Patient perceptions of coercion in mental hospital admission.
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Adult↗
Biomedical subjects
H R Wagner
Publications and source records attributed to H R Wagner.
Interpreting the effectiveness of involuntary outpatient commitment: a conceptual model.
Many experimental trials of community mental health interventions fail to develop testable conceptual models of the specific mechanisms and pathways by which relevant outcomes may occur, thus falling short of usefully interpreting what happens inside the experimental "black box." This paper describes a conceptual model of involuntary outpatient commitment (OPC) for persons with severe and persistent mental disorders. The model represents an attempt to "unpack" the effects of OPC by incorporating several interacting variables at various stages. According to this model, court-mandated outpatient treatment may improve long-term outcomes both directly and indirectly in several ways: by stimulating case management efforts, mobilizing supportive resources, improving individual compliance with treatment in the community, reducing clients' psychiatric symptoms and dangerous behavior, improving clients' social functioning, and finally by reducing the chance of illness relapse and rehospitalization. A randomized clinical trial of OPC is underway in North Carolina that will test the direct and indirect effects suggested by this model, using longitudinal data from the multiple perspectives of mental health clients, family members, and case managers.
Ambulatory Care↗
New directions in research on involuntary outpatient commitment.
OBJECTIVE: Involuntary outpatient commitment has been used as a method of improving tenure in community programs for individuals with severe and persistent mental illness. This paper reviews literature on research about involuntary outpatient commitment and suggests questions and methods for future research. METHODS: Literature describing research studies of involuntary outpatient commitment, located by searching MEDLINE and following up references cited in relevant articles, was reviewed with attention to patient characteristics and diagnostic, treatment, and outcomes measures. RESULTS: Involuntary outpatient commitment appears to provide limited but improved outcomes in rates of rehospitalization and lengths of hospital stay. Variability in community treatment makes interpretation of other types of outcome difficult. Few studies specifically identify results among patients with severe and persistent mental illness. CONCLUSIONS: No studies have examined the extent to which outpatient commitment affects compliance and treatment when essential community services such as case management are consistently and aggressively provided, nor have studies controlled for potentially confounding factors such as treatment and nontreatment effects, including informal coercion. A randomized trial of involuntary outpatient commitment should be useful in evaluating the effectiveness of this type of intervention.
Ambulatory Care↗
The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services.
OBJECTIVE: This study investigated how insurance coverage for mental health services affects outpatient mental health service utilization among those with and among those without a DSM-III psychiatric diagnosis. The authors used a representative community sample to compare the regression effects of insurance coverage on utilization of mental health services among these subjects. METHOD: Data are from the second wave of the Piedmont, North Carolina, site of the Epidemiologic Catchment Area project. These data contain DSM-III diagnostic measures derived from the National Institute of Mental Health Diagnostic Interview Schedule as well as measures of insurance coverage and utilization. Responses from 2,889 community residents were analyzed using both ordinary least squares and logistic regression. RESULTS: In both models, insurance coverage was strongly associated with care among those with as well as among those without a psychiatric disorder. The association between coverage and the probability of care was strongest among those with a disorder. CONCLUSIONS: The findings are not consistent with the claim that failing to provide insurance coverage will reduce discretionary but not necessary mental health care utilization. They provide evidence that failing to provide insurance coverage will reduce utilization as much or more among those with a psychiatric disorder as among those without. This result has important implications for health care reform.
Adult↗
Mental health service use by the elderly in nursing homes.
OBJECTIVES: Because current Omnibus Budget Reconciliation Act regulations influence the disposition of US nursing home residents who have mental illness, National Nursing Home Survey (1985) data are analyzed for predictors of mental health service use. METHODS: Elderly residents' rates of mental health service use are presented. Logistic regression yielded odds ratios for treatment by both mental health specialists and general practitioners for client and service system variables. RESULTS: Among the two thirds of elderly residents with a mental disorder (including dementia), only 4.5% receive any mental health treatment in a 1-month period. The ratio of specialist to general practitioner care is approximately 1:1. Patients seen by a specialist are likely to be younger (aged 65 to 74); live in the Northeast; and have a diagnosis of schizophrenia (13:1), dementia (3:1), or other mental disorders (5:1). Prior residence in a psychiatric hospital predicts care by both health professional types. Rural location, nonproprietary ownership of the nursing home, and aggressive behavior point to general physician care. CONCLUSIONS: Our findings indicate significant neglect of the mental health needs of older nursing home residents and underscore the importance of monitoring the regulations for screening and treatment of mental disorders under the Omnibus Budget Reconciliation Act.
Aged↗
Tetralogy of Fallot and coarctation of the aorta: a rare combination and its clinical implications.
A neonate with tetralogy of Fallot and aortic coarctation is described. The clinical course was remarkable, with early congestive heart failure followed by rapidly progressive left ventricular myocardial thickening and the presentation of hypercyanotic spells. Primary repair of tetralogy without correction of coarctation was attempted unsuccessfully at 1 month of age. Death followed postoperative bradycardia, hypotension, and low cardiac output. Fetal and neonatal hemodynamics and the clinical implication of this rare combination of defects are discussed. Initial surgical intervention should relieve left-sided obstruction.
Aortic Coarctation↗
Diagnosis and surgical correction of patent ductus venosus in a calf.
Patent ductus venosus was diagnosed in a 10-week-old Holstein heifer with acute onset of collapse and marked tenesmus. Additional clinical signs observed during the course of hospitalization included depression, anorexia, hind limb ataxia, bruxism, and poor growth. Clinicopathologic test results included high blood ammonia concentration, prolonged sulfobromophthalein half-life, and high serum bile acid concentration. Liver biopsy revealed mild periportal fibrosis, but no appreciable hepatocyte atrophy. Mesenteric portography and percutaneous ultrasonography confirmed the patent ductus venosus. An atrial septal defect prosthesis was placed in the ductus venosus, using a catheterization technique. After surgery, however, clinicopathologic test results were unchanged. Ultrasonography revealed that the prosthesis had pulled away from one side of the vessel. When the calf was 10.5 months old, surgical correction was achieved by a transhepatic ligation technique. Ultrasonography confirmed closure of the ductus venosus during and after surgery. Blood ammonia and serum bile acid concentrations and sulfobromophthalein half-life were normal 3 weeks after surgery. The calf had no further episodes of hepatoencephalopathy and was successfully bred at 18 months of age.
Animals↗
Pharmacodynamic profile of CQP 201-403, a novel 8 alpha-amino-ergoline.
The profile of action in animals of CQP 201-403, a novel 8 alpha-amino-ergoline, is in most aspects that of a very potent dopaminomimetic, both as a prolactin secretion inhibitor, and at the levels of the CNS and the cardiovascular system. Qualitatively CQP 201-403 differs slightly from bromocriptine and apomorphine in its effects on the CNS (no influence on serotonin metabolism in the rat cortex; induction of masculine mounting behavior in rats) and the cardiovascular system of the dog (reflex tachycardia in response to a blood-pressure fall). In man the new compound proved to be highly active in lowering prolactin serum levels and be more potent than bromocriptine (Parlodel).
Animals↗
Transposition of the great arteries with aortic arch obstruction. Anatomical review and report of surgical management.
Transposition of the great arteries (S,D,D) is a common congenital cardiovascular malformation that is occasionally associated with ventricular septal defect and left ventricular outflow tract obstruction. Recently right ventricular outflow tract obstruction associated with an aortic arch anomaly has been recognized as an infrequent but important variant of transposition of the great arteries, and this constellation presents a unique surgical challenge. Five infants with this constellation whose systemic circulation was dependent on flow through the ductus arteriosus have undergone definitive surgical treatment with four survivors. An anatomical review of 129 specimens with transposition of the great arteries revealed that 17% had right ventricular outflow tract obstruction and 7% had associated aortic arch obstruction as well. All specimens with aortic arch obstruction and ventricular septal defect except one had a malalignment type ventricular septal defect. Although several treatment options may be considered, recent experience with arterial switch repair in the neonate with transposition of the great arteries (S,D,D) prompted repair in these patients by arterial switch, ventricular septal defect closure, repair of aortic arch obstruction, and augmentation of the right ventricular outflow tract.
Aorta, Thoracic↗
Reserpine-induced up-regulation of dopamine D2 receptors in the rat striatum is enhanced by denervation but not by chronic receptor blockade.
Compensatory increases in the density of dopamine (DA) D2 receptors in the rat striatum occur following chronic interruption of dopaminergic neurotransmission. Substantia nigra lesions, DA depletion with reserpine and D2 receptor blockade by neuroleptics increase the number of striatal D2 receptors as identified with the D2 ligand, [3H]spiperone [( 3H]SPIP). Chronic administration of haloperidol to substantia nigra-lesioned rats causes an additive increase in binding over levels obtained with one treatment alone. In this study we have found a similar response when lesioned animals are treated with reserpine. However, compensatory increases in the number of [3H]SPIP binding sites found after combined administration of reserpine and haloperidol to intact rats do not exceed levels obtained following administration of either drug alone. The data suggest that up-regulation of striatal D2 binding sites occurring after substantia nigra lesions is unique relative to other forms of up-regulation and may involve the loss of a presynaptic regulatory factor other than DA.
Animals↗
The heart is under the lower third of the sternum. Implications for external cardiac massage.
Current guidelines for cardiopulmonary resuscitation in children state that the heart lies under the midsternum in infancy and descends with age. To verify this statement, we studied 55 patients, aged 1 day to 19 years, including eight premature infants, during either routine chest x-ray films or right-sided heart angiography. Using a Cartesian coordinate system determined by radiopaque markers placed on the chest, and computer digitization, we located the center of each patient's cardiac silhouette and/or right ventricle. Using descriptive statistics, we found that the heart lay under the lower third of the sternum in all age groups. Analysis of variance indicated that there was no significant difference in this location between age groups. These results suggest that recommendations for external cardiac massage in infants and children may need to be revised.
Adolescent↗
Historical aspects of interventional cardiology: past, present and future.
The purpose of this presentation is to report the progress of two interventional catheter techniques that have occupied my attention for the last 10 years; namely, transcatheter patent ductus arteriosus occlusion and patch atrial septal defect closure. A brief survey of the aspects of interventional cardiology, including its past, present and future, will also be included.
Journal Article↗
Clonazepam-induced up-regulation of serotonin1 and serotonin2 binding sites in rat frontal cortex.
Chronic administration of the benzodiazepine clonazepam increased the number of [3H]5-HT (5-HT1) and [3H]SPIP (5-HT2) binding sites in rat frontal cortex. In each instance, binding changes reflected increases in the maximum densities of binding sites (Bmax) with no change in ligand affinities (KD). Increases in binding required continued clonazepam exposure (10 days) at high doses. [3H]5-HT binding was significantly elevated at daily dose levels (i.p.) of 5.0 mg/kg but not 2.5 mg/kg. [3H]SPIP binding was significantly increased at drug doses of 2.5 mg/kg but not 1.0 mg/kg. Binding changes were regional in that they occurred in membranes from frontal cortex but not brainstem. A second benzodiazepine, diazepam, did not affect either binding site at daily doses of 30 mg/kg. These data suggest that serotonin receptor changes seen after chronic clonazepam may occur as a compensatory response to decreases in the presynaptic release of serotonin.
Animals↗
The effects of chronic bromocriptine treatment on behaviour and dopamine receptor binding in the rat striatum.
Agonist-induced rotation and striatal binding of [3H]spiperone ([3H]SPIP) were assessed in rats with unilateral lesions of the substantia nigra during and after a period of chronic bromocriptine administration. Agonist-induced rotation significantly increased over a three week period of daily administration of bromocriptine (10 mg/kg i.p.); control animals were tested for agonist-induced rotation at one week intervals, which remained constant. Rotation was increased by chronic bromocriptine administration in response to either of two DA agonists, apomorphine (APO) and bromocriptine, suggesting that increased agonist sensitivity did not reflect a reduction in the metabolism of bromocriptine. Striatal binding of the dopamine D2 radioligand, [3H]SPIP, was significantly increased in the denervated striata of nigra-lesioned rats. Chronic bromocriptine administration decreased binding in denervated striata to levels not significantly different from control values. [3H]SPIP binding in intact striata was significantly reduced by bromocriptine to below control values. Differences in receptor levels reflected changes in the maximum density of binding sites with no change in affinities. Paradoxical behavioural hypersensitivity developing during chronic bromocriptine levels is not apparently mediated by changes in striatal D2 binding sites.
Animals↗
Presynaptic inhibition of dopamine synthesis in rat striatum: effects of chronic dopamine depletion and receptor blockade.
These studies assessed the effects of dopamine (DA) depletion and receptor blockade on presynaptic inhibition of DA synthesis in the rat striatum. Chronic reserpine administration significantly decreased striatal DA levels but did not affect in vivo tyrosine hydroxylase activity, as determined by following dihydroxyphenylalanine (DOPA) accumulations. Both reserpine and haloperidol increased the sensitivity of presynaptic striatal DA response as determined by the ability of apomorphine (APO) to inhibit DOPA accumulation in NSD-1015-treated rats. The effect of concurrent administration of reserpine plus haloperidol on presynaptic response was additive. Additivity occurred at doses of reserpine and haloperidol which induced maximum sensitivity when administered singularly. The data suggest that increases in sensitivity of presynaptic DA response following DA depletion and receptor blockade are mediated by separate regulatory mechanisms.
Animals↗
Clonazepam-induced up-regulation of serotonin1 binding sites in frontal cortex of rat.
Chronic administration of the benzodiazepine, clonazepam, increased the number of [3H]5-hydroxytryptamine (5-HT1) binding sites in the frontal cortex of the rat. The increase reflected a change in the maximum density of binding sites (Bmax) with no change in ligand affinity (Kd). Increased binding occurred after continued exposure (10 days) to large (5.0 mg/kg) doses of clonazepam. The changes in [3H]5-HT binding were regional in that they occurred in membranes from the frontal cortex but not the brainstem. The effects were also at least partially selective for 5-HT receptors since the binding of the beta-adrenergic radioligand, [3H]dihydroalprenolol, was not affected by clonazepam. A second benzodiazepine, diazepam, did not affect the binding of [3H]5-HT at doses of 30 mg/kg per day. The latter data suggest that the effects of benzodiazepines on serotonin 5-HT1 receptors are unique to clonazepam.
Animals↗
Pneumothorax during positive-pressure mechanical ventilation.
The hemodynamic and respiratory effects of unilateral pneumothorax were studied during positive-pressure mechanical ventilation in five sheep. The sheep were anesthetized, intubated, and placed on mechanical ventilation with positive end-expiratory pressure (5 cm H2O). After baseline studies, including chest roentgenograms, were taken, increments of air were injected into the right pleural cavity. Measurements were repeated at pneumothoraces of 500, 1,000, and 1,500 ml. There was a steady fall in cardiac output (p less than 0.02) at pneumothoraces of 1,000 and 1,500 ml. The decrease in cardiac stroke volume paralleled that of cardiac output. Heart rate rose (p less than 0.05) at a pneumothorax of 1,500 ml. There appeared to be a linear relationship between the percent increase in pneumothorax as estimated by roentgenogram and the percent fall in cardiac output (r = 0.991). There was a steady rise in mean pulmonary arterial, pulmonary arterial capillary wedge, superior vena caval, and inferior vena caval pressures, although the changes in inferior vena caval pressure were not statistically different from baseline. Peak airway pressure increased from baseline at pneumothoraces of 1,000 and 1,500 ml. Both right and left end-expiratory intrapleural pressures increased and were statistically different (p less than 0.01) from baseline. However, there was a substantially greater rise in right intrapleural pressure than left. Arterial oxygen tension remained physiological throughout the study. This study indicates that cardiac output decreases as the amount of pneumothorax increases in sheep during mechanical ventilation. This study also demonstrates that, during positive-pressure mechanical ventilation, a relatively benign-appearing pneumothorax by chest roentgenogram may be associated with a significantly depressed cardiac output. In addition, arterial oxygen tension may not be useful in predicting the onset of pneumothorax during mechanical ventilation.
Animals↗
Electroconvulsive treatment and haloperidol: effects on pre- and postsynaptic dopamine receptors in rat brain.
Electroconvulsive treatment (ECT) has a transitory beneficial effect on patients with Parkinson's disease (PD). The possibility that this effect is mediated by dopamine (DA) receptors was investigated in the rat brain. Repeated ECT or chronic haloperidol treatment induced supersensitivity of putative autoreceptors in the nigrostrital and mesolimbic DA pathways as reflected by enhanced apomorphine-induced inhibition of DA synthesis. Effect of simultaneous administration of ECT plus haloperidol on DA receptor sensitivity were not additive. Chronic haloperidol treatment induced significant elevations in the density of 3[H]-spiperone striatal binding sites. Concurrent administration of ECT had no effect on the neuroleptic-induced supersensitivity. ECT alone was also without effect on 3[H]-spiperone binding. Thus, ECT-induced increases in the sensitivity of presynaptic autoinhibition of DA release was not reflected by changes in the striatal 3[H]-spiperone binding sites. This suggests that effects of ECT on the DA system are not mediated by dopamine D2 receptors.
Animals↗