Outpatient Treatment Center Research Articles

Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder

This randomized controlled trial compared the effectiveness of metacognitive therapy (MCT) and intolerance-of-uncertainty therapy (IUT) for generalized anxiety disorder (GAD) in an outpatient context. Patients with GAD ( N = 126) consecutively referred to an outpatient treatment center for anxiety disorder were randomly allocated to MCT, IUT, or a delayed treatment (DT) condition. Patients were treated individually for up to 14 sessions. Assessments were conducted before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). At posttreatment and follow-up assessments, substantial improvements were observed in both treatment conditions across all outcome variables. Both MCT and IUT, but not DT, produced significant reductions in GAD-specific symptoms with large effect sizes (ranging between 0.94 and 2.39) and high proportions of clinically significant change (ranging between 77% and 95%) on various outcome measures, and the vast majority of the patients (i.e., 91% in the MCT group, and 80% in the IUT group) no longer fulfilled the diagnostic criteria for GAD. Results further indicate that MCT produced better results than IUT. This was evident on most outcome measures, and also reflected in effect sizes and degree of clinical response and recovery.

Numbers and narratives. Relations between patient satisfaction, retention, outcome and program factors in outpatient substance abuse treatment

Aims Research on substance abuse treatment suggests patient satisfaction is linked to use of services and abstinence. However, patient perspectives on treatment are rarely examined. This study used mixed methods to examine correlations between patients’ treatment satisfaction, retention and abstinence from drugs and provide a transpersonal account of patient perspectives on treatment. Data and Methods Eight Danish outpatient substance abuse treatment centres participated in the study. Data was collected from 186 patients. Quantitative measures were used at baseline screenings and at 6 months follow-up interviews, including the Client Satisfaction Questionnaire-8 (CSQ-8). Qualitative measures were used for patient descriptions of treatment at follow-up. Results Patient satisfaction with treatment was linked to retention, abstinence and program differences. The qualitative data described patient's views on high or low treatment satisfaction. Conclusion The CSQ-8 is a valuable tool for monitoring patient engagement and treatment effect in substance abuse treatment services. The inclusion of patient perspectives underlined the importance of a more contextual understanding of program components.

Likelihood of Asking for Help in Caregivers of Women With Substance Use or Co-Occurring Substance Use and Mental Disorders

Family members are important to the well-being of their relatives with substance use disorders or co-occurring substance use and mental disorders. Many caregivers experience high levels of burden, negatively impacting their capacity to provide support to their ill family member. The Andersen health care utilization model (Andersen & Newman, 1973, 2005) was used to identify the impact of predisposing, enabling and need factors hypothesized to predict caregivers' likelihood of asking for help and support with their caregiving role. The sample include 82 women recruited from outpatient or inpatient substance abuse treatment centers and 82 family caregivers nominated by these women. Findings showed that almost half of caregivers were unlikely to ask for help. Multiple regression analysis found that two need variables were statistically signficant predictors of caregivers' likelihood to ask for help. Caregivers who had higher subject burden (worry) and caregivers who provided more assistance with daily living were more likely to ask for help. It is suggested that case managers assess the amount of worried family caregivers' experience because their worries may provide the motivation to ask for help or to participate in help when it is offered to them.

The effect of using assessment instruments on substance-abuse outpatients' adherence to treatment: a multi-centre randomised controlled trial.

BackgroundDrop-out is an important problem in the treatment of substance use disorder. The focus of this study was to investigate the effectiveness of within treatment assessment with feedback directly to patients with multiple substance use disorder on outpatient individual treatment adherence. Feedback consisted of personal resources' and readiness to change status and progress that facilitate or hinder change, thereby using graphical representation.MethodsInformed consent was obtained from both the control and experimental groups to be involved in research and follow-up. Following Zelen's single consent design, baseline participants (n = 280) were randomised (sample-size-estimation: 80%power, p=.05, 2-sided) and treatment consent was obtained from those allocated to the experiment (n = 142). In both groups, equal numbers of patients did not attend sessions after allocation. So, 227 persons were analyzed according to intention-to-treat analysis (ITT: experiment n = 116;control n = 111). Excluding refusals 211 participants remained for per-protocol analysis (PP: experiment n = 100; control n = 111), The study was conducted in five outpatient treatment-centres of a large network (De Sleutel) in Belgium. Participants were people with multiple substance use disorder -abuse and dependence- who had asked for treatment and who had been advised to start individual treatment after a standardised admission assessment with the European Addiction Severity Index.The experimental condition consisted of informing the patient about the intervention and of subsequent assessments plus feedback following a protocol within the first seven sessions. Assessments were made with the Readiness to Change Questionnaire and the Personal Resources Diagnostic System. The control group received the usual treatment without within treatment assessment with feedback. The most important outcome measure in this analysis of the study was the level of adherence to treatment at and beyond eight sessions.ResultsIndividual treatment that included assessment with feedback increased adherence to treatment at and beyond eight sessions (RR = 1.6,95%CI:1.2-2.2). Benefit was also found at and beyond twelve sessions, which was the number of sessions required to complete 90% of the assessments with feedback in practice (RR = 1.6,95%CI:1.2-2.5).ConclusionsAssessment with feedback in routine practice improved adherence to treatment. More research is needed to evaluate progress in social functioning and motivation to change in outpatient treatment of substance use disorder, thereby using objective measuresTrial registrationCurrent Controlled Trials ISRCTN65456186

Practical implementation of treatment guidelines concerning obesity in children and adolescents

Guidelines recommend a long-term outpatient lifestyle intervention in obese children and adolescents that also addresses the children's parents. However, lifestyle interventions are performed only in 1% of the 1,000,000 obese children and adolescents in Germany, suggesting a large gap between guidelines and medical care in real life. Possible reasons are a lacking awareness of the consequences of overweight, no time resources, and the lack of motivation to change lifestyle habits in some obese children and their families. Furthermore, there is no treatment option throughout Germany. The long-term success rate varies widely between outpatient treatment centers (<50% up to >70%), while the long-term effectiveness of short-term, inpatient intervention (rehabilitation) is unknown. However, many more obese children are treated by short-term rehabilitation compared to long-term outpatient intervention. Older and extreme obese children and adolescents are treated by lifestyle intervention, although this kind of intervention is more effective in younger and not so obese children. Some subgroups (extreme obese adolescents, obese disabled children) have no meaningful and effective treatment options.

P01-43 - Medication use in a dual pathology program: Observational study

IntroductionPolyfarmacy is frequent in patients with dual diagnosis.AimsTo quantify the number and describe the treatments prescribed in a cohort of outpatients with dual diagnosis.Material and methodsA descriptive and transversal study was performed. Patients with dual diagnosis treated at an Outpatient Drug Treatment Center from January 2005 to December 2009 were included. Data from demographic, clinical and therapeutical variables were gathered once. The instruments used for the diagnosis were EuropASI y SCID-I. The number and type of prescript drugs were related with protocol variables.ResultsThe study sample included 80 patients (71,6% men, average age 37,2 ± 9). Psychotic disorders (46.8%) and cocaine dependence/abuse (34.6%) were the most frequent comorbid psychiatric illnesses found. 40.8% of patients were polydrug users. The mean of prescript drugs was 3,06 ± 1,4 and only 14% of patients were on monotherapy. The frequency of drugs prescribed was: 68,4% antidepressant, 63,3% antipsychotic, 55,7% antiepileptic and 36,7% anxiolytic drugs. Older patients ( &gt; 45years) took a major number of prescripted drugs (3,88 ± 1,1). Patients with psychotic disorders took the 43.9% of drugs prescripted (p = 0,042). Patients with benzodiazepine abuse took higher number of prescription drugs (5 ± 1,4;p = 0,003) compared with patients with other dependence or abuse.ConclusionsPatients with dual diagnosis take high quantity of drugs. Older patients, diagnosis of psychosis and benzodiacepine abuse were related with polydrug prescription. Quantification of medication is recommended for treatment optimisation and avoiding yatrogenic.

Diagnosis and management of iron deficiency anaemia: a clinical update

Iron deficiency anaemia (IDA) remains prevalent in Australia and worldwide, especially among high-risk groups. IDA may be effectively diagnosed in most cases by full blood examination and serum ferritin level. Serum iron levels should not be used to diagnose iron deficiency. Although iron deficiency may be due to physiological demands in growing children, adolescents and pregnant women, the underlying cause(s) should be sought. Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal women) should be evaluated by gastroscopy/colonoscopy to exclude a source of gastrointestinal bleeding, particularly a malignant lesion. Patients with IDA should be assessed for coeliac disease. Oral iron therapy, in appropriate doses and for a sufficient duration, is an effective first-line strategy for most patients. In selected patients for whom intravenous (IV) iron therapy is indicated, current formulations can be safely administered in outpatient treatment centres and are relatively inexpensive. Red cell transfusion is inappropriate therapy for IDA unless an immediate increase in oxygen delivery is required, such as when the patient is experiencing end-organ compromise (eg, angina pectoris or cardiac failure), or IDA is complicated by serious, acute ongoing bleeding. Consensus methods for administration of available IV iron products are needed to improve the utilisation of these formulations in Australia and reduce inappropriate transfusion. New-generation IV products, supported by high-quality evidence of safety and efficacy, may facilitate rapid administration of higher doses of iron, and may make it easier to integrate IV iron replacement into routine care.

Valoración de los usuarios de un programa de reducción de daños integrado en un ambulatorio dedrogodependencias

Objectives We analyzed the perspective of users enrolled in a harm reduction program that provides syringe exchange, an educational room for «warmth and coffee», a methadone maintenance program, a room for supervised drug consumption, a place for personal hygiene, and medical and psychosocial follow-up. The particularity of this program lies in its integration within an outpatient drug treatment center forming part of a general hospital. Methods We performed a descriptive study using qualitative methods. Theoretical sampling was conducted. Twelve in-depth interviews and one focus group composed of eight users were carried out. Information analysis was based on grounded theory. Literal transcriptions were coded and subsequently sorted into broad categories. Three researchers participated in this process and finally a fourth researcher triangulated the results. Results Five dimensions were identified in the users’ discourse: accessibility, service, relationship, localization, and identity. Each consisted of several topics that were evaluated based on the participants’ experiences and expectations. The dimension of identity emerged as a distinctive element in patient-program bonding. Conclusions The users’ overall evaluation of the program was positive. Facilitators and barriers influencing patient-program bonding were identified and participants suggested ways to remove barriers. The coexistence among users of the harm reduction program and patients treated conventionally provoked ambivalence but the team's management was deemed helpful in easing the difficulties arising from this situation.

Accident Rates for Drug-Dependent Patients in Treatment for Substance Dependence: A Pilot Trial

Objectives: To analyze accident rates among drug-dependent patients before and after treatment for substance dependence. Methods: Self-reported lifetime data and data from the year prior to the start of treatment were analyzed from a cohort including 53 drug-dependent patients, 48 men and 5 women, who had started treatment for substance dependence in an outpatient treatment center in Valladolid, Spain. We also obtained prospective information about treatment dropout and accident rates in the 3-month follow-up period after the start of drug-dependency treatment. Results: Twenty-two percent of drug-dependent patients had an accident in the year prior to starting treatment, and 64.2 percent had an accident in his or her lifetime. Road traffic accidents were the most frequent, with 11.3 percent of patients reporting at least one in the prior year and 45.3 percent reporting at least one road traffic accident in his or her lifetime. Furthermore, drug-dependent patients were frequently under the influence of drugs when driving (13.2%), as well as when performing dangerous activities at work (11.3%), at home (9.4%), and during sporting activities (5.7%) in the year prior to starting treatment. Of the 30 patients who were still undergoing treatment after 3 months, 2 had had accidents during this period (6.6%), one occurring at work and the other at home. Conclusions: Accident involvement, and especially involvement in road traffic accidents, was common among drug-dependent patients. Many accidents occurred in the year prior to treatment initiation. Furthermore, drug-dependent patients often undertook risky activities while under the influence of drugs. There is a need to implement accident prevention strategies, especially strategies that target road traffic accidents, in treatment programs for drug-dependent patients.

Meet Editorial Board Member Robin Kirschner

68 My name is Robin Kirschner, EdD (Educational Administrative Leadership), MA (Leadership/ Critical Care nursing), RN, CPAN, CRN, CRA. I am the newest member of the JRN Editorial Board. I am currently employed at Banner Desert Medical Center & Cardon Children’s Medical Center in Mesa, AZ. I am the leader and manager for all of imaging nursing service, angiography, and outpatient treatment and infusion center (including postprocedure recovery). My experience, both clinical and management, includes neonatal intensive care unit (ICU), pediatric ICU, open heart ICU, general operating room, post anesthesia care unit (PACU), imaging (computed

Quality of Life, Needs, and Interest Among Cocaine Users: Differences by Cocaine Use Intensity and Lifetime Severity of Addiction to Cocaine

We examined the quality of life (QoL) of 149 patients who were recruited in 2005 at outpatient treatment centers for cocaine dependence in Spain. Important life areas and life areas with potential need and interest to change in order to improve the QoL were analyzed in terms of patients’ cocaine use intensity within the previous six months and lifetime severity addiction to cocaine. The Spanish versions of the Drug User Quality of Life Scale and the Lifetime Severity Index for Cocaine were used to measure QoL, needs and interest, and severity addiction to cocaine. The data analysis employed t-tests, linear regression, Mann–Whitney U tests, multivariate regression, and chi-square tests. Tailoring treatment programs to address the life areas that are considered relevant to cocaine users considering their intensity of consumption and lifetime severity addiction to cocaine may improve retention and treatment outcomes. Further research needs to consider patients of different ethnic backgrounds and cultural contexts. The study's limitations are noted.

P.6.c.006 Six month follow-up of cocaine users admitted in an outpatient treatment centre in Barcelona (Spain)

The prevalence, severity, and location of white matter signal hyperintensities (WMH) on brain magnetic resonance images were compared in patients with cocaine or opiate dependence and healthy subjects. Patients with cocaine (n=32) and opiate dependence (n=32), whose diagnoses were confirmed with the Structured Clinical Interview for DSM-IV, and age- and sex-matched healthy subjects (n=32) were scanned using a 1.5 T whole body GE magnetic resonance scanner. Axial proton-density and T2-weighted images were obtained as well as fluid-attenuated inversion recovery axial images. The severity of WMH was assessed separately for deep (and insular) and periventricular WMH, using a modified composite version of the rating scales of Fazekas and Coffey. The cocaine-dependent group had greater severity of WMH than the opiate-dependent group, which in turn had greater severity of WMH than the healthy comparison group (odds ratios=2.54 and 2.90, respectively). The cocaine-dependent group had greater lesion severity of deep and insular WMH than the opiate-dependent group and the healthy comparison group (odds ratio>3.25 for deep WMH; odds ratio>4.38 for insular WMH). For periventricular WMH, there were no significant differences between the three groups. The frontal lobes were the predominant locations of WMH in both substance-dependent groups. The greater prevalence and severity of WMH in cocaine-dependent subjects than in opiate-dependent subjects may reflect the fact that cocaine induces more ischemia via vasoconstriction than opiates. Also, there was a trend for lower WMH severity in substance-dependent women relative to the healthy comparison group, possibly due to estrogen's protective effect against cerebrovascular accidents.

Cigarette smoking knowledge, attitudes, and practices of patients and staff at a perinatal substance abuse treatment center

This study compares cigarette smoking knowledge, attitudes, and practices (S-KAP) of opioid- and other substance-dependent patients and their multidisciplinary staff at an outpatient perinatal substance abuse treatment center. Consenting patients ( n = 95) and staff ( n = 41) concurrently completed a modified form of the S-KAP survey instrument. Ninety-five percent of patients reported currently smoking, and half endorsed wanting “to quit smoking now.” This patient desire to quit smoking was significantly underrated by staff compared to the patients themselves ( p = .028). Both patients and staff demonstrated suboptimal knowledge of smoking health risks, but 73% of patients reported trying to quit with past pregnancies to avoid harm to the fetus/baby. Although results show that patients could benefit from smoking cessation strategies centered on smoking's fetal/neonatal health risks, organizational interventions that focus on changing staff attitudes about patient desire to quit smoking may first need to be implemented.

THE INFLUENCE OF DIFFERENT ANTIHYPERTENSIVE DRUGS ON BLOOD PRESSURE VARIABILITY: PP.38.499

Background: The exploration of Blood Pressure (BP) variability and of the influence of different antihypertensive drugs on BP variability may improve understanding of the mechanism involved in BP changes induced by drugs. We therefore evaluated the long-term effects of the angiotensin-receptor blocker Valsartan and of the ultraselective beta blocker Nebivolol. Methods: A prospective study was conducted at the regional outpatient Diagnosis and Treatment Center from Cluj-Napoca, Romania. The study included newly diagnosed adult hypertensives of either sex. All patients underwent 24 hour ambulatory blood pressure monitoring (ABPM) and systolic and diastolic 24 hour blood pressure variability was measured. A total of 80 hypertensive patients were randomely assigned to receive 80 mg of Valsartan or 5 mg of Nebivolol. Patients were divided into two groups according to antihypertensive medication: group A included 42 hypertensive patients treated with Valsartan and group B included 38 hypertensive patients treated with Nebivolol. Results: Both Valsartan and Nebivolol decreased 24 h BP variability but long-term treatment with Valsartan proved to be more efficient in reducing SBP variability during the night time period. Valsartan significantly reduced systolic BP variability during the night time period when compared to Nebivolol (-10.35 ± 3.01mmHg vs. 6.27 ± 4.26 mmHg, p < 0.05). Conclusions: Treatment with ARBs (Valsartan) and BBs (Nebivolol) efficiently reduces the BP variability during the day and night period of time as first line antihypertensive agents. Valsartan significantly reduces systolic BP variability during the night time period when compared to Nebivolol. Antihypertensive treatment using long acting agents like an angiotensin receptor blocker or an ultraselective beta blocker could offer a better cardiovascular protection by reducing the BP variability.

INSULIN RESISTANCE AS A RISK FACTOR FOR HYPERTENSIVE PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE: 7C.04

Background: Non-alcoholic fatty liver disease is present in 15–25% of the general population. The aim of this study was to investigate the relationship between insulin resistance and non alcoholic fatty liver disease (NAFLD) in essential hypertensive patients, according to the circadian blood pressure rhythm. Methods: A prospective pilot study was conducted at the regional outpatient Diagnosis and Treatment Center Cluj-Napoca, Romania. The study included mild to moderate hypertensive patients that have never been previously treated. Patients were divided into two groups according to the circadian (blood pressure) rhythm. Group I included dipper and Group II included hypertensive non-dipper patients. All patients underwent 24 hour ambulatory blood pressure (ABPM) monitoring and abdominal ultrasound, for the diagnosis of fatty liver disease. Plasma insulin and HOMA index (homeostatic model assessment) and the prevalence of NAFLD were measured. Thirty three patients were enrolled in the study, 14 of them in the dipper group and 19 of them in the nondipper group. Results: The nondipper hypertensive patients, showed a statistically higher plasma insulin and HOMA index (p < 0.001) and also a higher prevalence of the NAFLD when compared to the non-dippers. Conclusion: The nondipping BP status of hypertension associated both a higher prevalence of NAFLD and a higher insulin resistance. Although further expansive testing is necessary this study has found that insulin resistance is a pathogenetic link between the liver steatosis and nondipping BP status.

EEG Findings in Burnout Patients

EEG Findings in Burnout Patients

EEG Findings in Burnout Patients

The concept of burnout remains enigmatic since it is only determined by behavioral characteristics. Moreover, the differential diagnosis with depression and chronic fatigue syndrome is difficult. EEG-related variables in 13 patients diagnosed with burnout syndrome were compared with 13 healthy comparison subjects in order to explore the existence of neurobiological markers for burnout. Burnout patients showed reduced P300 amplitude, a lower alpha peak frequency and reduced beta power. These EEG-related differences in burnout patients differ from those described in the literature in depression and chronic fatigue patients. Our preliminary findings suggest that burnout might be considered as a separate clinical syndrome.

Self differentiation in women with and without mental disorders

Self differentiation, intimacy, love and marital quality in women with and without mental disorders were studied in a sample of 124 married women with a psychiatric diagnosis from inpatient and outpatient treatment centers and a group of 106 married women without any history of mental illness, or severe medical problem. Findings revealed that women in both groups showed low differentiation of self. Women with mental disorders reported low levels of intimacy, poorer understanding, greater sense of rejection, lower self-disclosure and role functioning problems. Both groups of women indicated that they were expected to be more differentiated from their families of origin. Cultural factors are of significance in understanding self-differentiation.

Effects of Repetitive Electrical Stimulation to Treat Sensory Loss in Persons Poststroke

Smith PS, Dinse HR, Kalisch T, Johnson M, Walker-Batson D. Effects of repetitive electrical stimulation to treat sensory loss in persons poststroke. Objective To explore the effectiveness of repetitive electrical stimulation referred to here as tactile coactivation and to improve sensory discrimination and function in the most involved hand of a person recovering from stroke. Design Pre-experimental 1-group (n=4) design with multiple measures. Setting Outpatient stroke treatment center. Participants Subjects with 6 months or longer poststroke with self-reported sensory loss and a mild motor impairment in the most involved hand. Intervention Electrical stimulation (coactivation) of the fingers of the involved hand for 90 minutes 4 days a week for 6 weeks. Main Outcome Measures Primary-dependent measures included touch threshold, tactile acuity, haptic object recognition, motor tapping task, pegboard activities, and functional tasks from the Wolf Motor Function Test. Results Posttreatment assessments revealed improvements in sensory discrimination and motor task performance in all subjects in varying degrees; these results held 4 weeks posttreatment. Conclusions The type of repetitive electrical stimulation or tactile coactivation used in this study has not been explored previously in subjects with sensory loss caused by stroke. The results of this pilot study suggest that coactivation may have the potential to be a useful therapeutic modality for this population.

Use of the Internet and Other Media for Health Information Among Clinic Outpatients With Serious Mental Illness

Use of the Internet and Other Media for Health Information Among Clinic Outpatients With Serious Mental Illness