Scaling up the dissemination of evidence-based mental health practice to large systems and long-term time frames.

This Open Forum raises issues related to large-scale dissemination of sustainable evidence-based practices. Current dissemination efforts have been time limited and primarily conducted at volunteer sites with the skills of external expert trainers. The authors describe an effort to implement supported employment at 166 veterans programs in what is hoped to be a permanent addition to mental health services offered by the Department of Veterans Affairs.

Cost-benefit analysis of second-generation antipsychotics and placebo in a randomized trial of the treatment of psychosis and aggression in Alzheimer disease.

Context: Second-generation antipsychotics (SGAs) are prescribed for psychosis, aggression, and agitation in Alzheimer disease (AD).

Objective: To conduct a cost-benefit analysis of SGAs and placebo (taken to represent a "watchful waiting" treatment strategy) for psychosis and aggression in outpatients with AD.

Design: Randomized placebo-controlled trial of alternative SGA initiation strategies.

Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization.

Objective: This study evaluated a modification of the critical time intervention (CTI) community case management model for homeless veterans with mental illness who were leaving Department of Veterans Affairs (VA) inpatient care. CTI offers time-limited intensive case management designed to negotiate transitions from institutional settings to community living.

Methods: CTI was implemented at eight VA medical centers through a training program that used primarily teleconference-based case review.

Second-generation antipsychotics: reviewing the cost-effectiveness component of the CATIE trial.

The cost-effectiveness component of the 18-month CATIE trial of schizophrenia pharmacotherapy (n = 1460) showed that the first-generation antipsychotic perphenazine was US$300-600 per month less expensive than each of four second-generation antipsychotics, and no less effective across multiple measures. We consider whether or not each of eight potential methodological limitations could weaken this conclusion: follow-up rates, study duration, sample characteristics, the choice of outcome measures, exclusion of patients with tardive dyskinesia from assignment to perphenazine, choice of study drugs and doses, reliance on intention-to-treat analysis, and differences in prestudy treatment. We conclude that results of CATIE are robust to these limitations.

Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: two-year outcomes.

Objective: There has been growing interest in the dissemination of supported employment, but few studies have used a control group to examine the benefits of multisite dissemination efforts for clients or have addressed the needs of homeless persons with psychiatric disorders, addiction disorders, or both. This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1).

Methods: Special funds and sustained training, which was based primarily on teleconferencing, were used to support implementation of the IPS model of supported employment at nine VA programs for homeless veterans.

Measuring outcome priorities and preferences in people with schizophrenia.

Background: Measures have not taken account of the relative importance patients place on various outcomes.

Aims: To construct and evaluate a multidimensional, preference-weighted mental health index.

Method: Each of over 1200 patients identified the relative importance of improvement in six domains: social life, energy, work, symptoms, confusion and side-effects.

The growth of psychopharmacology in the 1990s: evidence-based practice or irrational exuberance.

The rapid growth in sales of psychotropic medications during the late 1980s and 1990s, eventually reaching $20 billion/year, reflected the increased use of seritonin reuptake inhibitors for depression and atypical antipsychotics for schizophrenia. Recently, however, some of the therapeutic claims for these medications have been challenged, and under-appreciated risks have turned out to be significant liabilities. Drug manufacturers increasingly dominate clinical trials research and evidence suggests that study designs and data presentations have been slanted to show products in a favorable light while unfavorable data were suppressed.

Prevalence of Hepatitis C virus infection in a sample of homeless veterans.

Objective: This study measures the prevalence of Hepatitis C Virus (HCV) infection in a sample of homeless veterans treated in a Domiciliary Care for Homeless Veterans (DCHV) program in Massachusetts. We also examine risk factors and correlates for HCV infection, including substance abuse and service in Vietnam.

Methods: Patients admitted to the DCHV program over a 5-year period (n=418) were systematically tested for HCV infection.

Residential environment and quality of life among seriously mentally ill residents of board and care homes.

This study examined the relationship between residential environment of seriously mentally ill patients living in board and care homes and quality of life. Participants included 162 seriously mentally ill veteran patients living in 26 board and care homes in Los Angeles. Data from structured interviews were used to assess subjective quality of life (satisfaction with living situation and general well-being) and objective quality of life (social functioning and daily activities).

Cross-system service use among psychiatric patients: data from the Department of Veterans Affairs.

This study examines the cross-system use of non-Department of Veterans Affairs (VA) services in a sample of psychiatric patients from the VA in 1990. Data were collected over a two-week period on all mental health outpatients and included demographic information, diagnoses, and self-reported use of non-VA services in the previous two weeks and six months. In the entire sample, 10.

Effects of compensation-seeking on treatment outcomes among veterans with posttraumatic stress disorder.

The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation.

Social support and psychopathology in the war zone.

Unit cohesion and homecoming support are examined for their protective effects on the development of posttraumatic stress disorder (PTSD) and other psychopathology. Data on 1198 male theater veterans were taken from the National Vietnam Veterans Readjustment Study. Unit cohesion had no significant relationship, as a direct effect, to either PTSD or other psychopathology.

A short form of the Mississippi Scale for measuring change in combat-related PTSD.

In large-scale surveys or program evaluations, investigators most often wish to assess multiple domains of functioning, while at the same time minimizing the overall length of the data collection protocols. In addition, studies of treatment interventions require instruments which offer the greatest opportunity of detecting change in the variables of interest. Toward these ends, we present an 11-item version of the Mississippi Scale for Combat-Related PTSD.