RESUMEN
OBJECTIVE: To describe the implementation of a nationwide program to monitor the quality of treatment for substance use disorders in the Department of Veterans Affairs, and to examine how the provision of outpatient mental health care, and the duration and intensity of care, relate to patients' outcomes. METHOD: Clinicians completed a baseline Addiction Severity Index (ASI) on more than 34,000 patients with substance use disorders; more than 21,000 (63%) were reassessed with the ASI an average of 12 months later. Nationwide health service utilization databases were used to obtain information about patients' diagnoses and their use of services during an index episode of care. RESULTS: On average, patients who received specialty outpatient mental health care experienced better risk-adjusted outcomes than did patients who did not receive such care. Patients who had longer index episodes of mental health care improved more than did those who had shorter episodes. There was some evidence that the duration of care contributed more to better outcomes among patients with only substance use disorders, whereas the intensity of care was more important for patients with both substance use and psychiatric disorders. CONCLUSIONS: The provision of specialty outpatient mental health care, and longer episodes of specialty care, were associated with better risk-adjusted substance use, symptom and social functioning outcomes for patients with substance use disorders. More emphasis should be placed on ensuring that these patients enter specialty care and on keeping them in treatment.
Asunto(s)
Medicina/normas , Servicios de Salud Mental/normas , Calidad de la Atención de Salud , Especialización , Trastornos Relacionados con Sustancias/terapia , Adulto , Atención Ambulatoria/normas , California , Femenino , Humanos , Masculino , Servicios de Salud Mental/organización & administración , Resultado del TratamientoRESUMEN
PURPOSE: To examine characteristics of youth homelessness associated with engaging in risk behaviors for human immunodeficiency virus (HIV). METHODS: The sample included 288 currently homeless or runaway Washington, DC youth aged 14-21 years. Measures were self-reported homelessness characteristics, unsafe sexual behavior, injection drug use, and background characteristics. Bivariate and multivariable analyses of the relationships between homelessness characteristics and HIV risk behaviors were conducted. RESULTS: Both male (n = 140) and female (n = 148) participants reported high rates of unsafe sexual behaviors, but low rates of injection drug use. HIV risk was significantly associated in bivariate analyses with severity of homelessness circumstances (i.e., spending the night in public place or with strangers, going hungry, and participating in the street economy), the duration of homelessness (i.e., greater number of episodes of homelessness, longer time length of current episode), and specific reasons for being homeless (i.e., thrown out). In addition, sexual victimization and older age were associated with increased HIV risk. In multivariable models, a smaller set of these homelessness characteristics remained significant independent correlates and explained a substantial amount of the variation in the HIV risk indices for both males and females. CONCLUSIONS: The results contribute to greater theoretical understanding of the characteristics of homelessness associated with increased risk of HIV infection within this vulnerable population of youth. The associations between homelessness characteristics and HIV risk suggest the need for HIV prevention efforts to focus directly on ameliorating the homelessness circumstances of youth.
Asunto(s)
Infecciones por VIH/transmisión , Personas con Mala Vivienda/estadística & datos numéricos , Asunción de Riesgos , Conducta Sexual/estadística & datos numéricos , Adolescente , Conducta del Adolescente , Adulto , District of Columbia/epidemiología , Femenino , Humanos , Masculino , Abuso de Sustancias por Vía Intravenosa/epidemiologíaRESUMEN
Runaway and homeless youth are at high risk for substance abuse and unsafe sexual behavior. Our study describes the personal social networks of these youth and examines network characteristics associated with risky behaviors. In 1995 and 1996, we interviewed a purposive sample of youth aged 14 through 21 who were living in Washington, DC and were identified on the streets or through shelters or other service agencies (N = 327). Although we found that most youth reported current social relationships, a significant minority (26%) did not. Youth without a social network were significantly more likely to report current illicit drug use, multiple sex partners, and survival sex than youth with a network. For youth with a network, the networks were small, strong in affective and supportive qualities, comprised primarily of friends, typically included an alcohol or illicit drug user, and usually were not a source of pressure for risky behaviors. Our results indicate that networks had risk-enhancing and risk-decreasing properties in that network characteristics were associated in both positive and negative directions with risky behaviors.
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Jóvenes sin Hogar/psicología , Asunción de Riesgos , Conducta Fugitiva , Apoyo Social , Adolescente , Adulto , District of Columbia/epidemiología , Femenino , Humanos , Entrevistas como Asunto , Modelos Logísticos , Masculino , Grupo Paritario , Prevalencia , Conducta Sexual/estadística & datos numéricos , Trastornos Relacionados con Sustancias/epidemiologíaRESUMEN
The progression of substance use and the patterns of comorbidity of substance use and psychiatric disorders are explored prospectively in young adolescents enrolled in the Great Smoky Mountains Study. This study is an epidemiologic study of white and American Indian youths living in rural Southern Appalachia. Results from this study indicate that alcohol use without permission predicts subsequent use of illicit drugs and regular tobacco use. Use of tobacco was not associated with either later alcohol or drug use. Patterns of comorbidity showed strong cross-sectional relationships between substance use and behavioral disorders, but not emotional disorders. Use of alcohol was also associated with psychiatric diagnosis at a later interview. There were some differences between white and American Indian youths in the pattern of comorbidity of tobacco use and psychiatric disorder and the relationship between prior psychiatric disorder and later alcohol use. These findings suggest that alcohol use without permission may be an important marker for youths who are at risk for illicit drug use and/or psychiatric diagnoses.
Asunto(s)
Alcoholismo/epidemiología , Drogas Ilícitas , Indígenas Norteamericanos/estadística & datos numéricos , Trastornos Mentales/epidemiología , Psicotrópicos , Trastornos Relacionados con Sustancias/epidemiología , Población Blanca/estadística & datos numéricos , Adolescente , Alcoholismo/diagnóstico , Alcoholismo/psicología , Niño , Comorbilidad , Estudios Transversales , Humanos , Indígenas Norteamericanos/psicología , Estudios Longitudinales , Masculino , Abuso de Marihuana/diagnóstico , Abuso de Marihuana/epidemiología , Abuso de Marihuana/psicología , Trastornos Mentales/diagnóstico , Trastornos Mentales/psicología , North Carolina/epidemiología , Escalas de Valoración Psiquiátrica , Factores de Riesgo , Muestreo , Fumar/efectos adversos , Fumar/epidemiología , Fumar/psicología , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/psicología , Población Blanca/psicologíaRESUMEN
Prior magnetic resonance imaging (MRI) studies report both medial and lateral cortical temporal changes and disturbed temporal lobe asymmetries in schizophrenic patients compared with healthy controls. The specificity of temporal lobe (TL) changes in schizophrenia is unknown. We determined the occurrence and specificity of these TL changes. Forty-six schizophrenic patients were compared to 60 normal controls and 27 bipolar subjects on MRI measures of bilateral volumes of anterior and posterior superior temporal gyrus (STG), amygdala, entorhinal cortex, and multiple medial temporal structures, as well as global brain measures. Several regional comparisons distinguished schizophrenia from bipolar disorder. Entorhinal cortex, not previously assessed using MRI in schizophrenia, was bilaterally smaller than normal in schizophrenia but not in bipolar disorder. Schizophrenic but not bipolar patients had an alteration of normal posterior STG asymmetry. Additionally, left anterior STG and right amygdala were smaller than predicted in schizophrenia but not bipolar disorder. Left amygdala was smaller and right anterior STG larger in bipolar disorder but not schizophrenia.
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Trastorno Bipolar/diagnóstico , Dominancia Cerebral/fisiología , Esquizofrenia/diagnóstico , Lóbulo Temporal/patología , Adolescente , Adulto , Amígdala del Cerebelo/patología , Trastorno Bipolar/fisiopatología , Mapeo Encefálico , Corteza Entorrinal/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Esquizofrenia/fisiopatología , Sensibilidad y EspecificidadAsunto(s)
Complejo SIDA Demencia/epidemiología , Infecciones por VIH/epidemiología , Trastornos Mentales/epidemiología , Complejo SIDA Demencia/psicología , Comorbilidad , Estudios Transversales , Femenino , Infecciones por VIH/psicología , Humanos , Incidencia , Masculino , Trastornos Mentales/psicología , Escalas de Valoración Psiquiátrica , Factores de Riesgo , Rol del Enfermo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The authors hypothesized that cortical gray matter volume reduction in schizophrenia is greatest in the heteromodal association cortex. This area comprises a highly integrated, reciprocally interconnected system that coordinates higher order cortical functions. METHOD: Total brain and regional gray matter volumes were calculated in 46 schizophrenic patients and 60 age and sex-matched comparison subjects by using magnetic resonance images. Disease specificity was examined by assessing 27 patients with bipolar disorder. Approximations to the dorsolateral prefrontal cortex, inferior parietal lobule, and superior temporal gyrus were selected as regions of interest for the heteromodal association cortex. Occipital and sensorimotor areas were used as comparison regions to test the hypothesis for regional specificity. RESULTS: Gray matter volume was reduced in schizophrenic patients in index regions even after covariance for overall brain volume, sex, and age. Bipolar disorder patients did not exhibit heteromodal gray matter reduction. Comparison regions did not differ among the three groups. Global gray matter volume was not different among groups after covariance for global brain volume. Comprehensive individual region post hoc analysis found no additional gray matter differences. CONCLUSIONS: These findings support the theory of disproportionate reduction of gray matter volume in the heteromodal association cortex specific to schizophrenia.
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Corteza Cerebral/anatomía & histología , Esquizofrenia/diagnóstico , Adulto , Factores de Edad , Trastorno Bipolar/diagnóstico , Encéfalo/anatomía & histología , Diagnóstico Diferencial , Escolaridad , Femenino , Lóbulo Frontal/anatomía & histología , Humanos , Imagen por Resonancia Magnética , Masculino , Análisis Multivariante , Lóbulo Parietal/anatomía & histología , Grupos Raciales , Factores Sexuales , Clase Social , Lóbulo Temporal/anatomía & histologíaRESUMEN
A previous neuropathological report noted a non-linear pattern of change in cerebral grey-white matter ratio during ageing. In that report, grey-white ratio decreased from age 20 to age 50, then increased in elderly subjects. The objective of the current study was to attempt to replicate this pattern of age-related change in the grey-white ratio in living human subjects using quantitative magnetic resonance imaging segmentation analysis. We measured the grey-white ratio in 78 subjects between the ages of 19 and 77 years, using a computer segmentation algorithm with magnetic resonance images. In agreement with the previous neuropathological report, the current in vivo magnetic resonance study found that the grey-white ratio declined from age 20 to age 50, then increased in elderly subjects.
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Envejecimiento/patología , Encéfalo/patología , Adulto , Anciano , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana EdadRESUMEN
Longitudinal research in Stirling County, Atlantic Canada, indicated that during the 1950s and 1960s the prevalence of depression was significantly and persistently higher in the "low" socioeconomic status population than at other socioeconomic status levels. Anxiety was found to show a less clear picture. Incidence of depression after the study started was also higher among those who were initially in the low socioeconomic status group, supporting the view that the stress of poverty may be causally related to depression. There was also a trend for prior depression to be associated with subsequent downward social mobility, supporting the view that the concentration of depressed people at the lower end of the social hierarchy may result from handicapping aspects of the illness. Neither of these trends was statistically significant. More striking was evidence that, irrespective of socioeconomic status, depression carried a substantial risk for poor clinical course and outcome. Both depression and poverty tended to be chronic, and, accordingly, their association at the end of the study was influenced by their association at its beginning. The stability of the relationship between poverty and depression warrants the attention of caregivers and policymakers and raises new questions about strategies for the study of causal sequences.
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Trastornos de Ansiedad/epidemiología , Trastorno Depresivo/epidemiología , Clase Social , Adulto , Canadá/epidemiología , Causalidad , Estudios de Cohortes , Estudios Transversales , Femenino , Humanos , Masculino , Pobreza , Estudios Prospectivos , Factores de Riesgo , Factores Sexuales , Medio Social , Movilidad SocialRESUMEN
The effects of nifedipine and propranolol on cardiac function both at rest and at peak exercise were compared in 22 hypertensive patients whose diastolic blood pressures remained in excess of 95 mm Hg despite diuretic therapy. In this double-blind, placebo-controlled study, left ventricular systolic and diastolic function at rest and at peak exercise during bicycle ergometry was assessed by first-pass radionuclide angiography using the Baird Scinticor before and after treatment with either nifedipine or propranolol. Both agents effectively reduced blood pressure in the supine and upright positions and at peak exercise. Nifedipine was associated with a significant increase in cardiac output and stroke volume at rest and at peak exercise, while propranolol decreased cardiac output at rest and at peak exercise. Systemic vascular resistance decreased with nifedipine treatment at rest and at peak exercise, but increased significantly with propranolol. Nifedipine increased ejection fraction in patients at rest and also increased maximal oxygen consumption at peak exercise, while propranolol decreased maximal oxygen consumption at peak exercise. At rest and at peak exercise, nifedipine increased peak filling rate, but time to peak filling rate was not affected by either drug. The fraction of total diastolic filling at the midpoint of diastole was significantly increased by nifedipine therapy at rest but was not affected by propranolol therapy. Nifedipine significantly decreased atrial filling volume while propranolol had no effect. Propranolol therapy did not result in any improvement in left ventricular function. In contrast, nifedipine improved left ventricular systolic and diastolic function at rest and peak exercise. Future selection of an antihypertensive agent should include consideration of the impact of therapy on left ventricular function.
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Hipertensión/tratamiento farmacológico , Contracción Miocárdica/efectos de los fármacos , Nifedipino/uso terapéutico , Propranolol/uso terapéutico , Adulto , Anciano , Presión Sanguínea/efectos de los fármacos , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Angiografía por RadionúclidosRESUMEN
To study the effect of mild-to-moderate elevations in diastolic blood pressure (BP) on systolic left ventricular (LV) function, 28 hypertensive patients and 20 normal subjects underwent upright exercise first-pass radionuclide angiography. All were asymptomatic, had normal rest and exercise electrocardiographic findings and no evidence of LV hypertrophy or coronary artery disease. LV function at rest was similar in the 2 groups, but with exercise hypertensive patients had a greater end-systolic volume (69 +/- 19 vs 51 +/- 19 ml, p less than 0.002) and lower ejection fraction (EF) (0.59 +/- 0.09 vs 0.72 +/- 0.07, p less than 0.0001), stroke volume (101 +/- 28 vs 130 +/- 36 ml, p less than 0.005) and peak oxygen uptake (23 +/- 7 vs 33 +/- 9 ml/kl/min, p less than 0.05). Hypertensive patients were separated into 3 groups: group 1-12 patients with an increase in EF with exercise greater than or equal to 0.05; group 2-7 patients with a change in EF with exercise less than 0.05; and group 3-9 patients with a decrease in EF with exercise greater than or equal to 0.05. Group 3 hypertensive patients were older, had a higher heart rate at rest and lower peak oxygen uptake. Rest LV function was similar in the 3 hypertensive subgroups, but exercise end-systolic volumes were higher in groups 2 and 3. Exercise thallium-201 images was normal in all but 1 of 14 hypertensive group 2 or 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)