Search PubMed⌕ Search

Biomedical subjects

R E Drake

Publications and source records attributed to R E Drake.

At least 55 records · Page 3Linked to original sources
PubMed1998

Organizational guidelines for dual disorders programs.

Dual disorders--combined severe mental disorders and substance use disorders--were barely recognized two decades ago. As a result of the high prevalence and serious consequences of these disorders, they have received considerable attention over the last two decades. Knowledge has accumulated about dual disorders and their treatment, and treatment providers may now consider numerous options for clinical interventions and program designs. In this article, we offer guidelines concerning these options. We review the current knowledge about dual disorders and the results of recent research on the assessment and treatment of these disorders. We present treatment principles, recommendations on the components and organization of dual disorders programs, and suggestions for dealing with clinical issues that remain controversial. We conclude with comments on the demands of the managed care environment and the heightened importance of continued research in this area.

Counseling↗
PubMed1998

Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial.

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder.

Adult↗
PubMed1998

Program fidelity in assertive community treatment: development and use of a measure.

Assertive community treatment (ACT) is a complex community-based service approach to helping people with severe mental disorders live successfully in the community. Effective replication of the model and research on critical elements require explicit criteria and measurement. A measure of program fidelity to ACT and the results of its application to fifty diverse programs are presented.

Community Mental Health Services↗
PubMed1998

Methodological issues in assertive community treatment studies.

Recent evaluations of ACT programs have produced equivocal findings, often leading to the invocation of methodological problems as responsible for the lack of positive results. This paper discusses issues of theory and methodology as they pertain to improving research of ACT, with particular attention paid to issues of sampling, process evaluation, measurement, and data analysis.

Bias↗
PubMed1998

Models of community care for severe mental illness: a review of research on case management.

We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

Activities of Daily Living↗
PubMed1998

Review of integrated mental health and substance abuse treatment for patients with dual disorders.

Patients with severe mental disorders such as schizophrenia and co-occurring substance use disorders traditionally received treatments for their two disorders from two different sets of clinicians in parallel treatment systems. Dissatisfaction with this clinical tradition led to the development of integrated treatment models in which the same clinicians or teams of clinicians provide substance abuse treatment and mental health treatment in a coordinated fashion. We reviewed 36 research studies on the effectiveness of integrated treatment for dually diagnosed patients. Studies of adding dual-disorders groups to traditional services, studies of intensive integrated treatments in controlled settings, and studies of demonstration projects have thus far yielded disappointing results. On the other hand, 10 recent studies of comprehensive, integrated outpatient treatment programs provide encouraging evidence of the programs' potential to engage dually diagnosed patients in services and to help them reduce substance abuse and attain remission. Outcomes related to hospital use, psychiatric symptoms, and other domains are less consistent. Several program features appear to be associated with effectiveness: assertive outreach, case management, and a longitudinal, stage-wise, motivational approach to substance abuse treatment. Given the magnitude and severity of the problem of dual disorders, more controlled research on integrated treatment is needed.

Case Management↗
PubMed1998

Effect of sheep plasma and lymph on fibroblast proliferation.

Blood plasma contains many factors that influence cellular proliferation. However, cells within the tissue spaces of most organs are exposed to interstitial fluid, and the composition of interstitial fluid may be much different from plasma. Accordingly, the effect of interstitial fluid on cellular proliferation may be much different from the effect of plasma. The aim of this study was to test the effect of blood plasma and interstitial fluid (lymph) from the lung and intestine on the proliferation of fibroblasts. Plasma and lung and intestinal lymph were collected from anesthetized sheep and added to standard culture medium (final concentration = 10%). Cells (fibroblasts) were cultured from the lungs of the sheep and grown to confluence. Then the cells were subcultured at low density and incubated with the medium containing plasma or lymph. Control dishes contained only cells and medium. The cells were counted over a 6-day period. Cells incubated with medium alone grew very little over the 6-day period, but cells exposed to plasma increased approximately 100-fold, and cells exposed to lymph increased approximately 10-fold. We found no significant difference in cell growth for cells incubated with lung versus intestinal lymph. Our results show lung and intestinal lymph are less effective than plasma in stimulating cell growth.

Animals↗
PubMed1998

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness.

OBJECTIVE: Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness. METHOD: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. RESULTS: The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. CONCLUSIONS: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

Adult↗
PubMed1998

Lymphatic drainage reduces intestinal edema and fluid loss.

Lymphatic vessels are important in removing excess fluid from the intestine and transporting the fluid to veins in the neck. However, in some diseases, neck vein pressure is increased and the high pressure may slow lymph flow. This study was to test the hypothesis that lymphatic clearance of fluid from the intestine may be increased by draining the lymphatics. Inflatable cuffs were used to increase neck vein pressure and portal venous pressure in anesthetized sheep. The lymphatic vessel from one segment of small intestine was cannulated and drained. The lymphatic vessel to a control segment of intestine was left intact. After 90 min. we found significantly less fluid in the lumen of the drained vs. control segments (7.4 +/- 3.1 (SD) ml vs 11.5 +/- 4.7 ml per gram dry tissue, respectively). Also we found significantly less tissue fluid in the drained vs control segments (5.3 +/- 0.3 ml/g vs 6.0 +/- 0.4 ml/g). The findings support the hypothesis that external diversion of lymph in the presence of an elevated central venous pressure reduces edema formation.

Animals↗
PubMed1998

Cost-effectiveness of assertive community treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders.

OBJECTIVE: To determine the cost-effectiveness of Assertive Community Treatment (ACT) in comparison to Standard Case Management (SCM) for persons with severe mental illness and substance use disorders. DATA SOURCES AND STUDY SETTING: Original data on the effectiveness and social costs of ACT and SCM that were collected between 1989 and 1995. Seven community mental health centers in New Hampshire provided both types of treatment. STUDY DESIGN: Persons with schizophrenia, schizoaffective disorder, or bipolar disorder and a concurrent substance use disorder were randomly assigned to ACT or SCM and followed for three years. The primary variables assessed were substance use, psychiatric symptoms, functioning, quality of life, and social costs. DATA COLLECTION METHODS: Effectiveness data were obtained from interviews at six-month intervals with persons enrolled in treatment and with their service providers. Social cost and service utilization data came from client reports; interviews with informal caregivers; provider information systems and Medicaid claims; law enforcement agencies; courts; and community service providers. PRINCIPAL FINDINGS: Participants in both groups showed significant reductions in substance use over time. Focusing on quality of life and substance use outcomes, ACT and SCM were not significantly different in cost-effectiveness over the entire three-year study period. Longitudinal analyses showed that SCM tended to be more efficient during the first two years but that ACT was significantly more efficient than SCM during the final year of the study. CONCLUSIONS: In an adequately funded system, ACT is not more cost-effective than SCM. However, ACT efficiency appears to improve over time.

Adolescent↗
PubMed1997

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial behavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems.

Adult↗
PubMed1997

Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions.

An emerging body of research on the physical and sexual abuse of seriously mentally ill (SMI) women documents a high incidence and prevalence of victimization within this population. While causal links are not well understood, there is convergent evidence that victimization of SMI women is associated with increased symptom levels, HIV-related risk behaviors, and such comorbid conditions as homelessness and substance abuse. These abuse correlates may influence chronicity, service utilization patterns, and treatment alliance. This article reviews the research literature on the prevalence, symptomatic and behavioral correlates, and treatment of abuse among SMI women, particularly women with schizophrenia. Within each topic, we discuss relevant research findings, limitations of available studies, and key questions that remain unanswered. We also discuss mechanisms that may underlie the relationship between trauma and schizophrenia-spectrum disorders. We conclude by outlining directions for future research in this area.

Child↗
PubMed1997

Relationships between symptoms of schizophrenia and substance abuse.

Previous work posits that severity of substance abuse and severity of schizophrenic symptoms should be linked by either or both of two mechanisms: self-regulation of symptoms and drug-induced exacerbation of symptoms. Research on these relationships has yielded mixed results. We examined the interrelationships of schizophrenic symptoms and substance abuse in 172 patients with co-occurring disorders. Relationships were weak or nonexistent, without any consistent pattern. Our findings do not support the view that substances are used to self-regulate symptoms. In addition, our results suggest that substance abuse may lead to higher rates of institutionalization through mechanisms other than by exacerbating symptoms.

Adolescent↗
PubMed1997

Integrated treatment for dually diagnosed homeless adults.

This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.

Adolescent↗
PubMed1997

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis.

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

Activities of Daily Living↗
PubMed1997

Pulmonary microvascular reflection coefficients estimated with modified lymphatic washdown technique.

Many investigators have used the lymphatic protein washdown technique to estimate the pulmonary microvascular membrane reflection coefficient to protein (sigma d). With that technique, the investigator causes a high microvascular filtration rate then estimates sigma d from the lymph and plasma protein concentrations. However the lymph may contain protein washed from the lung tissue, and the tissue protein may cause investigators to underestimate sigma d. Plasma protein osmotic pressure (IIc) may cause investigators to underestimate sigma d because IIc opposes fluid filtration. To minimize the effect of IIc, we decreased IIc to 5.6 +/- 1.1 mmHg in five anesthetized sheep. We increased the microvascular filtration rate by increasing pulmonary microvascular pressure to 22 +/- 3 mmHg. Then we tagged plasma protein with Evans blue dye and estimated sigma d from the lymph and plasma dye concentrations. Because tissue protein was not tagged, it did not interfere with our sigma d estimate. Our sigma d estimate (0.79 +/- 0.08) was much higher than previous estimates in anesthetized animals.

Animals↗