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Family caregivers of persons with schizophrenia and other psychotic disorders experience high levels of burden. Although a number of patient and caregiver predictors of burden have been identified, little research has investigated the contributions of patient depression, suicidal ideation, and substance abuse. In addition, family psychoeducation interventions have reduced patient symptoms, as well as inpatient treatment utilization; however, it is not known whether or not these interventions reduce family burden. This study investigated predictors of family burden and tested to what degree multiple family group treatment (MFGT), relative to a standard care condition, was associated with reduced family burden. Participants were 90 outpatients with a diagnosis of schizophrenia or other psychotic disorders, and their caregivers who were enrolled in a 2 year psychoeducation intervention. The best set of predictors of burden, identified by stepwise linear regression, was young patient age, awareness of patient's suicidal ideation, and family resources. These variables accounted for 32% of the total variance in burden. Findings suggest that caregiver's awareness of patient's suicidal ideation, not patient's report of suicidal ideation; and that patient age, not duration of the illness, were significant independent predictors of burden. When compared to a standard-care condition over 2 years, MFGT did not reduce family caregiver burden. Discussions focus on the relationship between burden and its predictors, and possible reasons why MFGT did not decrease burden. Modifications are proposed that may increase the impact of MFGT. [ABSTRACT FROM AUTHOR]

Objective: To evaluate a Multiple Family Group (MFG) education and support intervention for individuals with Spinal Cord Injury (SCI) and their primary caregivers. We hypothesized that MFG would be superior to an Education Control Group (EC) for improving patient activation and coping skills, social supports, and relationship functioning. Setting: A large free-standing inpatient and outpatient rehabilitation facility. Participants: Community dwelling adults with SCI and their caregivers living in the Northwest United States. Interventions/Methods: Nineteen individuals with SCI who had been discharged from inpatient rehabilitation within the previous three years, and their primary caregivers participated. Patient/caregiver pairs were randomized to the MFG intervention or an active SCI EC condition in a two-armed clinical trial design. Participants were assessed pre- and post-program and 6 months post-program. Qualitative and quantitative outcomes were evaluated. Focus groups were conducted with each group to determine benefits and recommendations for improvement. Results: Relative to EC, MFG reduced passive coping and increased subjective and overall social support in participants with SCI. Relative to EC, MFG also reduced passive coping in caregivers. Patient activation relative to EC was non-significantly increased. Content analysis identified four themes describing participants' experiences: enhanced sense of belonging, increased opportunities for engagement, knowledge, and team work; results that were generally congruent with quantitative measures of improved social support. Conclusions: Relative to EC, MFG assisted participants with SCI and their caregivers to manage the difficult, long-term, life adjustments by improving coping and strengthening social support. Trial registration: ClinicalTrials.gov NCT02161913. Registered 10 June 2014.

The purpose of this randomized controlled trial ( n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.

Background: Over 12,000 individuals suffer a spinal cord injury (SCI) annually in the United States, necessitating long-term, complex adjustments and responsibilities for patients and their caregivers. Despite growing evidence that family education and support improves the management of chronic conditions for care recipients as well as caregiver outcomes, few systematic efforts have been made to involve caregivers in psycho-educational interventions for SCI. As a result, a serious gap exists in accumulated knowledge regarding effective, family-based treatment strategies for improving outcomes for individuals with SCI and their caregivers. The proposed research aims to fill this gap by evaluating the efficacy of a structured adaptation of an evidence-based psychosocial group treatment called Multi-Family Group (MFG) intervention. The objective of this study is to test, in a randomized-controlled design, an MFG intervention for the treatment of individuals with SCI and their primary caregivers. Our central hypothesis is that by providing support in an MFG format, we will improve coping skills of persons with SCI and their caregivers as well as supportive strategies employed by caregivers., Methods: We will recruit 32 individuals with SCI who have been discharged from inpatient rehabilitation within the previous 3 years and their primary caregivers. Patient/caregiver pairs will be randomized to the MFG intervention or an active SCI education control (SCIEC) condition in a two-armed randomized trial design. Participants will be assessed pre- and post-program and 6 months post-program. Intent to treat analyses will test two a priori hypotheses: (1) MFG-SCI will be superior to SCIEC for SCI patient activation, health status, and emotion regulation, caregiver burden and health status, and relationship functioning, and (2) MFG will be more effective for individuals with SCI and their caregivers when the person with SCI is within 18 months of discharge from inpatient rehabilitation compared to when the person is between 19 and 36 months post discharge., Discussion: Support for our hypotheses will indicate that MFG-SCI is superior to specific education for assisting patients and their caregivers in the management of difficult, long-term, life adjustments in the months and years after SCI, with increased efficacy closer in time to the injury., Trial Registration: ClinicalTrials.gov NCT02161913 . Registered 10 June 2014.

There is increasing need for early, pro-active programs that can delay dementia diagnosis and enhance well-being of individuals with mild cognitive impairment (MCI) and their care-partners (i.e., care-dyads). This randomized controlled trial evaluated the efficacy of a combined cognitive rehabilitation and multi-family group treatment (CR-MFG) that was designed to facilitate adoption of newly learned cognitive strategies into the care-dyads everyday lives. Analyzed data included 23 care-dyads who participated in CR-MFG treatment and 23 care-dyads in standard care (SC). The 3-month intervention consisted of individual joining sessions, an educational workshop, and 20/twice weekly multifamily memory strategy training and problem-solving sessions. Everyday functioning, memory, and psychological functioning (i.e., quality-of-life, depression, coping) were assessed. The CR-MFG intervention was associated with significant post-test group differences and improved post-test performances by the MCI participants on performance-based measures of everyday functioning and neuropsychological tests of memory. There was also some suggestion that CR-MFG care-partners perceived positive change in the everyday functioning of the MCI participants. In contrast, no post-test group differences were found for either care-dyad member on the self-report psychological measures; care-partners in the treatment group did self-report improved coping behaviors at post-test. These 3-month results are preliminary but suggestive that CR-MFG may produce modest, practical everyday functional benefits for persons with MCI.

This study assessed the social, demographic and clinical determinants of whether an opioid-dependent patient received buprenorphine versus an alternative therapy. A retrospective cohort analysis of opioid-dependent adults enrolled in Group Health Cooperative between January 1, 2006 and December 1, 2010 was performed. Increasing the number of physicians with DATA waivers in a region and living in a relatively-populated area increased the likelihood of being treated with buprenorphine, indicating that lack of access is a potential barrier. Comorbidity also appeared to be a factor in receipt of treatment, with the effect varying by diagnosis. Finally, patients with an insurance plan allowing health services to be sought from any provider, with increased cost sharing, were significantly more likely to receive buprenorphine, implying that patient demand is a factor. Programs integrating patient education, physician training, and support from addiction specialists would be likely facilitators of increasing access to this cost-effective treatment., (© 2014.)

Objective: This study evaluated the feasibility, acceptability, and helpfulness of implementation of multifamily group treatment for traumatic brain injury (TBI) among veterans who sustained a TBI during the wars in Iraq and Afghanistan and their families or caregivers., Methods: Veterans and their family members who participated in an open clinical trial (August 2010-March 2011) of multifamily psychoeducation for TBI at two Veterans Affairs medical centers were invited to one of three focus groups. Participants were asked about problems experienced before and during the intervention, aspects of treatment that were helpful, and improvements that would facilitate effective implementation of multifamily group treatment for TBI. Postintervention focus group transcripts were analyzed by utilizing qualitative content analysis., Results: Participants included eight veterans with TBI and eight family members. Five themes emerged: exploring common struggles and reducing isolation, building skills to cope with TBI and related problems, restoring relationships through communication and understanding, increasing understanding of the interconnection between TBI and posttraumatic stress disorder, and improving the multifamily group experience and increasing treatment engagement of veterans and families. Veterans and family members found multifamily group treatment for TBI highly acceptable and offered recommendations to improve and increase access to the program., Conclusions: The results supported the feasibility and acceptability of multifamily group treatment for TBI. Specific recommendations to improve this psychoeducational intervention and its implementation are offered.

Objective: This study evaluated the initial efficacy and feasibility of implementing multifamily group treatment for veterans with traumatic brain injury (TBI)., Methods: Veterans at two Veterans Affairs medical centers were prescreened by their providers for participation in an open trial of multifamily group treatment for TBI. Enrollment was limited to consenting veterans with a clinical diagnosis of TBI sustained during the Operation Enduring Freedom-Operation Iraqi Freedom era, a family member or partner consenting to participate, and a score ≥20 on the Mini-Mental State Examination. The nine-month (April 2010-March 2011) trial consisted of individual family sessions, an educational workshop, and bimonthly multifamily problem-solving sessions. Interpersonal functioning and symptomatic distress among veterans and family burden, empowerment, and symptomatic distress among families were assessed before and after treatment., Results: Providers referred 34 (58%) of 59 veterans screened for the study; of those, 14 (41%) met criteria and consented to participate, and 11 (32%) completed the study. Severity of TBI, insufficient knowledge about the benefits of family involvement, and access problems influenced decisions to exclude veterans or refuse to participate. Treatment was associated with decreased veteran anger expression (p≤.01) and increased social support and occupational activity (p≤.05), with effect sizes ranging from .6 to 1.0. Caregivers reported decreased burden (p≤.05) and increased empowerment (p≤.01)., Conclusions: The results supported implementation of a randomized controlled trial, building in education at the provider and family level.

Objective: The objective was to determine if patients hospitalized with a primary medical diagnosis and any co-occurring serious mental illness (SMI) were more likely than patients without any co-occurring SMI diagnosis to experience a subsequent medical hospitalization., Method: This was a longitudinal cohort study of 925,705 adult persons (aged 18+ years). Patients hospitalized in Washington State from 2004 to 2008 were followed through 2009 (for an average of 43 months)., Results: Compared to patients hospitalized for medical conditions without co-occurring SMI, patients with co-occurring dysthymia, bipolar and major depressive disorders were at an elevated risk for long-term subsequent hospitalization. Patients in the combined co-occurring mood disorders cohort were more likely (hazard ratio=1.13; 99% confidence interval=1.10-1.16; P<.001) than patients in the reference cohort to experience a subsequent medical hospitalization. A significant interaction between substance and mood disorders that increased risk for subsequent hospitalization was also observed., Conclusion: Hospitalized patients with co-occurring mood disorders are at high risk for repeat hospitalization for a medical reason. This high-risk population, including those with substance abuse, should be a focus of research efforts to identify and address ambulatory-care-sensitive conditions amenable to strategies that decrease complications and illness leading to subsequent hospitalizations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The impact of multiple-family group treatment (MFGT) on outpatient and inpatient mental health service utilization of 97 persons with schizophrenia was investigated. Participants were randomly assigned to standard care (n = 44) or standard care plus MFGT (n = 53). Service use for a year prior to randomization, the 2-year study period, and a 1-year follow-up were examined. Relative to standard care participants, the MFGT group had reduced community hospitalization during year 1 of the intervention and reduced state hospitalization at follow-up. During the intervention period, MFGT participants demonstrated a significant increase in outpatient utilization as a direct consequence of the intervention. However, when service use was summed across 3 years post-randomization, no group differences were observed. Results suggest that implementation of MFGT in a community mental health setting reduces inpatient service at specific time periods, without significantly increasing outpatient service utilization. These findings add to other outcomes from this study that demonstrate decreased psychiatric symptoms and caregiver distress.

An estimated 20% of children suffer from psychological disorders and only 10-20% receive adequate treatment. A lack of empirically supported treatments is one reason why relatively few children receive treatment for their psychological difficulties. Multiple-family group treatment (MFGT) is an empirically supported intervention for adults with chronic mental illnesses that may be an effective treatment for children with psychological disorders. This article reviewed the adult MFGT model and its empirical support. The quantity and quality of child MFGT research was then reviewed. Child MFGT models are compared with one another and to the adult MFGT model. All studies provided initial support of MFGT as an appropriate treatment for childhood disorders. However, the child literature as whole was relatively limited, unfocused, and lacked replication. Suggestions for future research are made, focusing on a structured and scientific approach to establishing MFGT as an empirically supported intervention for children.

The goals of the current study were to determine whether incorporating disability benefit management into combined outpatient psychiatric/addiction treatment was feasible and clinically useful for managing severely mentally ill, substance-abusing patients over time, and then if patients in this program would demonstrate the first-week-of-the-month increased substance abuse and hospitalizations shown in other studies. Forty-four patients were studied for an average of forty weeks, with little treatment or study dropout. There was no evidence in either the schizophrenic/cocaine abuser or the broader diagnostic sample of the cyclic first-of-the-month pattern of substance use and hospitalizations observed in other studies. Findings suggest that combined treatment/benefit management programs are clinically feasible and effective in stabilizing patients and keeping them in treatment.

To evaluate the feasibility and efficacy of a program to manage Social Security disability benefits in a clinical sample of patients with severe mental illness and co-occurring substance dependence, 41 patients were randomly assigned to have their benefits either contingently or noncontingently managed through their mental health center. Contingent management involved adjustments to the type or frequency (not amount) of disability benefits and payments for study participation based on ratings of substance use, money management, and treatment follow-through. The patients with contingent management used significantly less alcohol and drugs and showed much better money management than those with noncontingent management. Patients and case managers who participated in the study reported that they found the management strategy to be acceptable and useful.

Objective: The objective of this study was to evaluate the effects of multiple-family group treatment on distress and psychosocial resources among family caregivers of persons with schizophrenia., Methods: A total of 97 consumers with schizophrenia or another psychotic disorder and their caregivers were randomly assigned to receive multiple-family group treatment (N=53) or standard psychiatric outpatient care (N=44). Reliable and valid measures were used to assess caregivers' distress, caregivers' resources, and consumers' clinical status., Results: After consumers' clinical status and baseline rates of caregivers' distress and caregivers' resources were controlled for, the caregivers of consumers who received multiple-family group treatment experienced greater reductions in distress but no increases in resources compared with caregivers of consumers who received standard psychiatric care., Conclusions: Multiple-family group treatment reduced caregivers' distress but did not increase caregivers' resources relative to standard psychiatric care.

The study tests whether psychiatric services utilization may be predicted from administrative databases without clinical variables equally as well as from databases with clinical variables. Persons with a psychiatric hospitalization at an urban medical center were followed for 1 year postdischarge (N = 1384.) Dependent variables included statewide rehospitalization and the number of hours of outpatient services received. Three linear and logistic regression models were developed and cross-validated: a basic model with limited administrative independent variables, an intermediate model with diagnostic and limited clinical indicators, and a full model containing additional clinical predictors. For rehospitalization, the clinical cross-validated model accounted for twice the variance accounted by the basic model (adjusted R2 = .13 and .06, respectively). For outpatient hours, the basic cross-validated model performed as well as the clinical model (adjusted R2 = .36 and .34, respectively). Clinical indicators such as assessment of functioning and co-occurring substance use disorder should be considered for inclusion in predicting rehospitalization.

Use of drugs and alcohol by 43 predominantly male outpatients who had severe mental illness and a comorbid substance use disorder were assessed weekly through the ratings of experienced dual disorder case managers and through blinded research urine toxicology tests. The percentage of weeks in which drugs or alcohol were used was calculated on the basis of one or both assessments. The case managers often missed drug use over the weekends, which was detected by the urine toxicology tests. Agreement between the two methods varied widely, even when the ratings were made by highly experienced case managers. These findings have implications for monitoring patients with dual diagnoses and provide insight into the accuracy of case manager ratings.

Objectives: Outpatient and inpatient mental health service outcomes for outpatients with schizophrenia or schizoaffective disorder who received psychoeducational multiple-family group treatment were compared with outcomes for similar patients who received standard care., Methods: A total of 106 outpatients with schizophrenia or schizoaffective disorder who were receiving services from a large community mental health center were randomly assigned to receive standard care or standard care plus multiple-family group treatment. The two-year multiple-family intervention consisted of weekly group sessions designed to educate patients and their family members about the biological basis of mental illness and treatment, to improve illness management and coping skills, and to provide social support. The group sessions were conducted by two clinicians using a standardized protocol. Each multiple-family group included five to eight families and consumers. Service records for the year before and after random assignment to the study groups were examined in an intent-to-treat analysis., Results: During the year after random assignment to study groups, multiple-family group treatment was associated with a lower rate of psychiatric hospitalization than standard care. It was only marginally associated with lower use of crisis services, and it was not associated with the amount of outpatient service time., Conclusions: The findings suggest that implementation of multiple-family group treatment in a capitated community mental health setting improves hospitalization outcomes without increasing the overall volume of outpatient mental health services.

By applying the behavioral theory of Lewinsohn et al. [1985. An integrative theory of depression. In: S. Reiss, & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331-359). San Diego, CA: Academic Press.] to multiple sclerosis (MS), it was hypothesized that physical disability, fatigue, and psychosocial dysfunction would be significantly predictive of depressed mood in MS patients. Seventy-six MS patients completed the following measures: the Sickness Impact Profile (SIP), the Fatigue Impact Scale (FIS), and the mood subscale from the Chicago Multiscale Depression Inventory (CMDI). Structural equation modeling revealed that physical disability and fatigue were indirectly predictive of depressed mood via their effects on recreational functioning. Fatigue also had a direct effect on mood. If reductions in recreational activities actually cause decrements in mood, depressed mood in MS may be treatable by helping patients identify recreational activities that they can enjoy regardless of physical or fatigue-related difficulties.

Previous research shows that the Multnomah Community Ability Scale (MCAS) total score is reliable and has predictive validity. This study evaluates the MCAS total and sub-scale scores on a sample of 1,250 outpatient mental health clients in Washington State. The MCAS sub-scales are reliable, and there is evidence for their concurrent validity. However, the factor structure of the MCAS only partially replicated the hypothesized sub-scales, and the authors recommend that sub-scales as currently constructed not be used as performance indicators. If only the total MCAS is of interest to users, the authors recommend using the single-item SOFAS rather than the 17-item MCAS.

Objective: Outcomes for negative symptoms over a one-year period were examined in two groups of patients, one receiving psychoeducational multiple-family group treatment and one receiving standard care., Methods: A total of 63 outpatients, ages 18 to 45 years, with DSM-IV diagnoses of schizophrenic disorders were randomly assigned to standard care or multiple-family group psychoeducation treatment at a large mental health center in Spokane, Washington. Treatment assignment was stratified by whether patients were taking typical or atypical antipsychotic medications. Negative symptom status was monitored monthly for one year by raters blind to group assignment and measured as a composite of five symptoms using the Modified Scale for the Assessment of Negative Symptoms., Results: When the analysis controlled for baseline negative symptoms, participants in the multiple-family group experienced significantly reduced negative symptoms compared with those receiving standard care. Taking atypical antipsychotic medication or having a diagnosis of substance abuse was not associated with the severity of negative symptoms. An additional analysis of the five individual negative symptoms indicated small but consistent group differences on all dimensions except inattention. Negative symptoms were significantly correlated with relapse to acute illness but not with outpatient or inpatient service use., Conclusions: The study demonstrated that a psychoeducational multiple-family group intervention was more effective than standard care in managing negative symptoms over a 12-month period. The results are particularly relevant because negative symptoms are associated with relapse, poor social and occupational functioning, cognitive impairment, and lower subjective quality of life.

Objective: The objective of the study was to test predictive models of schizophrenia caregiver burden and infectious illness episodes for caregivers who had regular contact with their mentally ill family members., Methods: A nurse interviewer, blind to the patient's symptoms, caregiver burden, and psychosocial status, administered the Health Review to 70 caregivers. A second family interviewer, blind to caregiver health status and patient symptoms, assessed caregiver resources (eg, active coping and social support), vulnerabilities (eg, anger expression and passive coping) and burden. Concurrently, independent patient raters, blind to caregiver health and psychosocial status, assessed caregiver stressors. The Brief Psychiatric Rating Scale and the Modified Scale for the Assessment of Negative Symptoms were used to assess the severity of positive (eg, hallucinations and delusions) and negative (eg, anhedonia and asociality) symptoms, respectively., Results: Predictive models, including measures of stressors, resources, and vulnerability factors for caregiver burden and for presence of infectious illness, were each highly significant, accounting for 40% and 29% of the variance, respectively. However, the specific measures that predicted burden and infectious illness differed. Greater burden was predicted by more severe patient negative symptoms (stressor), greater anger control and blame self-coping (vulnerability), and decreased tangible social support (resource). Presence of infectious illness episodes was predicted by more severe patient positive symptoms (stressor) and less satisfaction with social support while controlling for the frequency of reporting on the Health Review. When scores from the Brief Psychiatric Rating Scale (stressors) were categorized into quartiles, it was found that the frequency of infectious illness in the highest quartile was four times that in the lowest quartile. Other results indicated that even though burden was not associated with infectious illness, it was associated with "continuing health problems," perceived stress, and depression., Conclusions: These data indicate that although schizophrenia caregiver burden and infectious illness are predicted by measures of patient stressors, vulnerabilities, and resources, the specific measures predicting these outcomes differ. The results also call attention to the powerful influence of patient symptoms as a predictor of burden and the presence of infectious illness among caregivers.

Objective: To develop and test risk-adjustment outcome models in publicly funded mental health outpatient settings. We developed prospective risk models that used demographic and diagnostic variables; client-reported functioning, satisfaction, and quality of life; and case manager clinical ratings to predict subsequent client functional status, health-related quality of life, and satisfaction with services., Data Sources/study Setting: Data collected from 289 adult clients at five- and ten-month intervals, from six community mental health agencies in Washington state located primarily in suburban and rural areas. Data sources included client self-report, case manager ratings, and management information system data., Study Design: Model specifications were tested using prospective linear regression analyses. Models were validated in a separate sample and comparative agency performance examined., Principal Findings: Presence of severe diagnoses, substance abuse, client age, and baseline functional status and quality of life were predictive of mental health outcomes. Unadjusted versus risk-adjusted scores resulted in differently ranked agency performance., Conclusions: Risk-adjusted functional status and patient satisfaction outcome models can be developed for public mental health outpatient programs. Research is needed to improve the predictive accuracy of the outcome models developed in this study, and to develop techniques for use in applied settings. The finding that risk adjustment changes comparative agency performance has important consequences for quality monitoring and improvement. Issues in public mental health risk adjustment are discussed, including static versus dynamic risk models, utilization versus outcome models, choice and timing of measures, and access and quality improvement incentives.

Interleukin (IL)-1, IL-2 and IL-6 influence central monoamine activity in a cytokine-specific manner. We demonstrated that whereas IL-2 increased hypothalamic and hippocampal norepinephrine (NE) utilization, and DA turnover in the prefrontal cortex, IL-6 induced profound elevations of serotonin (5-HT) and mesocortical dopamine (DA) activity in the hippocampus and prefrontal cortex [S. Zalcman, J.M. Green-Johnson, L. Murray, D.M. Nance, D.G. Dyck, H. Anisman, A. H. Greenberg, Cytokine-specific central monoamine alterations following IL-1, -2 and -6 administration, Brain Res. 643 (1994) 40-49]. IL-1, in contrast, induced a wide range of central monoamine alterations. We presently report that these cytokines also differentially influence behavior. Profound reductions in non-ambulatory and ambulatory exploration were induced in BALB/c mice following IL-1 administration. In contrast, IL-2-treated mice displayed significant increases in the time spent engaged in non-ambulatory exploration, digging, rearing (particularly the number of free rears), and in the investigation of a novel stimulus (i.e., increased number and duration of stimulus contacts). IL-6-treated mice, moreover, exhibited significant increases in the time spent engaged in ambulatory exploration, digging and rearing (particularly the number of free rears, which tended to be of short duration). Modest increases in locomotion and grooming were also observed in IL-6-treated animals. Plasma corticosterone levels did not vary significantly as a function of IL-6 treatment. Hence, cytokine-specific behavioral-activating effects were induced following administration of IL-2 and IL-6. We suggest that these effects have adaptive significance and relevance to sickness behavior; however, pathological outcomes (e.g., schizophrenia, anxious-like states, anxious depression, motor abnormalities) could develop should these cytokines be overproduced or dysregulated., (Copyright 1998 Elsevier Science B.V.)

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.

This article describes the client characteristics and services needs of community-dwelling older adults found through a unique case-finding model developed at the Spokane Mental health Center. The model trains the employees of community businesses and corporations who work with the public to serve as community gatekeepers by identifying and referring community-dwelling older adults who may be in need of aging and/or mental health services. These community case-finders perform a gatekeeping function for older adults that is similar to that performed by schools and the workplace for younger persons. Information was collected on 777 individuals aged 60 and older referred over an 18-month period (January 1, 1994, to June 30, 1995) to the Spokane Mental Health Clinical Case Management Program in Spokane, Washington, which provides aging and mental health services to older adults residing in the county. Findings indicate that 40% of clients referred were found by community-based gatekeepers. Clients referred by gatekeepers were more frequently socially isolated, economically disadvantaged, and less likely to have a physician. Gatekeeper clients were also more likely to be women and to be younger than others referred to the agency. Gatekeeper clients were receiving fewer services at referral and were identified as needing more services at intake. Gatekeepers find a distinct population of community-dwelling older adults who are not found by more traditional referral sources. The need to integrate this model within a comprehensive clinical case management system is discussed.

The present study used a taste aversion paradigm to condition lipopolysaccharide (LPS)-induced suppression of splenic lymphocyte interleukin-2 (IL-2) production, with concurrent measurement of corticosterone production and splenic norepinephrine (NE) content). In training, two groups of rats received saccharin and IP LPS in a paired (P) manner and a third group in a specifically unpaired (U) manner. In the test, the unpaired group (group U) and one of the paired (group P) groups were re-exposed (R) to the cue and the other not (NR). An additional group controlled for the effects of cues (conditional stimulus) and fluid deprivation (negative control; NC). A robust taste aversion in the P-R group was accompanied by suppression of IL-2 production, reduced splenic NE content, and elevated corticosterone production, relative to combined controls (i.e., groups U-R, P-NR, and NC). The conditioned modulation of IL-2 secretion, along with the concomitant alteration of adrenocortical and sympathetic mediators, supports the involvement of bidirectional central nervous-immune system pathways in this paradigm.

Developmentally disabled clients with a concomitant mental illness are often underserved or inappropriately treated because of interorganizational barriers, leading to unnecessary hospitalization and lengthy delays in community placement. To overcome these barriers, agencies responsible for developmental disabilities and mental health services in Spokane County in Washington State developed a collaborative system of care in 1989. An interagency consortium was established to promote coordination of services between the community mental health center, the state hospital, the county human services agency, the state's regional developmental disability service agency, the state institution for the developmentally disabled, and several community agencies serving developmentally disabled persons. Between 1990 and 1992, admissions of developmentally disabled persons to the state hospital were more likely to be appropriate admissions of persons suffering from a mental illness, developmentally disabled clients were discharged more efficiently, and crisis respite services were used in place of hospitalization. In addition, anecdotal reports indicated a reduction of interagency tensions.

This study examined relationships between cancer patients' preferences for involvement in making treatment decisions and preferences for information about diagnosis, treatment, side effects, and prognosis. Participants were 35 women with stage I and II breast cancer recruited from two medical oncology and radiation oncology clinics. Following administration of card sort measures of preference for involvement in treatment decision making and information needs, a semi-structured interview was conducted to provide patients with an opportunity to elaborate on their role preferences and health care experiences. Results showed that patients who desired an active role in treatment decision making also desired detailed information. This relationship was not as clear for passive patients. Relative to passive patients, active patients desired significantly more detailed explanations of their diagnosis, treatment alternatives, and treatment procedures. Active patients also preferred that their physicians use the words 'cancer' or 'malignancy' when referring to their illness while passive patients preferred that their physicians use a eupheumism. Further research is needed to critically detail the advantages and disadvantages of the active and passive roles and their impact on disease progression and psychological well-being.

The vasoactive eicosanoids, prostacyclin and thromboxane, are thought to play an important role in the genesis of cardiovascular disease. Since an altered basal production of these eicosanoids among individuals exhibiting the Type A behavior pattern had previously been observed by the authors, the present study evaluated the extent to which the TABP-eicosanoid relationship would be altered by two lifestyle variables known to affect platelet activity: alcohol consumption and stressful physical activity. 55 male participants aged 18-25 years, participated in the study. They were classified as either Type A or Type B on the basis of the Structured Interview and as either moderate, heavy, or abstinent alcohol drinkers. Bleeding times were performed and bleeding time thromboxane and prostacyclin metabolites were measured in all subjects both before and following treadmill exercise. The results indicated that following exercise, Type A participants, who reported moderate alcohol intake, had decreased levels of thromboxane B2 formation relative to Type As reporting heavy consumption. Further, prostacyclin production, measured as the primary metabolite, 6-keto-prostaglandin F1 alpha, was significantly suppressed following exercise among drinkers as compared with participants reporting abstinence. These results were discussed in relation to the proposition that moderate alcohol consumption reduces coronary heart disease risk.

We have previously shown that intracerebroventricular (ICV) injection of interleukin-1 beta (IL-1 beta) suppressed splenic macrophage function. Sympathetic noradrenergic innervation of the spleen was implicated as a mediator of this IL-1 beta signal as surgical sympathectomy ablated the macrophage suppression. In this study, we have determined whether ICV administration of IL-1 beta has an effect on sympathetic outflow and norepinephrine (NE) turnover in the spleen. Adult male rats were injected with 5 ng of IL-1 or saline, and NE turnover in the spleen was determined using the rate of decline of NE content in the spleen after synthesis inhibition. The splenic NE turnover rate was increased significantly from 69.52 ng/g/h in saline-treated animals to 111.05 ng/g/h in IL-1-treated animals. In addition, serum corticosterone and ACTH were significantly elevated in IL-1 beta-treated animals 4 h postinjection. These data indicate that central administration of IL-1 beta increases both sympathetic outflow to the spleen and activates the hypothalamic-pituitary-adrenal axis during the period when IL-1 beta induces immunosuppression.

The authors evaluated the interaction between physical fitness and Type A behavior on vascular production of prostacyclin and platelet thromboxane in response to a standard vessel injury. Ninety-seven male university students were classified as Type A or B on the basis of the Structured Interview of Rosenman. Reactivity, as measured by changes in systolic blood pressure (SBP), and heart rate (HR), measured before and after a stressful Stroop task 1 week later, showed that Type A individuals were more reactive to the stressor than Type Bs, providing independent confirmation of the behavioral interview assessment procedure. Fitness level was determined by a graded treadmill test and was not different for Type As and Type Bs. Basal thromboxane production, measured as the primary metabolite, thromboxane B2, in blood oozing from the bleeding-time site, was highest among unfit Type A subjects. Fit Type As and Type Bs showed significantly lower thromboxane production. No significant differences in prostacyclin production were seen. This study marks the first time that behavior pattern has been linked to an adverse aspect of a thrombosis-related parameter likely to be involved in the genesis of cardiovascular disease. The present results also indicate that physical fitness may, in some fashion, ameliorate the "toxic" effects of Type A behavior.

In this prospective, longitudinal study, 42 first-time mothers, recruited through prenatal classes, were assessed on variables predictive of postpartum depressive symptoms. Using a causal modelling structural analysis, it was found that prenatal depression, partners' support, and infant-related factors all contributed to the development of depression following childbirth.

Objective: To determine whether individuals exhibiting the type A behaviour pattern have a different extent of prostacyclin or thromboxane production after relaxation or after a structured interview compared to individuals exhibiting the type B behaviour pattern., Design: Subjects were randomized to receive prospectively either a relaxation session or a mildly stressful interview first. Each then received the alternate treatment second., Setting: Students attending an introductory psychology course at the University of Manitoba received a relaxation session (20 mins lying down listening to a tape) and an interview session (the structured interview of Rosenman)., Outcome Measures: Type A/B behaviour pattern was rated using the structured interview of Rosenman. Production of 6-keto prostaglandin F1-alpha and thromboxane B2, metabolites of prostacyclin and thromboxane A2, respectively, were measured in response to a standardized vascular injury-bleeding time., Main Results: No significant differences were observed in the length of bleeding time, in bleeding time thromboxane production or in prostacyclin production after relaxation between individuals exhibiting type A and B behaviour patterns. Prostacyclin production after the interview was lower in type A individuals (3.29 +/- 0.29 pg/min) than in individuals exhibiting type B behaviour (4.76 +/- 0.63 pg/min) (P = 0.04). No significant post interview differences in bleeding time or in thromboxane production were seen., Conclusion: After relaxation, type A and B subjects are similar in their prostacyclin and thromboxane responses to vascular injury. However, type A individuals show a less favorable prostacyclin response than type B when confronted with the structured interview; type A individuals responded in an aggressive or hostile fashion, while the type B individuals exhibited a more relaxed response.

In a previous investigation with mice, the paired presentation of either odor or taste cues with the peripheral (IP) administration of the immunoactive peptide interleukin-1 (IL-1) led to the conditioned enhancement of glucocorticoid production. The present study found that an initial central infusion of IL-1 in the presence of saccharin cues produced a robust taste aversion but not a conditioned elevation of either ACTH or corticosterone production. These results indicate that the glucocorticoid response induced by centrally administered IL-1 in rats is independent of the behaviorally aversive properties of this cytokine which are conditionable. The differential effects of IP versus ICV administration of IL-1 on glucocorticoid conditioning requires a clearer specification of the respective signaling mechanisms and pathways activated by these two routes of administration.

Intracerebroventricular (ICV) injections of interleukin-1 beta (IL-1 beta) produced a dose-dependent increase in plasma corticosterone and adrenocorticotropic hormone (ACTH) within 2 hr of injection and then declined over the next 24 hr. Using a potent steroidogenic dose of IL-1 beta (5 ng), ICV injection resulted in suppression of splenic macrophage IL-1 secretion following stimulation by LPS in vitro. Macrophage TGF-beta secretion was not affected, indicating a differential action of ICV IL-1 beta on macrophage cytokine production. Following adrenalectomy (ADX), the suppressive effect of ICV IL-1 beta was reversed and resulted in stimulation of macrophage IL-1 secretion, indicating that the suppression was mediated by adrenocorticol activation. However, surgical interruption of the splenic nerve to eliminate autonomic innervation of the spleen also prevented the macrophage suppressive signal in rats given ICV IL-1 beta. Furthermore, the combination of ADX and splenic nerve section resulted in a potent stimulatory effect of ICV IL-1 beta on splenic macrophage IL-1 secretion which was greater than either ADX or splenic nerve section alone. These results support the concept of a negative feedback on macrophage IL-1 secretion by the central action of IL-1 beta and indicate that both the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system mediate this effect.

Sixty-six male university students were classified as Type A or B on the basis of the Structured Interview of Rosenman and as hostile or non-hostile on the basis of the Cook-Medley scale. Vascular production of prostacyclin and platelet thromboxane in response to a standard vessel injury was evaluated. Basal thromboxane production, measured as the primary metabolite, thromboxane B2, in blood oozing from the bleeding-time site, was highest among hostile Type A subjects with significantly lower thromboxane production in hostile Type Bs and all non-hostile groups combined. Following an exercise treadmill test hostile subjects produced more thromboxane than non-hostile ones, and hostile Type As had significantly shorter bleeding times than hostile Type Bs. No significant differences on any measure were observed following a stressful color naming task. The observed interaction of hostility and Type A behavior on bleeding time thromboxane formation links behavior to an adverse aspect of a thrombosis-related parameter thought to be involved in the genesis of cardiovascular disease.

Recombinant IL-1-beta, which is capable of stimulating the pituitary-adrenal axis to secrete corticosterone, was paired with environmental cues in either a taste aversion or odor conditioning procedure. Among mice receiving paired delivery of cues and IL-1, subsequent re-exposure to cues elicited corticosterone production. This response was significantly greater than in animals that were conditioned but not re-exposed to the cues or were exposed to the cues alone. These results indicate that the IL-1 activation of adrenal cortical secretion can be conditioned to environmental stimuli.

The present study tested the hypothesis that Type A individuals would respond to a relevant stressor (ego-threat), but not an irrelevant one (cold pressor), with higher heart rate (HR) and larger pupil size than Type B's. These measures of physiological arousal were taken during baseline and during exposure to each of two sequentially presented, but counterbalanced stress conditions: ego threat and cold pressor. The physiological measures of sympathetic arousal were supplemented with repeated measures of self-reported anxiety. Three distinct findings emerged. First, Type A subjects had higher levels of HR in response to ego threat, but lower levels in response to cold pressor stress, compared to non-stressed baseline levels. Type B's on the other hand had slight, but nondifferential increased HR to the two different stress regimens. Second, the pupillary response to light did not produce results wholly parallel to those obtained with HR, or with the hypothesis that A's are more physiologically responsive than B's. Finally the Type A subjects in all conditions reported less anxiety than did Type B's. The present results generally indicate that A/B differences in cardiovascular arousal do not generalize readily across situations or to all autonomic indices.

This study examined differences in cognitive appraisal and causal attributions in response to a task among schoolchildren reporting high and low depressive symptomatology. From a sample of 361 fifth- and sixth-grade students, 72 children were classified as depressed or nondepressed on the basis of their scores on the Children's Depression Inventory. They were then presented with modified Picture Arrangement problems from the WISC-R and questioned about their performance. Pretask expectations, evaluations, and future expectations of performance for the self and that of same-aged peers were assessed, as well as causal explanations for solvable and unsolvable problems. Despite similar performance, the depressed group of children provided lower evaluations for themselves than for others on all three measures of self-appraisal, whereas the nondepressed group did not show this tendency. Further, the attribution results indicated that the two groups differed in their explanations for failure, with the depressed group emphasizing the importance of ability in failure and the nondepressed group emphasizing factors other than ability. Overall, the results provide support for the presence of negative cognitions and self-defeating attributional style among depressed relative to nondepressed children, as well as pointing to the importance of social comparison processes in depression.

Three experiments were conducted to evaluate the role of drug-dosage and stimulus-specificity parameters on the tolerance of drug-induced (poly I:C) natural killer (NK) cell activity. In the first experiment a protocol which provided mice with four weekly 20 micrograms/mouse ip injections of the immunostimulatory synthetic polynucleotide (poly I:C) following exposure to either a simple odor cue or a complex cue resulted in tolerance of NK cell activity. The identical protocol with a higher drug dose (50 micrograms/mouse) did not produce tolerance. In a second experiment, the stimulus specificity of tolerance was assessed by giving two groups of mice repeated signaled drug injections. For one of these groups the final poly I:C injection of the series was signaled, while for the other group it was not. Although both groups were tolerant relative to controls not previously exposed to the drug, indirect evidence of conditioning was obtained. Specifically, it was found that tolerance among mice receiving the signal on the test was such that they were not different from undrugged controls, while uncued mice had significantly higher levels of NK cell activity. The third experiment evaluated the role of stimulus specificity within an extinction paradigm. It was found that tolerance was reversed in mice provided with repeated nonreinforced reexposure to drug-signaling cues, while mice exposed to novel cues remained tolerant. These results further support the hypothesis that associative factors contribute to the tolerance of a drug-induced immune response.

Two experiments were conducted to assess the role of conditioning factors on the tolerance of drug-induced natural killer (NK) cell activity. A protocol in which mice were given four weekly injections of the immunostimulatory synthetic polynucleotide (poly I:C) paired with a complex environmental stimulus produced a reliable tolerance effect. The sensitivity of the observed tolerance to known decremental conditioning procedures--extinction (Experiment 1) and preexposure to the conditioning stimulus (latent inhibition, Experiment 2)--was investigated. The results indicated that posttreatment exposure to drug-signaling cues (i.e., extinction) significantly reversed tolerance such that NK cell activity was at a level comparable to that for controls receiving the drug for the first time (Experiment 1). In a similar fashion, pretreatment exposure to the drug-signaling cues (CS preexposure) inhibited the development of tolerance (Experiment 2). These results provide initial evidence that nonpharmacological manipulations of drug-signaling environmental cues can affect tolerance to the immunostimulatory effect of poly I:C, as would be expected with a conditioning analysis of such tolerance.

The hypothesis that neuroendocrine stimulation after aversive handling can alter natural resistance was examined in the tail electroshock (TES) model, a procedure that can activate pituitary neuropeptide secretion. Immediately after a brief TES session, the resistance of DBA/2J mice was suppressed in proportion to the intensity of the shock. Initial suppression of the natural resistance was rapidly reversed in longer treatment protocols, and repeated aversive stimulation augmented the antitumor response, leaving the mice more resistant to lymphoma than unhandled animals. Corticosterone was released into the serum after all acute handling procedures, and hydrocortisone inoculation suppressed antitumor responses. However, serum corticosterone levels did not quantitatively correlate with the alterations in natural resistance. The observation that TES-induced suppression of natural resistance could be reversed by the opiate receptor antagonist naltrexone suggested that endogenous opiated released after TES stimulation were immunosuppressive.