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Results for “Psychosocial functioning”

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PubMed2003

Does cannabis use predict poor outcome for heroin-dependent patients on maintenance treatment? Past findings and more evidence against.

AIMS: To determine whether cannabinoid-positive urine specimens in heroin-dependent out-patients predict other drug use or impairments in psychosocial functioning, and whether such outcomes are better predicted by cannabis-use disorders than by cannabis use itself. DESIGN: Retrospective analyses of three clinical trials; each included a behavioral intervention (contingency management) for cocaine or heroin use during methadone maintenance. Trials lasted 25-29 weeks; follow-up evaluations occurred 3, 6 and 12 months post-treatment. For the present analyses, data were pooled across trials where appropriate. SETTING: Urban out-patient methadone clinic. PARTICIPANTS: Four hundred and eight polydrug abusers meeting methadone-maintenance criteria. MEASUREMENTS: Participants were categorized as non-users, occasional users or frequent users of cannabis based on thrice-weekly qualitative urinalyses. Cannabis-use disorders were assessed with the Diagnostic Interview Schedule III-R. Outcome measures included proportion of cocaine- and opiate-positive urines and the Addiction Severity Index (at intake and follow-ups). FINDINGS: Cannabis use was not associated with retention, use of cocaine or heroin, or any other outcome measure during or after treatment. Our analyses had a power of 0.95 to detect an r2 of 0.11 between cannabis use and heroin or cocaine use; the r2 we detected was less than 0.03 and non-significant. A previous finding, that cannabis use predicted lapse to heroin use in heroin-abstinent patients, did not replicate in our sample. However, cannabis-use disorders were associated weakly with psychosocial problems at post-treatment follow-up. CONCLUSIONS: Cannabinoid-positive urines need not be a major focus of clinical attention during treatment for opiate dependence, unless patients report symptoms of cannabis-use disorders.

Adult↗

PubMed1995

Oxandrolone therapy in constitutionally delayed growth and puberty. Bio-Technology General Corporation Cooperative Study Group.

BACKGROUND: Male adolescents with constitutional delay of growth and puberty may have significant psychosocial difficulties related to their sexual immaturity and short stature. The purpose of this study was to test the hypothesis that 1 year of oxandrolone therapy would increase growth velocity and thereby improve psychosocial functioning in boys with constitutional delay of growth and pubertal development. METHODS: Forty boys (ages 11 to 14.7 years) with delayed pubertal development and short stature were recruited from the pediatric endocrine clinics of 14 medical centers. The boys were randomized using a block design stratified for age to receive either oxandrolone (0.1 mg/kg daily for 1 year) or an identical-appearing placebo tablet, using a double-masked design. RESULTS: Growth velocity in the oxandrolone-treated boys was significantly greater than in the control boys (9.5 vs 6.8 cm/y). Likewise, the mean height SD score increased 0.41 in the oxandrolone group, whereas it decreased 0.03 in the control group. Those in the oxandrolone group gained 2.4 kg more than those in the placebo group. Mean predicted adult heights did not change in either group. The mean rates of pubertal progression were equivalent in both groups. Self-image (Piers-Harris Self Concept Scale) and social competence (Child Behavior Profile) were normal at baseline in both groups and did not change significantly over the course of the study in either group. No complications of oxandrolone therapy were identified. CONCLUSIONS: This randomized, placebo-controlled trial demonstrates that low-dose oxandrolone can increase both height and weight velocity in boys with delayed puberty safely. Under the conditions of this study, however, the increased growth velocity in the oxandrolone-treated boys was not associated with a greater improvement in psychosocial status compared with the control boys.

Adolescent↗

PubMed2005

The psychosocial impact of hair loss among men: a multinational European study.

OBJECTIVE: Hair plays an important role in determining self-image, social perceptions, and psychosocial functioning. The objectives of this survey were to identify the impact of hair loss on the self-image of men in five European countries and their level of concern about hair loss with regard to image and personal attractiveness. Moreover, we evaluated participants' use of treatments for hair loss and whether treatment success was associated with psychological benefit. RESEARCH DESIGN AND METHODS: A structured questionnaire of closed-ended questions was administered by telephone in major cities in Germany, France, Italy, Spain, and the United Kingdom. Random sampling was used, and eligible respondents were men from 18 to 45 years old. RESULTS: Of the 1536 men responding to the telephone survey, 729 (47%) reported hair loss; these men are the subject of this report. Over 70% of these men reported hair to be an important feature of image, and 62% agreed that hair loss could affect self-esteem. The realization that they were losing hair was linked to concern about losing an important part of personal attractiveness (43% of men), fear of becoming bald (42%), concern about getting older (37%), negative effects on social life (22%), and feelings of depression (21%). Reduced self-confidence in personal attractiveness was also reported by 38% of men who were not in stable romantic relationships. Less than 10% of men were currently pursuing treatment for hair loss, and three out of four had never pursued treatment for hair loss, either at present or in the past. Those few men who pursued treatment and reported success (n = 73) also reported psychosocial benefits as a result: from 43% to 59% experienced improvements in parameters of self-esteem and perception of personal attractiveness. Reliance on self-reporting of hair loss and use of nonvalidated instruments to measure psychological outcomes are important study limitations. CONCLUSIONS: The results of this survey indicate a gap between the need for treatment of hair loss and initiation of such treatment among men in five European countries. Further research is needed into the factors affecting men's willingness to seek treatment for hair loss.

Adolescent↗

PubMed2006

Evaluation of the ventricular assist device programme in the UK.

OBJECTIVES: To summarise the relevant clinical effectiveness and cost-effectiveness literature, to collect data on survival, transplantation rates, health-related quality of life (HRQoL) and resource use for ventricular assist device (VAD) and non-VAD transplant candidates in the UK, and to construct cost-effectiveness and cost-utility models of VADs in a UK context. Also to investigate the factors that drive costs and survival. DESIGN: A comprehensive systematic review was carried out. Data were collected from April 2002 to December 2004, with follow-up to March 2005. Cost-effectiveness and cost-utility models of VAD devices were developed based on UK activity and outcomes collected from April 2002 to March 2005. SETTING: National Specialist Commissioning Advisory Group funded VAD implantation was carried out at the Freeman, Harefield and Papworth transplant centres in the UK. PARTICIPANTS: Seventy patients were implanted with a VAD as a bridge to transplantation between April 2002 and December 2004. Non-VAD-supported transplant candidates (n = 250), listed at the three centres between April 2002 and December 2004, were divided into an inotrope-dependent group (n = 71) and a non-inotrope-dependent group (n = 179). Although patients in the inotrope-dependent group were closest to the VAD group they were less sick. The last group comprised a hypothetical worst case scenario, which assumed that all VAD patients would die in the intensive care unit (ICU) within 1 month without VAD technology. INTERVENTIONS: Patients were included who were implanted with a VAD designed for circulatory support for more than 30 days, with intention to bridge to transplantation. A multistate model of VAD and transplant activity was constructed; this was populated by data from the UK. MAIN OUTCOME MEASURES: Survival from VAD implant or from transplant listing for non-VAD patients to 31 March 2005. Serious adverse events and quality of life measures were used. Cognitive functioning was also assessed. Utility weights were derived from EuroQoL responses to estimate quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios (ICERs) were defined as the additional cost of VADs divided by additional QALYs. Time-horizons were 3 years, 10 years and the lifetime of the patients. RESULTS: Of 70 VAD patients, 30 (43%) died pretransplant, 31 (44%) underwent transplantation, and four (6%) recovered and had the VAD removed. Five patients (7%) were still supported for median of 279 days at the end of March 2005. Successful bridge-to-transplantation/recovery rates were consistent with published rates. Survival from VAD implantation was 74% at 30 days and 52% at 12 months. There were 320 non-fatal adverse events in 62 patients during 300 months of VAD support, mostly in the first month after implantation. Commonly observed events were bleeding, infection and respiratory dysfunction. Twenty-nine (41%) patients were discharged from hospital with a VAD. The 1-year survival post-transplantation was 84%. For the inotrope-dependent and non-inotrope-dependent transplant candidates, death rates while listed were 10% and 8% and the median waiting times were 16 and 87 days, respectively. For transplant recipients, 1-year survival was 85% and 84%, respectively. Both VAD and non-VAD patients demonstrated similar significant improvements in their New York Heart Association class after transplantation. All patients had poor EQ-5D pretransplantation; after transplantation the groups had similar EQ-5D of 0.76 irrespective of time after surgery. HRQoL was poor in the first month for VAD patients but better for those who waited longer in all groups. VAD patients reported more problems with sleep and rest and with ambulation in the first month. Symptom scores were similar in all groups pretransplant. After transplantation all groups showed a marked and similar improvement in physical and psychosocial function. Mean VAD implant cost, including device, was pound 63,830, with costs of VAD support for survivors of pound 21,696 in month 1 and pound 11,312 in month 2. Main cost drivers were device itself, staffing, ICU stay, hospital stay and events such as bleeding, stroke and infection. For the base case, extrapolating over the lifetime of the patients the mean cost for a VAD patient was pound 173,841, with mean survival of 5.63 years and mean QALYs of 3.27. Corresponding costs for inotrope-dependent patients were pound 130,905, with mean survival 8.62 years and mean QALYs 4.99. Since inotrope-dependent patients had lower costs and higher QALYs than VAD patients, this group is said to be dominant. Non-inotrope-dependent transplant candidates had similar survival rates to those on inotropes but lower costs, also dominant. Compared with the worst case scenario the mean lifetime ICER for VADs was pound 49,384 per QALY. In a range of sensitivity analyses this ranged from pound 35,121 if the device cost was zero to pound 49,384. Since neither inotrope-dependent transplant candidates nor the worst case scenario were considered fair controls the assumption was investigated that, without VAD technology, there would be a mixture of these situations. For mixtures considered the ICER for VADs ranged from pound 79,212 per QALY to the non-VAD group being both cheaper and more effective. CONCLUSIONS: There are insufficient data from either published studies or the current study to construct a fair comparison group for VADs. Overall survival of 52% is an excellent clinical achievement for those young patients with rapidly failing hearts. However, if the worst case scenario were plausible, and one could reliably extrapolate results to the lifetime of the patients, VADs would not be cost-effective at traditional thresholds. Further randomised controlled trials are required, using current second generation devices or subsequent devices and conducted in the UK.

Cost-Benefit Analysis↗

PubMed2004

Parent-training programmes for improving maternal psychosocial health.

BACKGROUND: Mental health problems are common and there is evidence to suggest that the origins of such problems lie in infancy and childhood. In particular, there is evidence from a range of studies to suggest that maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this in turn can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and elsewhere and evidence of their effectiveness in improving outcomes for children has been provided. Evidence is now required of their effectiveness in improving outcomes for mothers. OBJECTIVES: The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem. SEARCH STRATEGY: A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR). SELECTION CRITERIA: Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health. DATA COLLECTION AND ANALYSIS: A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings. MAIN RESULTS: A total of 23 studies were included in the original review which was increased to 26 at the first udate (2003). Of these 20 provided sufficient data to calculate effect sizes. The 20 studies provided a total of 64 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. Data sufficient to combine in a meta-analysis existed for only five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment). The results of the meta-analyses show statistically significant results favouring the intervention group for depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data showed no evidence of effectiveness. Of the remaining data that it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed non-significant differences favouring the intervention group. Approximately one-third of outcomes showed no evidence of effectiveness.A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression, and marital adjustment at follow-up, although the latter two findings were not statistically significant. This review has been updated (2003) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting 03) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting assessment and 2 ongoing studies listed for inclusion at a future update of this review. The size of effect for the main outcomes has not been substantially altered by this update. Additional sensitivity analyses to assess the impact of quasi randomised studies on the result have also been added. Where the quasi randomised studies are excluded from the analysis, the result was found to be slightly more conservative. REVIEWER'S CONCLUSIONS: It is suggested that parenting programmes can make a significant contribution to the short-term psychosocial health of mothers. However, there is currently a paucity of evidence concerning whether these results are maintained over time, and the limited follow-up data which are available show equivocal results. This points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Whilst the results of this review are positive overall, some studies showed no effect. Further research is needed to assess which factors contribute to successful outcomes in these programmes with particular attention being paid to the quality of delivery.These results suggest that parenting programmes have a potential role to play in the promotion of mental health.

Anxiety↗

PubMed2006

Associations between preschool attendance and developmental impairments in pre-school children in a six-year retrospective survey.

BACKGROUND: Many school-aged children suffer physical and mental impairments which can adversely affect their development and result in significant morbidity. A high proportion of children in western countries attend pre-school, and it is likely that the preschool environment influences the prevalence and severity of these impairments. Currently there is insufficient data available on the prevalence of these impairments and their causal associations. The influence that location of a pre-school and the duration of preschool attendance have on the prevalence of these impairments is not known. METHODS: In a retrospective survey spanning six years (1997-2002) we reviewed the records of 6,230 preschool children who had undergone routine school entry assessments. These children had been assessed utilising a modified manual of the "Bavarian Model" for school entry examinations. This model outlines specific criteria for impairments of motor, cognitive, behavioural and psychosocial functioning. Prevalence rates for physical and behavioural impairments were based on the results of these assessments. The relationship between the prevalence of impairments and the duration of preschool attendance and the location of the preschool attended was estimated utilizing logistic regression models. RESULTS: We found that 20.7% of children met the criteria for at least one type of impairment. Highest prevalence rates (11.5%) were seen for speech impairments and lowest (3.5%) for arithmetic impairments. Boys were disproportionately over represented, with 25.5% meeting the criteria for impairment, compared to 13.0% for girls. Children who had attended preschool for less than one year demonstrated higher rates of impairment (up to 19.1% for difficulties with memory, concentration or perseverance) compared to those who had attended for a longer duration (up to 11.6% for difficulties with pronunciation). Children attending preschool in an urban location had slightly elevated rates of impairment (up to 12.7%), compared to their rural counterparts (up to 11.1%). CONCLUSION: Our results demonstrate that there are high prevalence rates for physical and mental impairments among preschool children. Furthermore, children without preschool experience are a risk group for struggling with educational successes. The associations between the duration of preschool attendance and location of preschool attended and rates of impairment need replication and further exploration. Larger prospective studies are needed to examine if these relationships are causal and may therefore lend themselves to specific intervention strategies.

Age Distribution↗

PubMed1998

Impact of HIV on families of HIV-infected women who have recently given birth, Bangkok, Thailand.

The objective of this study was to assess changes in the family situation of HIV-infected women who have recently given birth. As part of a prospective perinatal HIV transmission study, interviews were conducted with a subset of HIV-infected women at 18 to 24 months postpartum, and answers were compared with baseline information obtained during pregnancy. Standardized scales were used to assess levels of psychosocial functioning. A convenience sample of 129 HIV-infected women enrolled during pregnancy was interviewed at 18 to 24 months postpartum. At delivery, the women were young (median age, 22 years), primiparous (57%), and asymptomatic (93%). When baseline and follow-up data were compared, more women were living alone (1% versus 6%; p = 0.03), fewer women were living with their partners (98% versus 73%; p < 0.001), and 30% of families had reduced incomes. At follow-up, 10% of partners had died, and more partners than wives had become ill or died (21% versus 4%; p = 0.02). Most children (78%) were living with their mothers, but only 57% of the HIV-infected women were the primary caretakers. Fewer women had disclosed their HIV status to others (e.g., family, friends) than to their partners (34% versus 84%; p < 0.001), largely because of fear of disclosure. The women appeared to have high levels of depression and worry. The women's greatest worries were about their children's health and the family's future. Within 2 years after childbirth, substantial change within the families of HIV-infected women was evident. These were manifest by partner illness or death, family separation, reduced family income, shifting responsibilities for child care, and signs of depression and isolation. Providing family support is a major challenge in Thailand as the perinatal HIV epidemic progresses.

Adult↗

PubMed2000

Functional activities and psychosocial factors in the rehabilitation of patients with low back pain.

A four-week rehabilitation programme for back patients, focusing on functional activities and psychosocial factors in the demands of work and daily living, was evaluated. The programme is a combination of training of functional activities and increased psychological knowledge, body awareness and coping. A total of 40 patients with lumbago or lumbago ischias participated in the program and were compared with a matched control group. The results showed that the patients had significantly more ergonomic and psychosocial problems in their working environment than did the controls. A significant reduction in ratings of low back pain was noted in patients compared with controls after rehabilitation. Increased functional ability and physical fitness were shown in the patient group after rehabilitation. Significantly more patients than controls returned to work after the rehabilitation.

Activities of Daily Living↗

PubMed1993

Psychosocial aspects of strabismus study.

OBJECTIVE: To assess the psychosocial implications of growing up with and living with socially noticeable strabismus. DESIGN: Self-report mailed questionnaire and the Hopkins Symptom Checklist. SETTING: Patients with strabismus who were seen at the University of California, Davis, Medical Center, Department of Ophthalmology, from 1976 to 1989. PARTICIPANTS: Forty-three female and male subjects aged 15 years or older who had a history of childhood strabismus that was uncorrected or incompletely corrected past the age of 13 years. INTERVENTION: None. MAIN OUTCOME MEASURES: Participants' responses to our survey and to the Hopkins Symptom Checklist. RESULTS: Strabismus had a negative impact on many aspects of our subjects' lives. They report difficulty with self-image, securing employment, interpersonal relationships, school, work, and sports. Furthermore, difficulties encountered did not go away after childhood, rather, the problems encountered by our subjects intensified in the teenage and adult years. Subjects demonstrated generalized higher levels of distress on the Hopkins Symptom Checklist than age- and sex-matched controls (P < .01). CONCLUSIONS: Psychosocial difficulties relating to socially noticeable strabismus are not just a problem for school-children but also for teenagers and adults. Correction of strabismus in the older teenager or adult may offer them improvement in psychosocial functioning, a benefit not previously reported in the literature.

Adolescent↗

PubMed2000

The health impact of chronic recurrent rhinosinusitis in children.

OBJECTIVES: To report and quantify the health-related quality of life of children who require surgical intervention for chronic recurrent rhinosinusitis and to assess the perspective of the child vs that of the parent. DESIGN: Prospective, observational. PATIENTS AND INTERVENTION: Twenty-one of a consecutive sample of 35 children undergoing endoscopic sinus surgery for infectious indications completed, along with their parents, the Child Health Questionnaire. The Child Health Questionnaire measures in parallel both child and parent perceptions of health by means of separate parent proxy report (Child Health Questionnaire-Parent Form 50) and child self-report (Child Health Questionnaire-Child Form 87) questionnaires concerning physical and psychosocial functioning. MAIN OUTCOME MEASURES: Tabulated scores from both the Child Health Questionnaire-Parent Form 50 and Child Health Questionnaire-Child Form 87 were compared with published data from age-matched normative populations and several pediatric chronic disease groups. RESULTS: Significant decrements in the general health of children with chronic recurrent rhinosinusitis compared with a normative sample were observed for both child- and parent-reported data, particularly in the physical domains. Children with rhinosinusitis were perceived by their parents to have significantly more bodily pain (P<.001)and to be more limited in their physical activities (P<.05)than children with asthma, juvenile rheumatoid arthritis, and other chronic disorders. Parent-child perceptions did vary, with parents reporting more pain and general behavioral effects relative to their children's reports in these areas. CONCLUSION: The health impact of chronic recurrent rhinosinusitis as reported by the subjective evaluations of pediatric patients and their parents is severe.

Adolescent↗

PubMed1997

Outcome for patients with bulimia and breast hypertrophy after reduction mammaplasty.

OBJECTIVES: To determine the outcome of patients with bulimia nervosa and symptomatic breast hypertrophy (macromastia) who had reduction mammaplasty and to identify factors that were associated with positive outcomes. DESIGN: Case series with semistructured, retrospective, personal interviews performed an average of 4 years after the procedure. SETTING: University hospital-based adolescent eating disorder program. PATIENTS: Five adolescent and young adult females who had been treated for bulimia nervosa and underwent reduction mammaplasty. OUTCOME MEASURES: Presurgical and postsurgical report of physical symptoms, body image and weight control habits, ability to exercise, psychosocial functioning and self-esteem. RESULTS: All patients experienced improvement in physical symptoms (pain and inframammary dermatitis), in their posture, and in their ability to find clothes that fit properly, to exercise, and to avoid embarrassment in social situations. Preoperative eating disorder habits were a dysfunctional attempt to achieve more "normal" body proportions; postoperatively, symptoms of an eating disorder were completely eliminated or greatly reduced. Factors related to favorable outcome included professional validation of patient's symptoms, realistic patient expectations from the surgical procedure, supportive family dynamics, and ongoing treatment for the eating disorder. CONCLUSION: This series of patients with bulimia nervosa and macromastia experienced significant improvement in symptoms related to their eating disorder and their breast hypertrophy following reduction mammaplasty.

Adolescent↗

PubMed1994

Minor depression in a cohort of young adults in Israel.

BACKGROUND: A diagnosis of minor depression was considered for DSM-IV. Mild depression is thought to be common in primary care settings and the community, but studies of the validity of minor depression as a separate diagnostic category are few. METHODS: Minor depression as defined by Research Diagnostic Criteria was assessed by psychiatrists using a modified Schedule for Affective Disorders and Schizophrenia-Lifetime version in a cohort of 5200 young adults in Israel. Subjects with year-prevalent minor depression were compared with subjects with major depression or generalized anxiety disorder and with controls on aspects of psychopathologic condition, psychosocial functioning, help-seeking behaviors, and demographic correlates. RESULTS: Symptomatically, minor depression appeared to be a mild version of major depression. Minor depression was associated with good teenage and general social functioning, but also with absence from work, separation or divorce, recent impairment in overall functioning, and help-seeking. CONCLUSIONS: The results lend support for including minor depression or expanding severity modifiers in future classifications to better capture the phenomenon of subthreshold depression.

Adult↗

PubMed1994

Awareness of illness in schizophrenia and schizoaffective and mood disorders.

BACKGROUND: The literature on insight, or self-awareness, in schizophrenia suggests that this cognitive dimension may be of nosological value. Poor insight has descriptive validity at the phenomenological and neuropsychological levels of schizophrenia and has prognostic validity in terms of the prediction of the course of illness. The lack of empirical data on the diagnostic specificity of poor insight to schizophrenia and the previous use of insight measures with questionable reliability and validity have limited this interpretation. METHODS: In the present study, we assessed insight into multiple aspects of mental disorder using a measure with demonstrated reliability and validity. A sample of 412 patients with psychotic and mood disorders coming from geographically diverse regions of the United States and one international site was studied. The main aims were to determine the prevalence of self-awareness deficits in patients in whom schizophrenia was diagnosed, to examine the relative severity of self-awareness deficits associated with schizophrenia compared with that of schizoaffective and mood disorders with and without psychosis, and to evaluate the clinical correlates of self-awareness in patients with schizophrenia. RESULTS: The results indicated that poor insight is a prevalent feature of schizophrenia. A variety of self-awareness deficits are more severe and pervasive in patients with schizophrenia than in patients with schizoaffective or major depressive disorders with or without psychosis and are associated with poorer psychosocial functioning. CONCLUSIONS: The results suggest that severe self-awareness deficits are a prevalent feature of schizophrenia, perhaps stemming from the neuropsychological dysfunction associated with the disorder, and are more common in schizophrenia than in other psychotic disorders.

Adaptation, Psychological↗

PubMed2003

Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities.

CONTEXT: Little is known about the prevalence and characteristics of chronic pain among patients with different types of chemical dependency. OBJECTIVES: To estimate the prevalence and to examine the characteristics of chronic severe pain in chemically dependent populations receiving methadone maintenance or inpatient residential treatment. DESIGN, SETTING, AND PARTICIPANTS: Representative samples of 390 patients from 2 methadone maintenance treatment programs (MMTPs) and 531 patients from 13 short-term residential substance abuse treatment (inpatient) programs, all in New York State, were surveyed in late 2000 and early 2001. MAIN OUTCOME MEASURE: Prevalence of chronic severe pain, defined as pain that persisted for more than 6 months and was of moderate to severe intensity or that significantly interfered with daily activities. RESULTS: Chronic severe pain was experienced by 37% of MMTP patients (95% confidence interval [CI], 32%-41%) and 24% of inpatients (95% CI, 20%-28%; P =.03). Pain of any type or duration during the past week was reported by 80% of MMTP patients and 78% of inpatients. Among those with chronic severe pain, 65% of MMTP patients and 48% of inpatients reported high levels of pain-related interference in physical and psychosocial functioning. Among MMTP patients, correlates of chronic pain in a multivariate model were age (odds ratio [OR], 2.08; 95% CI, 1.17-3.70), chronic illness (OR, 1.88; 95% CI, 1.07-3.29), lifetime psychiatric illness (OR, 1.77; 95% CI, 1.06-2.97), psychiatric distress (OR, 1.63; 95% CI, 1.22-2.18), and time in treatment (OR, 2.23; 95% CI, 1.06-4.68). Among inpatients, the correlates of chronic pain were race (blacks vs whites: OR, 0.52; 95% CI, 0.31-0.90; Hispanics vs whites: OR, 0.48; 95% CI, 0.24-0.95), drug craving (OR, 2.78; 95% CI, 1.54-5.02), chronic illness (OR, 2.17; 95% CI, 1.37-3.43), and psychiatric distress (OR, 1.36; 95% CI, 1.03-1.81). Among those with chronic severe pain, inpatients were significantly more likely than MMTP patients to have used illicit drugs, as well as alcohol, to treat their pain complaint (51% vs 34%, P =.005) but were less likely to have been prescribed pain medications (52% vs 67%, P =.01). CONCLUSIONS: Chronic severe pain is prevalent among patients in substance abuse treatment, especially MMTP patients. Pain is associated with functional impairment and correlates of pain vary with the population. Self-medication for pain with psychoactive drugs appears especially problematic among substance users who enroll in drug-free treatment programs. Substance abuse treatment programs need to develop comprehensive and structured pain management programs.

Adult↗

PubMed2003

Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond.

During the past decade, evidence from research on mood disorders has demonstrated that remission is the optimal outcome of treatment. However, there continues to be considerable variability in the specific characteristics that are accepted as indicators of remission. Increasing knowledge of mood disorders and their underlying mechanisms may allow for the development of a new diagnostic and assessment system that no longer is based solely on symptoms and other descriptive phenomena. Continued advances in neuroscience may allow for more knowledge of the underlying neurobiological status and more accurate assessments of the underlying disease state and response to treatment, thus enabling physicians to use treatments that will most effectively bring patients back to euthymia and a truly disease-free healthy state. Until then, remission should continue to be based on the descriptive and experiential phenomena of symptoms and psychosocial functioning.

Depression↗

PubMed2003

A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial.

CONTEXT: No randomized controlled studies have been conducted to date on the effectiveness of psychological interventions for children with symptoms of posttraumatic stress disorder (PTSD) that has resulted from personally witnessing or being personally exposed to violence. OBJECTIVE: To evaluate the effectiveness of a collaboratively designed school-based intervention for reducing children's symptoms of PTSD and depression that has resulted from exposure to violence. DESIGN: A randomized controlled trial conducted during the 2001-2002 academic year. SETTING AND PARTICIPANTS: Sixth-grade students at 2 large middle schools in Los Angeles who reported exposure to violence and had clinical levels of symptoms of PTSD. INTERVENTION: Students were randomly assigned to a 10-session standardized cognitive-behavioral therapy (the Cognitive-Behavioral Intervention for Trauma in Schools) early intervention group (n = 61) or to a wait-list delayed intervention comparison group (n = 65) conducted by trained school mental health clinicians. MAIN OUTCOME MEASURES: Students were assessed before the intervention and 3 months after the intervention on measures assessing child-reported symptoms of PTSD (Child PTSD Symptom Scale; range, 0-51 points) and depression (Child Depression Inventory; range, 0-52 points), parent-reported psychosocial dysfunction (Pediatric Symptom Checklist; range, 0-70 points), and teacher-reported classroom problems using the Teacher-Child Rating Scale (acting out, shyness/anxiousness, and learning problems; range of subscales, 6-30 points). RESULTS: Compared with the wait-list delayed intervention group (no intervention), after 3 months of intervention students who were randomly assigned to the early intervention group had significantly lower scores on symptoms of PTSD (8.9 vs 15.5, adjusted mean difference, - 7.0; 95% confidence interval [CI], - 10.8 to - 3.2), depression (9.4 vs 12.7, adjusted mean difference, - 3.4; 95% CI, - 6.5 to - 0.4), and psychosocial dysfunction (12.5 vs 16.5, adjusted mean difference, - 6.4; 95% CI, -10.4 to -2.3). Adjusted mean differences between the 2 groups at 3 months did not show significant differences for teacher-reported classroom problems in acting out (-1.0; 95% CI, -2.5 to 0.5), shyness/anxiousness (0.1; 95% CI, -1.5 to 1.7), and learning (-1.1, 95% CI, -2.9 to 0.8). At 6 months, after both groups had received the intervention, the differences between the 2 groups were not significantly different for symptoms of PTSD and depression; showed similar ratings for psychosocial function; and teachers did not report significant differences in classroom behaviors. CONCLUSION: A standardized 10-session cognitive-behavioral group intervention can significantly decrease symptoms of PTSD and depression in students who are exposed to violence and can be effectively delivered on school campuses by trained school-based mental health clinicians.

Child↗

PubMed2005

Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial.

CONTEXT: Observational studies have shown that psychosocial factors are associated with increased risk for cardiovascular morbidity and mortality, but the effects of behavioral interventions on psychosocial and medical end points remain uncertain. OBJECTIVE: To determine the effect of 2 behavioral programs, aerobic exercise training and stress management training, with routine medical care on psychosocial functioning and markers of cardiovascular risk. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial of 134 patients (92 male and 42 female; aged 40-84 years) with stable ischemic heart disease (IHD) and exercise-induced myocardial ischemia. Conducted from January 1999 to February 2003. INTERVENTIONS: Routine medical care (usual care); usual care plus supervised aerobic exercise training for 35 minutes 3 times per week for 16 weeks; usual care plus weekly 1.5-hour stress management training for 16 weeks. MAIN OUTCOME MEASURES: Self-reported measures of general distress (General Health Questionnaire [GHQ]) and depression (Beck Depression Inventory [BDI]); left ventricular ejection fraction (LVEF) and wall motion abnormalities (WMA); flow-mediated dilation; and cardiac autonomic control (heart rate variability during deep breathing and baroreflex sensitivity). RESULTS: Patients in the exercise and stress management groups had lower mean (SE) BDI scores (exercise: 8.2 [0.6]; stress management: 8.2 [0.6]) vs usual care (10.1 [0.6]; P = .02); reduced distress by GHQ scores (exercise: 56.3 [0.9]; stress management: 56.8 [0.9]) vs usual care (53.6 [0.9]; P = .02); and smaller reductions in LVEF during mental stress testing (exercise: -0.54% [0.44%]; stress management: -0.34% [0.45%]) vs usual care (-1.69% [0.46%]; P = .03). Exercise and stress management were associated with lower mean (SE) WMA rating scores (exercise: 0.20 [0.07]; stress management: 0.10 [0.07]) in a subset of patients with significant stress-induced WMA at baseline vs usual care (0.36 [0.07]; P = .02). Patients in the exercise and stress management groups had greater mean (SE) improvements in flow-mediated dilation (exercise: mean [SD], 5.6% [0.45%]; stress management: 5.2% [0.47%]) vs usual care patients (4.1% [0.48%]; P = .03). In a subgroup, those receiving stress management showed improved mean (SE) baroreflex sensitivity (8.2 [0.8] ms/mm Hg) vs usual care (5.1 [0.9] ms/mm Hg; P = .02) and significant increases in heart rate variability (193.7 [19.6] ms) vs usual care (132.1 [21.5] ms; P = .04). CONCLUSION: For patients with stable IHD, exercise and stress management training reduced emotional distress and improved markers of cardiovascular risk more than usual medical care alone.

Adult↗

PubMed1999

Agenesis of the penis: patterns of associated malformations.

Agenesis of the penis is a rare malformation that occurs in otherwise normal males or together with other anomalies. In this article, we document unusual patterns of malformations in four such infants and analyze the nature and incidence of defects in 57 cases by clinical evaluation and numerical classification techniques. Although patients with this condition previously have been divided into groups based on the position of the urethral meatus in relation to the anus (presphincteric, postsphincteric, urethral atresia), our analyses suggest that most cases can be classified into either a severe form (16%) with renal aplasia or dysplasia and other caudal anomalies or a second group (72%) with low mortality and fewer additional malformations. The remaining cases in our group represented unique patterns stemming from a variety of causes, including etretinate embryopathy and the human homologue of the disorganization mutation. Agenesis of the penis occurs as a consequence of single gene disorders, teratogenic effects, or malformation sequences and associations and in unrecognized patterns of anomalies. It thus should be considered a developmental field defect. Its concurrence with scrotal hypoplasia, absent raphe, and anal anomalies implies a major disturbance of the caudal mesoderm. In such cases, severe renal defects are usually seen, and the prognosis is poor. When the patient has a patent urethra and normal scrotum, raphe, and testes, however, penile agenesis may be a localized malformation of the genital tubercle potentially related to penoscrotal transposition, a phylogenetic anomaly that is the normal genital arrangement in male marsupials, rabbits, and certain other mammals. Infants with isolated penile agenesis have generally done well. In the past, many were not treated; however, current recommendations are to use appropriate surgical and endocrine techniques to reassign female gender and enhance sexual and psychosocial functioning, though this approach is the subject of controversy.

Child, Preschool↗