W. Dean Klinkenberg

Prevalence of human immunodeficiency virus, hepatitis B, and hepatitis C among homeless persons with co-occurring severe mental illness and substance use disorders

This study was undertaken to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among homeless persons with co-occurring severe mental illness (SMI) and substance use disorders and to determine associated risk factors. As part of a longitudinal study of the effectiveness of integrated treatment for homeless persons with SMI and substance abuse or dependence, serological testing was performed to ascertain the prevalence of HIV, HBV, and HCV. At baseline, 6.2% of participants (11/172) were HIV-positive. Nearly one third of participants (37/114) had evidence of prior exposure to HBV, and 30% (34/114) were antibody positive for HCV. About 44% of participants (50/114) had a reactive test for either HBV or HCV. Having a reactive test was strongly associated with substance use, especially with a history of injection drug use. A significant threat exists to the health and well-being of homeless person with SMI due to high prevalence of blood-borne pathogens. Mental health providers need to play a proactive role in the identification of health-related needs and to assist with access to general health services for persons with SMI.

Moderators and mediators of client satisfaction in case management programs for clients with severe mental illness.

This randomized experiment first determined that clients with severe mental illness who received Assertive Community Treatment (ACT) were more satisfied with their treatment program than were clients in a brokered case management program (BCM). Eight demographic and diagnostic variables were examined as potential moderators of the treatment effect. Only one of the eight varables, diagnosis of depression, interacted with treatment condition to effect client satisfaction. However, there were several important mediators of client satisfaction: intensity of program contacts, continuity of program contacts, supportive services (i.e, assistance with activities of daily living), and the strength of the helping alliance as perceived by the client.

Evaluation of Treatment Programs for Persons with Severe Mental Illness Moderator and Mediator Effects

This study evaluated several statistical models for estimating treatment effects in a randomized, longitudinal experiment comparing assertive community treatment (ACT) versus brokered case management (BCM). In addition, mediator and moderator analyses were conducted. The ACT clients had improved outcomes in terms of housing and psychiatric symptoms thanBCM clients. Case management housing assistance and financial assistance partially mediated housing outcomes. No reliable mediators were found for psychiatric symptoms, and no reliable moderators were found for either housing or psychiatric symptoms. The study also made several important methodological advances in the analysis of longitudinal data in randomized experiments.

Collecting data via the internet: the development and deployment of a web-based survey

SUMMARY This report discusses the process of developing and deploying an Internet-based study that sought to replicate the results of a traditionally administered questionnaire. We present data on the characteristics of respondents, hit and completion rates, and the effectiveness of a dozen different methods of advertising the survey. Overall, we were very successful in soliciting a gay and lesbian sample of Internet-users and collected one of the largest samples for a Web-based survey to date. Publicity methods that addressed the target audiences specific interests were far more effective than broader advertising methods.

Client outcomes and the working alliance in assertive community treatment programs.

This study examined the relationship between outcomes and the working alliance in clients who were receiving assertive community treatment only or integrated assertive community treatment (assertive community treatment plus substance abuse treatment). All 98 participants had a severe mental illness and a substance use disorder. The Working Alliance Inventory assessed the alliance from the perspective of both the client and the case manager at 3 and 15 months into treatment. The six outcome measures were stable housing, client rating of psychiatric distress, interviewer rating of psychiatric symptoms, self-report of days used alcohol or drugs, and interviewer rating of substance use. Only 4 of 24 correlations were significant, indicating little relationship between the strength of the working alliance and client outcome.

Predictors of Psychiatric Hospitalization: A Multivariate Analysis

Inpatient treatment continues to be the most expensive form of mental health service. This study sought to improve the methodological weaknesses, e.g., poor statistical controls, in the literature by using multivariate statistics to predict hospitalization. Results revealed that aftercare, i.e., outpatient treatment, is an important factor in reducing the utilization of inpatient resources, even when controlling for demographic and psychiatric history variables. Further, background characteristics, while easily measured, are not important predictors of hospitalization.

Prototypical Profiles of the Brief Psychiatric Rating Scale

Three prototypical profiles of the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) were isolated using a Q-type factor-analytic strategy with a sample of homeless men with mental illness (N =165). The 3 profiles-depressed, actively psychotic, and withdrawn-were used to study changes in BPRS profiles over time in a control group and a group that received assertive community treatment (ACT). Over 2 time periods (inception to 12 months and 12-24 months), the 2 groups did not differ in terms of changes in profile shape, but they did differ in terms of changes in profile elevation. The ACT group evidenced a decrease in symptom severity during the last 12 months, whereas the control group showed an increase. Although changes in profile shape in both groups did occur, there was a significant tendency for the shape of the BPRS profiles to remain stable from the inception of the study to the 12-month assessment and from that time to the 24-month assessment. We describe the uses of these prototypical profiles and discuss the applicability of this analytical approach to other assessment instruments.

Consistency of Recall of Sexual and Drug-Using Behaviors for Homeless Persons with Dual Diagnosis

In this paper we present data from a study of the consistency of recall of several sexual and drug-using behaviors gathered from face-to-face interviews with homeless persons who have dual diagnosis (severe mental illness plus a substance use disorder). Factors associated with inconsistent reporting are also examined. One hundred and thirty-three individuals participating in a longitudinal study of HIV risk behaviors were recruited for a retrospective recall study. Participants were completing monthly interviews that included assessments of sexual behaviors and drug use. Participants completed an additional interview using the same instruments and were randomly assigned to a 3- or 6-month recall condition; the data from the additional interview were correlated with the regular, monthly interviews. Results indicated that reports of sexual and substance-using behaviors were generally reported consistently for both 3- and 6-month recall periods; however, coefficients for the 3-month interval were generally better than those for the 6-month interval. One exception was that protected intercourse was generally not reported consistently. Inconsistent reporting of sexual and drug-using behaviors was associated with the severity of substance abuse; inconsistent reporting of sexual behaviors was also associated with African-American race. Our data suggest that a 3-month recall interval is generally superior to a 6-month interval for persons with severe mental illness.

Gender differences in the receipt of aftercare and psychiatric hospitalization among adults with severe mental illness

Gender differences in receiving aftercare and being hospitalized for persons with severe mental illness were examined. For women, unique predictors for receiving aftercare were primarily treatment system responsiveness variables. For men, unique predictors of aftercare were from all categories and included being accompanied to the psychiatric emergency room (PER) by family or friends and having previous psychiatric admissions. More recent outpatient treatment and a greater number of previous admissions predicted hospitalization for both men and women. Receiving less intense aftercare predicted hospitalization for women but not men. Unique predictors of hospitalization for men were a higher level of education and a psychotic disorder diagnosis.

Integrated Treatment for Homeless Clients With Dual Disorders: A Quasi-Experimental Evaluation

ABSTRACT The purpose of this study was to compare the effectiveness of four interventions in providing services to homeless clients with dual disorders: standard care (SC), assertive community treatment only (ACTO), integrated assertive community treatment (IACT), and new integrated assertive community treatment (NIACT). Participants had to be homeless, have a substance use disorder, and have a severe mental illness to be eligible for the study. One hundred ninety-six individuals were randomly assigned to SC, ACTO, or IACT. Approximately two years later, 85 participants were assigned to NIACT. A quasi-experimental design was employed to analyze the data. Clients in the NIACT program had better outcomes on consumer satisfaction than clients in the other conditions. Clients in NIACT, IACT, and ACTO groups had better housing outcomes than clients in SC. Clients in NIACT reduced their use of drugs more than clients in the other programs, but there was no difference between conditions on the other substance abuse variables. There was no difference between conditions on psychiatric symptoms. IACT may need to be augmented with other services to reduce substance use and produce better psychiatric outcomes for dual-disorder homeless individuals.