Winston M. Turner

Sex differences in olfactory identification and Wisconsin card sorting performance in schizophrenia: Relationship to attention and verbal ability

We investigated the hypothesis that different prefrontal brain systems (i.e., dorsal vs. ventral) and sex contribute differentially to cognitive deficit in schizophrenia. Performance was assessed among clinically stable, chronic schizophrenic outpatients and matched normal control subjects on olfactory identification [on the University of Pennsylvania Smell Identification Test (UPSIT)] and on executive functions [using the Wisconsin Card Sorting Test (WCST)]. Patients were impaired on both tests compared to controls, and male schizophrenics were impaired on the WCST compared to female schizophrenics. The pattern of results suggests that gender differences on the UPSIT are mildly accentuated in schizophrenia. The data support our previous study indicating that UPSIT performance is largely independent of the executive or attentional deficits typically associated with schizophrenia, with the exception of verbal ability. Further research with larger samples is required to test the hypothesis that there is a severely impaired subgroup of male patients with diffuse prefrontal dysfunctions.

Self-report and observer measures of substance abuse among homeless mentally ill persons in the cross-section and over time

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Feasibility of multidimensional substance abuse treatment matching: automating the ASAM Patient Placement Criteria

UNLABELLED The Patient Placement Criteria published by the American Society of Addiction Medicine (ASAM Criteria) established a non-proprietary standard for matching substance use disorder patients to treatment settings. METHODS Data from 593 substance dependent adults who were assessed using the first computerized implementation of the ASAM Criteria were analyzed to determine whether the level of care assignments showed significant differences on a variety of clinical measures. RESULTS The algorithm showed acceptable discrimination between each of three ASAM Levels of Care across numerous clinical subscales. CONCLUSIONS It is feasible to implement complex, multidimensional criteria for substance abuse treatment that may improve reliability and facilitate validity studies.

The effects of increasing resource demand on vigilance performance in adults with schizophrenia or developmental attentional/learning disorders: a preliminary study.

The goal of this study was to assess whether degree of information processing load differentially affects vigilance performance in patients with schizophrenia as compared to normal controls or patients with other attentional disorders. We contrasted the performance of clinically stable outpatients with schizophrenia (n = 18), with that of normal controls (n = 17), and adults with developmental attentional/learning disorders (n = 13) on simple and demanding versions of a visual continuous performance test (CPT). Patients with schizophrenia were significantly impaired on both versions of the CPT compared to normal controls, and showed a significant decline in perceptual sensitivity and significantly more omission errors with increased processing demands. Compared to adults with developmental attentional/learning disorders, patients with schizophrenia manifested a tendency toward a decline in perceptual sensitivity. There were no significant differences between groups on a measure of response bias. The data support the hypothesis that patients with schizophrenia have insufficient information processing resources to cope with higher processing demands on effortful attention tasks. Further study comparing schizophrenic patients with patients who have other neuropsychiatric disorders, controlling for severity of illness, is required to determine the specificity of this deficit in schizophrenia.

Neuropsychological Function in Homeless Mentally Ill Individuals

Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.

Why Do They Leave? Factors Associated With Job Termination Among Personal Assistant Workers in Home Care

Recruiting and retaining an adequate number of personal support workers in home care is both challenging and essential to allowing elders to age in place. A mixed-method, longitudinal study examined turnover in a sample of 261 personal support workers in Maine; 70 workers (26.8%) left their employment in the first year of the study. Logistic regression analysis indicated that younger age and lack of health insurance were significant predictors of turnover. Analysis of telephone interviews revealed three overarching themes related to termination: job not worthwhile, personal reasons, and burnout. Implications of study findings for gerontological social workers are outlined.

Predictive validity of the ASAM Patient Placement Criteria for hospital utilization.

SUMMARY We tested the validity of the ASAM Patient Placement Criteria (PPC) using the first complete and reliable computerized implementation of these criteria. Adult U.S. veterans (N = 95) seeking substance abuse treatment were blindly assessed for level of care need according to the PPC but were naturalistically assigned by counselors to residential rehabilitation (Level III) without knowledge of the PPC recommendation. Analyses compared subjects across three levels of recommended care, based on the algorithm, for utilization outcomes of VA hospital admissions and bed days of care. Subjects who were mismatched to lesser level of care than recommended utilized nearly twice as many hospital bed-days over the subsequent year (F (2;92) = 3.88; p < .05); this was unrelated to differential pre-assessment chronicity. The computerized algorithm is a promising new tool for facilitating field trials of the validity of the ASAM Criteria. A comprehensive implementation is an important methodologic requirement. These preliminary results support predictive validity for the ASAM Criteria, in that mismatching may be associated with excessive hospital utilization.

The severity index: An indicator of alcohol and drug dependence using administrative data

ABSTRACT Administrative data systems are a valuable resource for health care services research, especially in the assessment of treatment services for alcohol and drug dependence. However, clinical and diagnostic indicators are commonly not collected. The current report describes the development of a composite measure of substance abuse severity from items routinely recorded by publicly funded alcohol and drug abuse treatment services. Designed to capture varying patterns of substance use, the Severity Index can be readily calculated, interpreted and applied by health care providers as part of routine clinical care. To determine its validity, the performance of the Severity Index, was tested against the Addiction Severity Index (ASI), a well-researched measure of substance abuse severity.

Determining Service Variations Between and Within ASAM Levels of Care

SUMMARY The American Society of Addiction Medicine (ASAM) Criteria Validity Study at Massachusetts General Hospital and Harvard Medical School randomized patients between programs in two levels of care. It therefore became critical to determine the extent to which programs met ASAM level of care (LOC) descriptions. Quantitative surveys (checklist) and qualitative case studies (field observation, key informant interviews) documented care variation within and between two ASAM LOCs in 12 substance abuse treatment units. These LOCs were: Level II (Intensive Outpatient Treatment) and Level III (Medically Monitored Residential Treatment). The Level II and Level III programs, as a group, met ASAM LOC criteria, but data showed major within-level variation by hours per day and number and type of skilled treatment services. Observational data suggest considerable within-level variation due to managed care and staff training. In multi-site PPC validity studies, it will be crucial to examine within-LOC variation and take into account payment sources and staff training when assessing patient outcomes.

New constructs and assessments for relapse and continued use potential in the ASAM Patient Placement Criteria.

SUMMARY One area of intensive study in recent years in addiction research is the characterization and prediction of relapse risk. Given the growing list of findings and assessment tools in this area, in preparation for the second edition, revised volume of the Patient Placement Criteria (PPC) of the American Society of Addiction Medicine (ASAM), a workgroup of the Coalition for National Criteria was assigned the task of creating a revised conceptual organization for Dimension 5: Relapse/ Continued Use Potential. The workgroup conducted a review of the previous Dimension 5 constructs and criteria, including a decision analysis of the previous Dimension 5 decision rules. Following that analysis, field data from the ASAM Criteria Validity Study at Massachusetts General Hospital and Harvard Medical School were analyzed from a large cohort of public and indigent patients in eastern Massachusetts. After determining the concurrent validity of the Dimension 5 decision rules and their limitations, the decision rules were rewritten to gain improved validity. This exercise revealed techniques that can and should be used to improve the discrimination of levels of care among all Dimensions. Finally, the workgroup expanded and refined the constructs that should comprise a revised Dimension 5. This revised list of constructs is sequential and hierarchical. It offers face validity on several levels of current basic and clinical research knowledge: behavioral pharmacology, behavioral psychology, learning theory and psychopathology. While the Second Edition-Revised volume of the ASAM PPC (PPC-2R) does not go so far as to propose final decision rules for Dimension 5 based on these new constructs, it does recommend pilot adoption of several new assessment tools for this dimension and provides the framework incorporating those constructs and assessments in the next complete PPC edition.