Showing papers in "Psychiatric Services in 1997"

A consumer-constructed scale to measure empowerment among users of mental health services

Abstract: Objective A scale to measure the personal construct of empowerment as defined by consumers of mental health services was developed and field tested. Methods After extensive development, pilot testing, and analyses, a 28-item scale to measure empowerment was tested on 271 members of six self-help programs in six states. Factor analyses were used to identify the underlying dimensions of empowerment. To establish the scale's reliability and validity, responses were factor analyzed, and other analyses were conducted. Results Analyses revealed five factors: self-efficacy-self-esteem, power-powerlessness, community activism, righteous anger, and optimism-control over the future. Empowerment was related to quality of life and income but not to the demographic variables of age, gender, ethnicity, marital status, education level, or employment status. Empowerment was inversely related to use of traditional mental health services and positively related to community activism. Conclusions The findings set a framework for a clearer understanding of the imprecise and overused concept of empowerment. The scale demonstrated adequate internal consistency and some evidence for validity. Further testing must be done to establish whether it has discriminant validity and is sensitive to change.

The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions.

Abstract: Objective The feasibility, reliability, and validity of a new instrument, the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), which was developed for use by clinicians, was tested. The instrument assesses patients' competence to make treatment decisions by examining their capacities in four areas--understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice. Method The MacCAT-T and instruments to measure symptom severity were administered to 40 patients recently hospitalized with schizophrenia or schizoaffective disorder and 40 matched subjects in the community without mental illness. Results A high degree of ease of use and interrater reliability was found for the MacCAT-T. Overall, the hospitalized patients performed significantly more poorly than the community subjects on understanding and reasoning, although many patients performed as well as community subjects. Poor performance was related to higher levels of some psychiatric symptoms, such as conceptual disorganization, hallucinations, and disorientation. Conclusions The MacCAT-T offers a flexible yet structured method with which caregivers can assess, rate, and report patients' abilities relevant for evaluating competence to consent to treatment.

An update on supported employment for people with severe mental illness.

Abstract: Objective This review examines the effectiveness of supported employment for people with severe mental illness Methods A comprehensive search was made for quantitative studies, primarily in the published literature Results Seven descriptive studies, three surveys, one quasi-experimental study, and six experimental studies were found All studies suggested significant gains in obtaining employment for persons enrolled in supported employment programs In experimental studies, a mean of 58 percent of clients in supported employment programs achieved competitive employment, compared with 21 percent for control subjects, who typically received traditional vocational services Employment outcomes relating to time employed and employment earnings also favored clients in supported employment over control subjects No evidence was found that supported employment led to stress levels precipitating higher rehospitalization rates Two features of many supported employment programs have the most empirical support: integration of mental health and vocational services within a single service team and the avoidance of preplacement training Two other widely held principles-ongoing support and attention to client preferences-have not been systematically evaluated Conclusions Supported employment appears to be a promising approach for people with severe mental illness, but more studies are needed, with close attention to program implementation and long-term follow-up

Homelessness, severe mental illness, and the institutional circuit.

Abstract: Objective: Research on homelessness among persons with severe mental illness tends to focus on aspects of demand, such as risk factors or structural and economic forces. The authors address the complementary role of supply factors, arguing that “solutions” to residential instability-typically, a series of institutional placements alternating with shelter stays-effectively perpetuate homelessness among some persons with severe mental illness. Methods: Thirty-six consecutive applicants for shelter in Westchester County, New York, in the first half of 1995 who were judged to be severely mentally ill by intake workers were interviewed using a modified life chart format. Detailed narrative histories were constructed and reviewed with the subjects. Results: Twenty of the 36 subjects had spent a mean of 59 percent of the last five years in institutions and shelters. Analysis of the residential histories of the 36 subjects revealed that shelters functioned in four distinctive ways in their lives: as part of a more extended institutional circuit, as a temporary source of fransitional housing, as a surrogate for exhausted support from kin, and as a haphazard resource in essentially nomadic lives. The first pattern dominated in this group. Conclusions: Shelters and other custodial institutions have acquired hybrid functions that effectively substitute for more stable and appropriate housing for some persons with severe mental illness. (Psychiatric Services 48:659-665, 1997)

Risk appraisal and management of violent behavior

Abstract: OBJECTIVE: To help clinicians enhance the safety of the public, hospital staff, and patients and improve patient management, this article briefly reviews recent empirical work on appraisal of the risk of violence and the management of violent individuals. METHODS: Research on the prediction, management, and treatment of violent persons published in the last decade was reviewed. RESULTS: Risk appraisal research indicates that violence is predictable in some populations. The factors most highly and consistently related to risk are historical, including age, sex, past antisocial and violent conduct, psychopathy, aggressive childhood behavior, and substance abuse. Major mental disorder and psychiatric disturbance are poor predictors of violence. Actuarial methods are more accurate in predicting risk than unaided clinical judgment, which is a poor index. The Violence Risk Appraisal Guide has been shown to be a reliable and accurate actuarial instrument. Well-controlled studies have shown the effectiveness of behavior therapy and of behavioral staff training programs to reduce violence by persons in institutions, chronic psychiatric patients, and other populations. Otherwise, little is known about what psychotherapeutic or pharmacological treatments reduce violent recidivism by which clients under what circumstances. Recent work on the neurophysiology of aggression holds exciting promise but does not yet provide a scientific basis for prescriptive treatment. CONCLUSIONS: The most exciting and promising avenues for research on the management of violence lie in the joining of two scientific paths to understanding violence--biology and psychology. Language: en

Assessment of the quality of life of patients with major depression.

Abstract: Objective This study examined the relationship between a measure of quality of life and measures of depressive symptoms among patients with major depression. Methods One hundred patients with primary major depression and 61 control subjects from the San Diego Veterans Affairs Medical Center and surrounding area were compared using a variety of measures, including the Quality of Well-Being (QWB) scale, the Hamilton Rating Scale for Depression, and the Beck Depression Inventory. Results After analyses controlled for age, gender, family history of mental illness, and comorbid axis III diagnosis, subjects' scores on the QWB were significantly correlated with their scores on the Hamilton scale and Beck inventory. The severity of depressive symptoms was inversely related to quality of life as measured by the QWB, independent of the variables that were controlled for. Conclusions The QWB is sensitive to symptoms of depression among patients diagnosed with major depression. The reduction in quality of life associated with psychiatric symptoms of depression is comparable to that observed among physically ill patients.

Gifted Children: Myths and Realities

Abstract: PSYCHIA1’RIC SERVICES . December 1997 Vol. 48 No. 12 1605 scription of the “good patient.” His list included “to be dull, harmless, and inconspicuous; to evade responsibility, minimize stress, ignore othens, to retain the right to behave unpredictably, and to have a certain ‘diplomatic immunity.’ “ With such long-term patients, it has always been difficult to determine if the reasons for lack of significant improvement or recovery are due to “the residual effects of the illness or institutionalization, socialization in the patient role, lack of rehabilitation, reduced economic opportunities, reduced social status, side-effects ofrnedication, lack of staff expectations, or loss of hope” (4). These questions remain unanswered by the Iowa team. It should be noted that the viewpoint that these authors reflect stems from 100 years ofbeliefs in the field of psychiatry about poor outcdrne in schizophrenia and better outcome in affective disorders. Further, their cxperience with outcome of psychosis, before “effective treatment,” has reinforced their entire epistemological outlook of the possibilities. Such cxpenience colors and shapes a very pessimistic view of the range of outcomes possible for these patients. Therefore, readers need to remernben that the entire slant of the book, and the interpretation ofthc data, discounts the newer eras of atypical antipsychotics, rehabilitation, peer and family movements, assertive community cane, and integrated systems. Nevertheless, the book represents a significant historical documentation that advanced our understanding of these disorders at the time the study occurred.

Lack of insight among outpatients with schizophrenia.

Abstract: Objective This study investigated the prevalence of lack of insight among outpatients with schizophrenia and the relationship between lack of insight and other variables, including whether patients received professional residential supervision Methods A total of 87 stable outpatients with schizophrenia were drawn from community programs in a public-private mental health system Subjects' clinical symptoms and insight about their illness were assessed using the Positive and Negative Syndrome Scale, a battery of neuropsychological tests, and the Social Functioning Scale Results The illness insight of 43 subjects, or 495 percent, was at least moderately impaired Twenty-one subjects, or 25 percent, had severe insight deficits In a multiple regression analysis, 40 percent of the variance in lack of insight was predicted by ratings of the severity of delusions, difficulty with abstract thinking, lack of social activities, and absence of anxiety Patients who received professional residential supervision had more impaired insight than those living independently or with family Conclusions Insight deficits are common among stable outpatients engaged in community-based care These deficits have implications for patients' use of limited services such as residential supervision

Homeless mentally ill clients' and providers' perceptions of service needs and clients' use of services.

Abstract: Objective: Clients’ and providers’ perceptions of clients’ needs were compared in 18 community treatment programs participating in the Access to Community Care and Effective Services and Supports program of the Center for Mental Health Services, a national demonstration project on treatment of homeless persons with mental illness. The study sought to determine whether perceptions differed and whether assessed needs for services were related to service use. Methods: A total of 1,482 clients contacted through community outreach who entered the case management phase of the program after an average of 32 days were given an evaluation interview at entry into the program. The clients and outreach workers identified clients’ needs in seven core domains-mental health, general health, substance abuse, public financial support, housing assistance and support, dental care, and employment. Use of related services in the 60 days before the case management evaluation was determined. Results: The greatest differences between clients’ and providers’ perceptions of service needs were in dental and medical services, which were more frequently identified as needs by clients, and in substance abuse and mental health services, which were more frequently identified by providers. Clients’ and providers’ assessments of need were significantly, but not strongly, correlated with each other, and both were correlated with use of mental health and substance abuse services. Conclusions: Mental health service providers are less likely than clients to identify needs for services other than mental health services. Service use, at least in the short run, is related to both clients’ and providers’ assessments of need. (Psychiatric Services 48:381-386, 1997)

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports.

Abstract: The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.

An experimental comparison of three types of case management for homeless mentally ill persons.

Abstract: Objective Three types of case management were compared to determine their relative effectiveness in helping people with severe mental illness who were homeless or at risk of homelessness. Methods Subjects recruited from a psychiatric emergency room and inpatient units were randomly assigned to one of the three treatment conditions: broker case management, in which the client's needs were assessed, services were purchased from multiple providers, and the client was monitored; assertive community treatment only, in which comprehensive services were provided for an unlimited period; and assertive community treatment augmented by support from community workers, who assisted with activities of daily living and were available for leisure activities. Of 165 subjects recruited, 135 were followed for 18 months. Results Compared with clients assigned to broker case management, clients assigned to assertive community treatment only and assertive community treatment with community workers had superior outcomes on several variables. They were number of contacts with the assigned treatment program, resource utilization (for example, use of entitlements), severity of thought disorder, activity level, and client satisfaction. Clients in the assertive community treatment only condition achieved more days in stable housing than those in the other two treatment conditions. No significant treatment group effects were found on income, self-esteem, or substance abuse. Conclusions Assertive community treatment is superior to broker case management in assisting individuals with serious mental illness who are at risk of homelessness.

Influence of patient and hospital factors on consumer satisfaction with inpatient mental health treatment.

Abstract: OBJECTIVE This study examines patient- and facility-related determinants of satisfaction with inpatient mental health services. METHODS A random sample of veterans discharged from Department of Veterans Affairs inpatient units with primary diagnoses of a psychiatric or substance use disorder (N = 13,574) were mailed a 73-item questionnaire that addressed aspects of their recent hospital experience. Multiple regression analysis was used to evaluate the relationship between patient and hospital characteristics and both the likelihood of responding to the survey and aspects of satisfaction measured by 14 subscales. RESULTS A total of 4,968 veterans, or 37 percent, mailed back responses to the questionnaire. Respondents were older than nonrespondents and were more likely to be white and married and to have nonpsychotic disorders other than substance use disorders. The strongest and most consistent predictors of satisfaction were older age and better self-reported health. Longer length of stay was also associated with greater satisfaction on a majority of subscales. Findings among female and minority veterans were mixed across measures. Large facilities and facilities that specialize in mental health treatment had lower levels of satisfaction than others. Patient characteristics accounted for more of the variance in satisfaction than did facility characteristics. CONCLUSIONS Older and healthier patients reported greater satisfaction with mental health care services. Accurate comparison of patient satisfaction between facilities requires that adjustments be made for differences in patient characteristics. Large facilities may need to make special efforts to personalize their services.

Ethnic and racial differences in perceptions of dangerousness of persons with mental illness

Abstract: Ethnic and racial differences in the stigma associated with mental illness in the general population were examined through secondary analysis of data from a survey of a nationally representative sample (N = 1,468) on attitudes toward homeless and homeless mentally ill people. American Indian (1 percent of the sample), Asian-Pacific Islander (1.5 percent), black (10 percent), and Hispanic respondents (4 percent) were compared with white respondents (82 percent) to determine if the groups differed in their perception of the dangerousness of mental patients and if contact with mentally ill persons moderated ethnic and racial differences in perceptions of dangerousness. Asian and Hispanic respondents perceived mental patients as significantly more dangerous than did white respondents. Increased contact with mentally ill people was associated with lower levels of perceived dangerousness among white respondents but not among black respondents.

Early-onset substance abuse and community violence by outpatients with chronic mental illness.

Abstract: OBJECTIVE: This study examined the relationship between violence and substance abuse among patients with chronic mental illness living in the community METHODS: All referrals over a one-year period to an urban assertive community treatment team were evaluated systematically with a standardized intake protocol Thirty-seven patients with a history of violence in the community were compared with 27 patients without such a history on a variety of clinical and demographic variables RESULTS: More than half of the patients (58 percent) had a history of violence in the community The only significant differences between those with a history of violence and those without involved alcohol or drug use The single best predictor of violence was the onset of alcohol or drug abuse in late childhood or early adolescence CONCLUSIONS: In this sample, very early onset of substance abuse among people who developed mental illness was associated with the greatest risk of community violence Thus at least some of the causal determinants of violence in this sample may precede the onset of adult mental illness Language: en

Comparative outcomes of emotionally disturbed children and adolescents in a system of services and usual care.

Abstract: Objective This study compared six-month functional and symptom outcomes of children and adolescents with serious emotional disturbance who received services in an exemplary system of care with outcomes of children who received traditional care. The system of care offers a comprehensive and coordinated network of mental health and other necessary services. Methods The study used a randomized longitudinal experimental design. Baseline data on symptoms, functioning, and family characteristics were collected from 350 families selected from among those who sought services for children from community agencies in Stark County, Ohio. The families were randomly assigned to either the experimental group, which received services from the system of care, or the control group, which received usual care in the community. Six-month outcome measures of children's symptoms and functioning were compared for the two groups. Results Although access to care and the amount of care received increased under the system of care, no differences in clinical or functional outcomes were found between the group served in the system of care and the group who received usual care. Conclusions The effects of systems of care are primarily limited to system-level outcomes such as access to and cost of care and do not appear to affect clinical outcomes such as functioning and symptoms.

Clinicians' referral and matching of substance abuse patients to self-help groups after treatment.

Abstract: OBJECTIVE The clinical practice guidelines for substance use disorders from the American Psychiatric Association (APA) recommend referral of some patients to self-help groups. The purpose of this study was to determine current patterns of referral to self-help groups in substance abuse treatment programs in the United States and compare them with referral recommendations in APA guidelines. METHODS Directors of all 389 substance abuse treatment programs in the Department of Veterans Affairs health care system completed a mailed survey on posttreatment self-help referral practices. RESULTS Survey responses indicated that a large proportion of substance abuse patients were referred to Alcoholics Anonymous (79.4 percent), with other self-help organizations receiving a smaller but significant number of referrals. Referrals to 12-step self-help organizations were more common in programs that endorsed a 12-step treatment orientation and that employed a higher proportion of staff members in recovery from substance use disorders. Consistent with APA practice guidelines, clinicians were less likely to make a referral to a 12-step self-help group if a patient was an atheist, had a comorbid psychiatric disorder, or had less severe substance abuse problems. In deciding whom to refer to self-help groups, clinicians also considered other variables that are not addressed in current practice guidelines, such as age and previous involvement in 12-step groups. CONCLUSIONS Clinicians make extensive use of self-help groups for their patients, as recommended in APA practice guidelines. However, some differences between current practice and recommended practice warrant further investigation.

Housing outcomes for homeless adults with mental illness: results from the second-round McKinney program.

Abstract: In the early 1990s the National Institute of Mental Health sponsored projects in four cities that served a total of 896 homeless mentally ill adults Each project tested the effectiveness of different housing, support, and rehabilitative services in reducing homelessness Most homeless individuals resided in community housing after the intervention The proportion in community housing varied between sites A 475 percent increase in community housing was found for those in active treatment conditions At final follow-up, 78 percent of participants in community housing were stably housed The findings indicate that effective strategies are available for serving homeless individuals with severe mental illness

Psychiatric patients' attitudes about medication and factors affecting noncompliance.

Abstract: OBJECTIVE: Attitudes about medication and factors affecting medication compliance were investigated in a sample of 148 psychiatric patients. METHODS: Structured interviews assessed attitudes about medication, history of compliance, and other relevant clinical and psychosocial variables. RESULTS: Eighty-seven subjects expressed positive attitudes about medication in general. Forty believed that their illness was biologically or chemically based. A large proportion attributed their illness to situational factors, including stress (36 subjects) and family problems (18 subjects). Fifty-one subjects said that they required medications to get better. Approximately half of the subjects previously either changed their medication regimen or discontinued their medication. Opposition to the idea of taking medication, belief that the medication did not work, and physical side effects were the most frequent reasons for stopping. Previous patient-initiated changes in the medication regimen, education level, and inpatient or outpatient status were the only variables associated with noncompliance. CONCLUSIONS: The findings suggest that several relevant clinical, demographic, and attitudinal variables may not be associated with medication compliance.

Dispelling the stigma of schizophrenia

Abstract: Introduction by the column editors: The current political controversy over parity for insurance coverage of mental disorders is a consequence of the long-standing stigma against mental illness, its treatments, and the professionals who provide the treatments. Psychiatrists have traditionally been viewed by their colleagues in other fields of medicine as lacking the full credentials and abilities of other practicing physicians. Psychiatric disorders have been caught up in the “mind” segment of the “mindbody” dualism still subscribed to by most citizens, many physicians, and even many in the mental health field itself. Few policy makers and legislators, and even few mental health providers, are aware that the success rate of many modern biobehavioral treatments for major mental disorders surpasses that of treatments for heart disease, cancer, and diseases of the kidneys, liver, and lungs. In this month’s Rehab Rounds column, Samatha Kommana and her colleagues conceptualize stigma from a social-psychological perspective and describe several methods for attacking stigma that are based on principles of social psychology. One such method-the media campaign-has been shown in controlled multisite studies to be effective in reducing risk for cardiovas-

A survey on issues in the lives of women with severe mental illness.

Abstract: OBJECTIVE: Women with severe mental illness were surveyed to explore issues in living with mental illness, personal relationships, and professional relationships and health care. The topics were drawn from the literature on the psychology of women and from separate focus groups of therapists and mental health care consumers. The women's survey responses were compared with men's responses to an equivalent survey to determine if the issues affected women and men similarly. METHODS: A 76-item questionnaire was completed by 107 women and 59 men from ten rehabilitation centers in Maryland. RESULTS: A larger proportion of women than men cited personal relationships as their most important formative experiences, with only 32 percent of women citing severe mental illness or related issues as formative experiences. Despite acknowledging the negative impact of several mental illness on their lives, most respondents reported normal concerns rather than illness-related ones, and most were relatively satisfied with their lives. Respondents made sense of their problems in diverse ways, although most knew their diagnosis. Women reported both more and better quality personal relationships than men. However, women were more likely than men to report a history of sexual abuse. Women reported generally good relationships with providers. About one-quarter to one-third of women reported not receiving proper care for birth control and menopause and not receiving pelvic or breast examinations. CONCLUSIONS: The survey results suggested that personal relationships are central in women's lives, that women with severe mental illness do not see their mental illness as the main feature of their identities, and that women's experience of living with severe mental illness is considerably different from that of men. Language: en

Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence

Abstract: Objective The study investigated whether contingency management could reduce cocaine use by patients with schizophrenia. Methods An A-B-A research design, with two-month baseline, intervention, and follow-up phases, was used to study two homeless, treatment-resistant male outpatients with DSM-III-R diagnoses of schizophrenia and cocaine dependence. During the intervention phase, subjects provided daily urine specimens for testing for the cocaine metabolite benzoylecgonine (BE) and received $25 for each negative test. Concentrations of BE and metabolites of other illicit drugs were assayed twice a week to determine the amount of drug use in addition to frequency. Analysis of variance was used to compare drug use during the three study phases. Results During the intervention, the proportion of tests positive for cocaine was lower for both subjects. Mean urinary concentrations of BE were significantly lower during the intervention than during the baseline. Conclusions These results suggest that modest monetary reinforcement of abstinence may decrease cocaine use among cocaine-dependent patients with schizophrenia.

Savings from a Medicaid carve-out for mental health and substance abuse services in Massachusetts.

Abstract: Objective: The study examined the financial performance of a managed behavioral health care organization responsible for mental health and substance abuse services under the Massachusetts Medicaid program. Financial performance is considered in light of incentives in the contract between the managed care firm and Medicaid. Methods: Data on the financial performance of the managed care organization were obtained from documents related to a recent rebidding of the contract and other publicly available documents. Financial incentives associated with claims costs and administrative services are also reported. Results: Spending by the managed care organization was about 25 percent lower than projected expenditures adjusted for inflation. Explicit financial incentives associated with cost reduction did not give the managed care organization strong inducements to attain these sayings. The profit and loss features based on cost targets were quite limited. The organization had a much greater incentive and opportunity to make profits by conserving its administrative costs rather than by controlling Medicaid claims costs. Conclusions: In light of the contract’s weak cost-saving incentives, it may be surprising that so much was saved. One explanation is that it was easy to achieve such savings in a state with high expenditures. However, in examining the particular amounts saved, it is clear that the organization came close to contract targets even when incentives to achieve them were weak. The authors label this behavior “managing to the contract” and discuss some reasons why a managed care organization might behave in this way and the implications this behavior has for contract design. (Psychiatric Services tracts. In these contracts, the managed behavioral health firm enjoys some profit or bears some loss depending on how costs compare with the negotiated target in the contract. In private insurance, carve-out firms have a disproportionately large representation in plans purchased by large employers. Umland (2) reported that 35 percent of employers with 5,000 or more employees had contracts with a managed behavioral health care vendor, whereas only 3 percent of fIrms with fewer than 500 employees did so. Fourteen state employee health plans have adopted managed behavioral health carve-out arrangements. State Medicaid programs have also been making use of the carve-out form oforganization for managing mental health and substance abuse care. By the end of 1995, a total of 12 states had adopted some form of managed behavioral health carve-out program for their

Housing status among formerly homeless dually diagnosed adults.

Abstract: Objective Residential outcomes of homeless adults with severe mental illness and a substance use disorder were studied over 18 months during which participants received integrated dual diagnosis services and housing supports based on a continuum model. Methods Interviews with 158 participants at baseline and at six-, 12-, and 18-month follow-ups assessed housing status, residential history, substance abuse and progress toward recovery, psychiatric symptoms, and quality of life. Complete data were available for 122 participants. If participants lived continuously in high-quality housing with no housing loss or nights of homelessness during the final six months of the study, they were classified as having stable housing. Results Of the 122 participants for whom complete data were available, 64 (52 percent) achieved stable housing. Most participants who achieved stable housing first entered staffed and supervised housing and then moved to independent arrangements by the end of the study. Stable housing during the final evaluation period was associated with lower substance use, greater progress toward substance abuse recovery, and higher quality of life. Final housing status was not predicted by baseline variables but was predicted by progress toward recovery during months 0 to 6 and 6 to 12 and by less severe drug use during months 6 to 12. Participants who abused no illicit drugs during months 6 to 12 were almost three times as likely to achieve stable housing as those who abused illicit drugs. Conclusions Housing stability is strongly mediated by substance abuse and progress toward recovery. Nevertheless, when formerly homeless persons with dual diagnoses are provided integrated dual diagnosis treatment, they can gradually achieve stable housing.

Consumer satisfaction with telemedicine child psychiatry consultation in rural Kentucky.

Abstract: Forty-three rural Kentucky families who obtained child psychiatry consultation during the initial eight months of the University of Kentucky's telemedicine program completed questionnaires assessing their satisfaction with telemedicine. Respondents were 46 parents and nine children. All respondents reported that they were very satisfied with the consultation; all of the children and 98 percent of the parents reported that they were as satisfied with the telemedicine consultation as with an in-person visit. Few respondents reported nervousness about using the equipment. These results suggest that child psychiatry consultation via telemedicine provides high levels of satisfaction for both children and adults.