the right jugular vein. Inhaled and exhaled gases were continuously analyzed using a metabolic gas monitor. The animals were subjected to 90 mins of controlled hemorrhagic shock. They were then randomly given a 2.5‐mL/kg equimolar injection of 8.4% sodium bicarbonate, Carbicarb, or 5.84% hypertonic saline. The sodium load per kilogram of body weight was identical in all three groups. Thirty minutes later, the animals were retransfused with the shed blood over 15 mins and further observed for 120 mins. Measurements and Main Results: Carbicarb and sodium bicarbonate both significantly increased bicarbonate concentrations compared with saline. Arterial and venous blood pH increased more with Carbicarb than with bicarbonate but this increase was not statistically significant. After shock but before retransfusion, all three treatments moderately increased blood pressure, cardiac index, oxygen delivery index, and oxygen consumption index to a similar extent. After retransfusion, blood pressure, cardiac index, and oxygen dynamics temporarily improved in all groups, without significant improvement in the bicarbonate and Carbicarbtreated animals, despite their excellent acidbase status. Conclusions: In severe canine hemorrhagic shock, Carbicarb, bicarbonate, and hypertonic saline appear to possess similar hemodynamic properties despite the buffering properties of bicarbonate and Carbicarb. The similar responses may be due to their identical sodium content. Arterial pH correction does not appear to further improve the responses to blood retransfusion. (Crit Care Med 1994; 22:1616–1623)

Predicting coronary heart disease events in women: a longitudinal cohort study.

Background:More than 240 000 women in the United States die of coronary heart disease annually. Identifying women’s symptoms that predict a coronary heart disease event such as myocardial infarction (MI) could decrease mortality. Objective:For this longitudinal observational study, we recruited 1097 women, who were either clinician referred or self-referred to a cardiologist and undergoing initial evaluation by a cardiologist, to assess the utility of the prodromal symptoms (PS) section of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) in predicting the occurrence of cardiac events in women. Methods and Results:Seventy-seven women experienced events (angioplasty, stent placement, coronary artery bypass, MI, death) during the 2-year follow up. The most common events were stents alone (38.9%) or in combination with angioplasty (18.2%). Ten women had MIs; 4 experienced cardiac death. Cox proportional hazards was used to model time to event. The prodromal score was significantly associated with risk of an event (hazard ratio, 1.10; 95% confidence interval, 1.06–1.13), as was the number of PSs endorsed by each woman per visit. After covariate adjustment, 5 symptoms were significantly associated with increased risk: discomfort in jaws/teeth, unusual fatigue, arm discomfort, shortness of breath, and general chest discomfort (hazard ratio, 3.97; 95% confidence interval, 2.32–6.78). Women reporting 1 or more of these symptoms were 4 times as likely to experience a cardiac event as women with none. Conclusions:Both the MAPMISS PS scores and number of PS were significantly associated with cardiac events, independent of risk factors, suggesting that there are specific PSs that can be easily assessed using the MAPMISS. This instrument could be an important component of a predictive screen to assist clinicians in deciding the course of management for women.

Women's prehospital delay associated with myocardial infarction: does race really matter?

Background/Research Objective: Well-documented disparities in cardiovascular health account for approximately one third of the difference in life expectancy between blacks and whites. Mortality from cardiovascular disease is greater among black women than among white women, and black women report longer delays in treatment seeking following onset of symptoms of acute myocardial infarction (AMI). Despite this disparate burden, there is little race-specific data on correlates of delay for black or white women. This secondary data analysis compares duration and correlates of delay in treatment seeking by race following onset of AMI symptoms. Subjects/Methods: We analyzed self-report data from 509 black and 500 white women, interviewed 4 to 6 months after AMI, using multivariable logistic and linear regression. Results/Conclusions: Median delay time was nonsignificantly shorter for black than for white women (1.0 vs 1.5 hours). Equal proportions of black and white women (57% vs 54%) sought treatment within 2 hours of symptom onset. In multivariable analyses, correct attribution of symptoms to AMI was a significant predictor of treatment seeking within 2 hours of symptom onset for black and white women (odds ratios = 2.79 and 3.86, respectively); eligibility for public insurance was a significant predictor for black women only (odds ratio = 2.3). Common comorbidities, AMI risk factors, and other demographics were not significantly associated with delay time. Insurance coverage and the correct attribution of symptoms to cardiac causes are substantial and modifiable predictors of delay in seeking treatment of AMI.

A New Engagement Strategy in a VA-Based Family Psychoeducation Program

OBJECTIVE This brief report describes the engagement strategy used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a nine-month family psychoeducation program for veterans with serious mental illness or posttraumatic stress disorder (PTSD). METHODS A motivational interviewing-based strategy was created and implemented in a Veterans Affairs hospital to engage providers and veterans and their families into the intervention. RESULTS Of the 1,539 veterans told about the program, 41% had a family member living nearby and were willing to meet with a provider to learn more. REACH providers met with 505 veterans for a motivational-interviewing session to explore family participation. Of the 436 veterans who were eligible to participate in REACH, 28% of veterans with PTSD, 34% of veterans with an affective disorder, and 25% of veterans with a schizophrenia spectrum disorder went on to participate in at least one session of the REACH program with a family member; these rates compare favorably with those for programs requiring a much shorter commitment. CONCLUSIONS This engagement strategy shows promise as an effective tool in recruiting veterans and their families into family psychoeducation.