Biomedical subjects

R E Drake

Publications and source records attributed to R E Drake.

At least 19 recordsLinked to original sources

PubMed2001

Rural and urban differences in patients with a dual diagnosis.

OBJECTIVES: To evaluate the differences between two cohorts of patients with severe mental illness (schizophrenia-spectrum or bipolar disorder) and co-occurring substance-use disorders, living in either predominantly rural areas or urban areas. METHODS: Two study groups of patients with a dual diagnosis, recruited using the same criteria, were evaluated, including 225 patients from New Hampshire and 166 patients from two cities in Connecticut. The two study groups were compared on demographic characteristics, housing, legal problems, psychiatric and substance use diagnoses, substance use and abuse, psychiatric symptoms, and quality of life. RESULTS: Patients in the Connecticut study group had higher rates of cocaine-use disorder, more involvement in the criminal justice system, more homelessness, and were more likely to be from minority backgrounds. The Connecticut group also had a higher proportion of patients with schizophrenia and more severe symptoms, as well as lower rates of marriage, educational attainment, and work than the New Hampshire study group. Alcohol-use disorder was higher in the New Hampshire group. Subsequent analyses within the Connecticut group indicated that although African American patients had higher rates of cocaine-use disorder than white patients, cocaine disorder and not minority status was most strongly related to criminal involvement and homelessness. CONCLUSIONS: Because of the substances abused and the greater degree of psychiatric illness severity, patients with a dual diagnosis who are living in urban areas may require greater ancillary services, such as residential programs, Assertive Community Treatment, and jail diversion programs in order to treat their disorders successfully.

Adult↗

PubMed2001

Managing comorbid schizophrenia and substance abuse.

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.

Cognitive Behavioral Therapy↗

PubMed2001

Social patterns of substance use among people with dual diagnoses.

An ethnography, part of the larger New Hampshire Dual Diagnosis Study, discovered in a small subsample (n = 16) that clients participated in 1 (or sometimes 2) of 4 distinct and different social patterns of substance-use. These 4 patterns, (1) "the lone user," (2) "the small, closed social clique," (3) "the large, open user syndicate," and (4) the "entrepreneurial drug provider," manifest important social functions of such substance-use. These social functions need to be taken into account as case managers attempt to persuade clients to abstain from using substances, because changing one's substance-use immediately affects one's participation in these user networks. Case managers can understand the social pressures toward certain patterns of substance-use by attending to the social patterning of that use. Many social functions provided by these social patterns must be continued by other means if clients, once persuaded to attempt abstinence, are to be effectively supported in their sobriety.

Diagnosis, Dual (Psychiatry)↗

PubMed2001

Reliability of instruments in a cooperative, multisite study: employment intervention demonstration program.

Reliability of well-known instruments was examined in 202 people with severe mental illness participating in a multisite vocational study. We examined interrater reliability of the Positive and Negative Syndrome Scale (PANSS) and the internal consistency and test-retest reliability of the PANSS, the Rosenberg Self-Esteem Scale, the Medical Outcomes Study Short Form-36 (SF-36), and the Quality of Life Interview. Most scales had good levels of reliability, with intraclass correlation coefficients (ICCs) and coefficient alphas above .70. However, the SF-36 scales were generally less stable over time, particularly Social Functioning (ICC = .55). Test-retest reliability was lower among less educated respondents and among ethnic minorities. We recommend close monitoring of psychometric issues in future multisite studies.

Adult↗

PubMed2001

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.

Adult↗

PubMed2001

Ethnographic findings from the Washington, D.C., Vocational Services Study.

Based on a 20-month period of participant observations and interviews of persons receiving services, employment specialists and clinicians, this ethnographic substudy identified and documented dilemmas encountered during implementation of an assertive, manualized supported employment program, Individual Placement and Support (IPS), situated in a Washington, D.C., community mental health organization that previously focused on clinical interventions but lacked vocational services. Those receiving services, primarily African Americans, had extensive histories of homelessness and dual diagnosis, and minimal work experiences. Real-world issues centered on conflicting expectations and priorities, diverse perceptions of the role of work, and difficulties in integrating vocational rehabilitation with clinical treatment.

Employment, Supported↗

PubMed2001

Implementing evidence-based practices for persons with severe mental illnesses.

Extensive empirical research, summarized in several reviews and codified in practice guidelines, recommendations, and algorithms, demonstrates that several pharmacological and psychosocial interventions are effective in improving the lives of persons with severe mental illnesses. Yet the practices validated by research are not widely offered in routine mental health practice settings. As part of an effort to promote the implementation of evidence-based practice, the authors summarize perspectives on how best to change and sustain effective practice from the research literature and from the experiences of administrators, clinicians, family advocates, and services researchers. They describe an implementation plan for evidence-based practices based on the use of toolkits to promote the consistent delivery of such practices. The toolkits will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Special materials will address the concerns of mental health authorities (funders), administrators of provider organizations, clinicians, and consumers and their families.

Community Mental Health Services↗

PubMed2001

Requirements for multidisciplinary teamwork in psychiatric rehabilitation.

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.

Case Management↗

PubMed2001

Developing effective treatments for posttraumatic disorders among people with severe mental illness.

OBJECTIVE: The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms. METHODS: The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities. RESULTS AND CONCLUSIONS: Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.

Female↗

PubMed2001

Policy implications for implementing evidence-based practices.

The authors describe the policy and administrative-practice implications of implementing evidence-based services, particularly in public-sector settings. They review the observations of the contributors to the evidence-based practices series published throughout 2001 in Psychiatric Services. Quality and accountability have become the watchwords of health and mental health services; evidence-based practices are a means to both ends. If the objective of accountable, high-quality services is to be achieved by implementing evidence-based practices, the right incentives must be put in place, and systemic barriers must be overcome. The authors use the framework from the U.S. Surgeon General's 1999 report on mental health to describe eight courses of action for addressing the gap between science and practice: continue to build the science base; overcome stigma; improve public awareness of effective treatments; ensure the supply of mental health services and providers; ensure delivery of state-of-the-art treatments; tailor treatment to age, sex, race, and culture; facilitate entry into treatment; and reduce financial barriers to treatment.

Ethnicity↗

PubMed2001

Implementing evidence-based practices in routine mental health service settings.

The authors describe the rationale for implementing evidence-based practices in routine mental health service settings. Evidence-based practices are interventions for which there is scientific evidence consistently showing that they improve client outcomes. Despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research shows that routine mental health programs do not provide evidence-based practices to the great majority of their clients with these illnesses. The authors define the differences between evidence-based practices and related concepts, such as guidelines and algorithms. They discuss common concerns about the use of evidence-based practices, such as whether ethical values have a role in shaping such practices and how to deal with clinical situations for which no scientific evidence exists.

Combined Modality Therapy↗

PubMed2001

Implementing supported employment as an evidence-based practice.

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.

Community Mental Health Centers↗

PubMed2001

Converting day treatment centers to supported employment programs in Rhode Island.

OBJECTIVE: The purpose of the study was to compare vocational and nonvocational outcomes of clients of two community mental health centers that underwent conversion from day treatment programs to supported employment programs with outcomes of clients of a center that delayed conversion until after the study was completed. METHODS: As part of a statewide effort in Rhode Island to convert day treatment programs to supported employment programs, the authors assessed 127 day treatment clients with severe mental illness in three community mental health centers. Two of the centers converted to supported employment, and one continued its rehabilitative day program. Participants were assessed prospectively for 30 to 36 months, with special attention to vocational and social outcomes. RESULTS: Former day treatment clients in the converted centers attained higher rates of competitive employment than those in the comparison group (44.2 percent and 56.7 percent versus 19.5 percent). Other employment outcomes also improved, and hospitalization rates and overall social functioning were unchanged. CONCLUSIONS: This study supports findings of previous studies suggesting that replacing rehabilitative day treatment programs with supported employment programs yields improvements in employment outcomes without adverse effects.

Adolescent↗

PubMed2001

Implementing dual diagnosis services for clients with severe mental illness.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Counseling↗

PubMed2001

A comparison of long-term and short-term residential treatment programs for dual diagnosis patients.

The authors compared measures of process and six-month outcomes for 45 individuals who were treated in a long-term residential treatment program for patients with dual diagnoses with measures for 39 individuals who were treated in a short-term program. They also compared outcomes for individuals within each group. Those who received long-term treatment experienced improvements between entry into the program and six-month follow-up, and they were more likely to have engaged in treatment than individuals in the short-term group. At follow-up, individuals in the long-term residential treatment group were more likely to have maintained abstinence and less likely to have experienced homelessness than those in the short-term group.

Adult↗

PubMed2001

Moving assertive community treatment into standard practice.

This article describes the assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness and discusses issues pertaining to implementation of the model. The assertive community treatment model has been the subject of more than 25 randomized controlled trials. Research has shown that this type of program is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care. Despite evidence of the efficacy of assertive community treatment, it is not uniformly available to the individuals who might benefit from it.

Community Mental Health Services↗

PubMed2001

Fidelity of supported employment programs and employment outcomes.

This study attempted to identify critical components of a supported employment program that were strongly correlated with competitive employment outcomes in a state mental health system. Researchers used a supported employment fidelity scale to rate programs at ten community mental health centers in Vermont. The staff at the centers concurrently assessed competitive employment outcomes for 2,639 clients who had been diagnosed as having severe and persistent mental illness. Higher competitive employment rates were strongly correlated with overall program fidelity and with two program components, namely, providing services in the community as opposed to providing them in the clinic and using full-time employment specialists as opposed to staff with mixed roles.

Adolescent↗

PubMed2000

Evidence-based treatment of schizophrenia.

People with schizophrenia can be helped greatly with pharmacologic and psychosocial interventions that are known to be effective. Several interventions are now supported by research: use of medications following specific guidelines, training in illness self-management, case management based on principles of assertive community treatment, family psychoeducation, supported employment, and integrated substance abuse treatment. However, few patients actually receive these evidence-based interventions because they are not provided in routine mental health settings. Therefore, implementing effective treatments in mental health treatment programs is a critical challenge for the field. We review the six areas of evidence-based treatment of schizophrenia, as well as knowledge regarding implementation of mental health programs in routine practice settings.

Antipsychotic Agents↗