Richard K. Ries

The MOS 36-Item Short Form Health Survey: reliability, validity, and preliminary findings in schizophrenic outpatients.

OBJECTIVES The authors test the reliability and validity of the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) as a written, self-administered survey in outpatients with chronic schizophrenia. METHODS Thirty-six schizophrenic outpatients completed a written and oral form of the SF-36. A psychiatrist rated the patients using the Brief Psychiatric Rating Scale to determine severity of psychopathology. Cognitive functioning and academic achievement were also assessed. Internal consistency, test-retest reliability, concurrent and discriminative validity of the oral and written versions were determined. RESULTS The SF-36 in both forms was shown to have good internal consistency, stability, and concurrent validity. The mental health SF-36 subscales had poor discriminant validity, compared with the physical functioning scale that demonstrated good discriminant validity. CONCLUSIONS The validity of using the written form of the SF-36 on a sample of patients with chronic mental illness was demonstrated. The SF-36 appears to be an appropriate outcome measure for changes in physical and role functioning in consumers of outpatient mental health programs.

Brief Intervention for Problem Drug Use in Safety-Net Primary Care Settings: A Randomized Clinical Trial

IMPORTANCE Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00877331.

Longitudinal assessment of quality of life in acute psychiatric inpatients: reliability and validity.

This study examined the reliability, validity, and responsiveness of Lehmans Quality of Life Interview (QOLI) as an outcome measure on 981 acutely ill psychiatric inpatients assessed longitudinally at admission and discharge. Patients were stratified into five diagnostic (DX) (depressed bipolar, depressed unipolar, schizophrenia, mania, and other diagnoses) and two substance use disorder (SA) strata (with and without concurrent substance abuse/dependence) based on DSM-III-R criteria. There was good replication of the factor structure, excellent internal consistency, overall and within DX and SA groups. Intercorrelations showed that the functional and satisfaction indices measure unique aspects of the quality of life. The construct consistency of the QOLI was dependent upon psychiatric diagnosis and life domain. Intercorrelations of functional and satisfaction indices for patients with depression were greater than for manic patients. We demonstrated strong consistency of construct validity for family and social relation domains, but not safety or leisure activities. Construct validity was shown to hold longitudinally. Analyses of DX and SA group differences on satisfaction and functional indices of the 8 life domains supported discriminative validity: Depressed patients reported the most dissatisfaction, followed by schizophrenic patients, and manic patients reported the greatest satisfaction in most life domains. Patients with concurrent substance abuse generally reported less satisfaction and lower quality of life than patients without a dual diagnosis. Examination of longitudinal changes in satisfaction indicated the QOLI is responsive to changes in global life, leisure activities, living situation, and social relations from hospital admission to discharge (an average of 2 weeks). This study supports the use of the QOLI as an outcome measure to assess quality of life in acutely ill hospitalized psychiatric patients.

Part II: A ospective DSM-III study of 100 consecutive somatization patients

Abstract In this study the authors defined somatization and prospectively studied the prevalence of somatizing patients referred to a psychiatric consultation service. Included are the demographic characteristics and five-axis DSM-III diagnoses of 100 consecutive somatizing patients. A comparison of these patients was made to a control group (N = 161) of nonsomatizing patients also referred for consultation. There were significantly more patients with depression, panic disorder, personality disorders and psychophysiologic illness in the somatization patient sample and significantly more patients with schizophrenia, manic depressive illness, organic brain syndromes, adjustment disorder and serious medical illness in the non-somatization control group. Age, sex, and DSM-III axes IV and V did not significantly differentiate the two groups. The role of somatization as a process as distinguished from a DSM-III somatoform disorder is discsssed, and the importance of somatic symptoms as they relate to an underlying mental disorder is reviewed.

Hazardous drinking by trauma patients during the year after injury

BACKGROUND To improve reinjury prevention strategies targeting hazardous drinking, we determined its predictors and longitudinal course in the year after injury. METHODS This was a prospective study of 101 randomly selected hospitalized trauma patients who before injury represented the full range of substance abuse, from severe to none. We hypothesized that clinical data obtained routinely by trauma centers would predict hazardous drinking during the postinjury year. RESULTS Drug and alcohol use dropped markedly 1 month after injury but returned to preinjury levels by 4 months. Forty-one percent of the sample drank hazardously before injury, and 55% drank hazardously after. From before to after injury, 20% of patients worsened their hazardous drinking status, and only 6% of patients improved it. Three clinical predictors of hazardous drinking during the year were identified: any positive blood alcohol concentration > 0 at admission (odds ratio [OR], 9.18; 95% confidence interval [CI], 2.51-33.56), any days > 0 of using nonprescription drugs of abuse in the month before injury (OR, 6.63; 95% CI, 1.76-25.04), and suffering an intentional injury (OR, 5.1; 95% CI, 1.38-18.77). CONCLUSION Efforts to reduce hazardous drinking after injury should target patients with this risk profile and focus on the 1- to 4-month period after injury hospitalization.

Nefazodone treatment of major Depression in alcohol-dependent patients : A double-blind, placebo-controlled trial

Depression is the most common comorbid psychiatric illness in patients with alcohol dependence. This double-blind study tested the efficacy of nefazodone versus placebo for the treatment of depression in actively drinking alcohol-dependent patients who were also participating in weekly group treatment for alcoholism. Sixty-four subjects with major depression disorder and alcohol dependence with a history of at least one prior episode of depression when not drinking were randomly assigned to receive 12 weeks of either nefazodone or placebo and participated in a weekly psychoeducational group on alcoholism. Subjects were assessed every 2 weeks for depression, anxiety, side effects, and drinking frequency. Subjects taking nefazodone were significantly more likely to complete the study (62%) than those taking placebo (34%). Analyses of covariance using drinks per week as a time-dependent covariate showed lower Hamilton Rating Scale for Depression scores at week 8 for end-point analysis and at weeks 8 and 12 for completers. The endpoint analysis demonstrated a significantly greater response in the nefazodone group (48%) than in the placebo group (16%). Both groups showed a similarly significant decrease in the average number of alcoholic drinks consumed per day over the course of the study. Although the number of adverse effects was significantly greater for the nefazodone group, there were no severe adverse events, and nefazodone was well tolerated. Nefazodone is a safe and effective antidepressant to use in a population of alcohol-dependent patients with depression who have a high degree of comorbidity. Nefazodone treatment was superior to placebo in alleviating depression in these patients but did not add any advantage over the psychoeducational group in terms of drinking outcomes.

Antipsychotic drugs and plasma vasopressin in normals and acute schizophrenic patients

Elevated plasma vasopressin concentrations have been documented in antipsychotic drug-treated patients as well as a drug-free acutely psychotic patients. To evaluate the effects of antipsychotic drugs on plasma vasopressin, we measured vasopressin response to a single dose of intramuscular chlorpromazine or intravenous haloperidol in normal individuals and to 2 weeks of oral antipsychotics in patients with acute schizophrenia. Neither intramuscular chlorpromazine nor intravenous haloperidol affected plasma vasopressin in normals, except in one subject who developed high plasma vasopressin concentrations coincident with marked hypotension following chlorpromazine. Prior to antipsychotics, two acute schizophrenia patients had elevated plasma vasopressin concentrations, which normalized during antipsychotic drug treatment. We conclude that antipsychotics do not directly stimulate vasopressin release, but may indirectly stimulate vasopressin release by well-described baroreceptor reflex mechanisms if hypotension occurs. Also, acute schizophrenia may be associated with increased plasma vasopressin levels in some patients.

Poor interrater reliability of MECTA EEG seizure duration measurement during ECT.

Seizure duration assessed from the MECTA EEG (mEEG) tape was not found to be a reliable measurement across five independent examiners. Although all examiners agreed that an electrical seizure was demonstrated on the mEEG, the examiners were markedly different in their duration assessments (p less than 0.0001). Criteria are needed for mEEG measurement and interpretation.

Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients.

BACKGROUND Suicide is a major risk for those with bipolar disorder, a risk amplified by comorbid substance abuse in some, but not all, previous studies. To further explore the relationships of substance abuse, suicide, and bipolarity as they present in clinical practice, we analyzed standardized clinical data from a large acute psychiatric inpatient service. METHODS Standardized clinical evaluations of 7819 patients with diagnoses of bipolar depression (n=990), bipolar mania (n=948), unipolar depressive episode (n=3626), or schizophrenia-schizoaffective disorders (n=2255) were analyzed to evaluate the relationship between current substance-use problems, substance-induced symptoms, and a current suicide crisis, as well as lifetime suicide attempts, with logistic regressions adjusting for age, gender, and ethnicity. RESULTS Across the combined groups, current substance-use problems were significantly associated with a lifetime suicide attempt (odds ratios [ORs] 1.6-2.5) and to a lesser degree to the admission suicide crisis (ORs 1-2.2). Among bipolar (depressed/manic) patients, but not other diagnostic groups, those with both current substance-use problems and substance-induced symptoms had even higher rates of a recent suicide crisis (ORs 1.5-3.1) and of a lifetime attempt (ORs 2.5-3.4). CONCLUSIONS In bipolar patients, substance use disorder doubled and substance use disorder plus substance-induced symptoms tripled the suicidal risk. Implications for future research are discussed.

The CAGE questionnaire and the Short Michigan Alcohol Screening Test in trauma patients: comparison of their correlations with biological alcohol markers.

STUDY OBJECTIVES To explore and compare the sex-specific correlation of two standard behavioral screening instruments, the Short Michigan Alcohol Screening Test (SMAST) and the CAGE, with a weighted scale that combines the three most commonly used biological alcohol markers (blood alcohol level, mean corpuscular volume, and gamma-glutamyltransferase level). DESIGN A prospective cohort study. SETTING Regional level I trauma center, in Seattle, Washington. PARTICIPANTS 1980 male and 602 female patients 18 years of age or older, admitted with blunt or penetrating trauma. MAIN RESULTS Spearman rank correlations were used to compare the two screening measures with the weighted scale. The CAGE was found to correlate better than the SMAST with the weighted combination. Correlations for both measures were higher in women than in men. Among the individual biological alcohol markers used to construct the weighted scale, blood alcohol level was the marker that displayed the strongest correlation with both the CAGE and the SMAST. CONCLUSION We conclude that the CAGE questionnaire showed a higher correlation with a combination of biological alcohol markers than did the SMAST, and that the CAGE may be the questionnaire of choice for identification of alcohol problems in patients seen in trauma centers.