Focus on optimal health, not ideal health

Providers strive to help patients live the best, healthiest life they are capable of living. However, those efforts should involve a careful assessment of what the patient’s optimal health status is. It is deleterious to the therapeutic relationship to drive a patient towards a health status they are not able to attain. This article provides a brief commentary on the author’s experience as a patient to illustrate this point. Experience Framework This article is associated with the Patient, Family & Community Engagement lens of The Beryl Institute Experience Framework (https://www.theberylinstitute.org/ExperienceFramework). Access other PXJ articles related to this lens. Access other resources related to this lens

Homelessness predicts attrition but not alcohol abstinence in outpatients experiencing co-occurring alcohol dependence and serious mental illness.

BACKGROUND: Adults experiencing homelessness and serious mental illnesses (SMI) are at an increased risk of poor mental health and treatment outcomes compared with stably housed adults with SMI. The additional issue of alcohol misuse further complicates the difficulties of those living with homelessness and SMI. In this secondary data analysis, the authors investigated the impact of homelessness on attrition and alcohol use in a contingency management (CM) intervention that rewarded alcohol abstinence in outpatients with SMI. METHODS: The associations between housing status and attrition and alcohol abstinence during treatment, as assessed by ethyl glucuronide (EtG) urine tests, were evaluated in 79 adults diagnosed with alcohol dependence and SMI. RESULTS: Thirty-nine percent (n = 31) of participants reported being homeless at baseline. Individuals who were homeless were more likely to drop out of CM (n = 10, 62.5%) than those who were housed (n = 4, 16.7%), χ CONCLUSIONS: Individuals experiencing homelessness and co-occurring alcohol dependence and SMI receiving CM had higher rates of attrition, relative to those who were housed. Homelessness was not associated with differences in biologically assessed alcohol abstinence

Prevalence and Correlates of Cannabis Use in Outpatients with Serious Mental Illness Receiving Treatment for Alcohol Use Disorders.

Introduction: People with serious mental illness (SMI) use cannabis more than any other illicit drug. Cannabis use is associated with increased psychotic symptoms and is highly comorbid with alcohol use disorders (AUDs). Despite the national trend toward decriminalization, little is known about the prevalence, correlates, and impact of cannabis use on those with SMI receiving treatment for substance use disorders, a group at high risk for the negative effects of cannabis use. Methods: In this secondary data analysis, cannabis use prevalence, correlates, and impact on treatment outcomes were examined in 121 adults with cooccurring SMI and AUDs receiving outpatient addiction treatment in a randomized trial of contingency management (CM) for alcohol. Prevalence and frequency of cannabis use were calculated across the 7-month study period using self-report and urine tests. Cannabis users were compared with nonusers by SMI diagnosis, psychiatric symptoms, medical problems, legal problems, and HIV-risk behavior. The relationship between cannabis use and longest duration of alcohol abstinence in participants randomized to CM (n=40) was assessed. Results: Fifty-seven (47%) of participants submitted at least one cannabis-positive urine sample during the study. Out of the 2834 total samples submitted, 751 (27%) were positive for cannabis. Cannabis users were 2.2 times more likely to submit an alcohol-positive sample, and 2.5 times more likely to submit a cocaine-positive sample at baseline, relative to noncannabis users (p=0.01). Cannabis users were more likely to engage in risky sexual behavior (p=0.01) and to report being homeless (p=0.03) than nonusers. When controlling for pretreatment alcohol use, the relationship between comorbid cannabis use and alcohol abstinence during CM was not significant (p=0.77). Conclusion: Rates of comorbid cannabis use were high in this sample of adults with SMI and AUDs. Cannabis use was correlated with recent alcohol and cocaine use, risky sexual behavior, and homelessness, but not with alcohol abstinence during CM

Surveying the Inner Halo of the Galaxy with 2MASS-Selected Horizontal Branch Candidates

We use 2MASS photometry to select blue horizontal branch (BHB) candidates covering the sky |b|>15 deg. A 12.5<J<15.5 sample of BHB stars traces the thick disk and inner halo to d<9 kpc, with a density comparable to that of M giant stars. We base our sample selection strategy on the Century Survey Galactic Halo Project, a survey that provides a complete, spectroscopically-identified sample of blue stars to a similar depth as the 2MASS catalog. We show that a -0.20<(J-H)_0<0.10, -0.10<(H-K)_0<0.10 color-selected sample of stars is 65% complete for BHB stars, and is composed of 47% BHB stars. We apply this photometric selection to the full 2MASS catalog, and see no spatial overdensities of BHB candidates at high Galactic latitude |b|>50 deg. We insert simulated star streams into the data and conclude that the high Galactic latitude BHB candidates are consistent with having no ~5 deg wide star stream with density greater than 0.33 objects deg^-2 at the 95% confidence level. The absence of structure suggests there have been no major accretion events in the inner halo in the last few Gyr. However, at low Galactic latitudes a two-point angular correlation analysis reveals structure on angular scales <1 deg. This structure is apparently associated with stars in the thick disk, and has a physical scale of 10-100 pc. Interestingly, such structures are expected by cosmological simulations that predict the majority of the thick disk may arise from accretion and disruption of satellite mergers.Comment: 11 pages, including figures. Accepted by AJ with minor revision

Interaction between pre-treatment drug use and heterogeneity of psychiatric diagnosis predicts outcomes in outpatients with co-occurring disorders.

We examined whether the interaction of baseline stimulant use, assessed by urine drug tests, and type of serious mental illness (SMI) diagnosis predicted stimulant use in a trial of contingency management (CM). The interaction between baseline stimulant use and SMI diagnoses was significant in the overall sample (p=0.002) when controlling for the main effects of treatment condition, baseline stimulant use, and SMI diagnosis. Similar results were also found within the CM sample. Individuals with bipolar disorder were more or less likely, depending on their baseline stimulant-drug test results, to use stimulants during treatment compared to those with other SMI diagnoses

A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness.

OBJECTIVE: The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior. METHOD: Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement prize draw procedure contingent on EtG-negative samples (/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods. RESULTS: Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up. CONCLUSIONS: This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness

The Redshift of the Optical Transient Associated with GRB 010222

The gamma-ray burst (GRB) 010222 is the brightest GRB detected to date by the BeppoSAX satellite. Prompt identification of the associated optical transient (OT) allowed for spectroscopy with the Tillinghast 1.5m telescope at F. L. Whipple Observatory while the source was still relatively bright (R ~ 18.6 mag), within five hours of the burst. The OT shows a blue continuum with many superimposed absorption features corresponding to metal lines at z = 1.477, 1.157, and possibly also at 0.928. The redshift of GRB 010222 is therefore unambiguously placed at z >= 1.477. The high number of Mg II absorbers and especially the large equivalent widths of the Mg II, Mg I, and Fe II absorption lines in the z = 1.477 system further argue either for a very small impact parameter or that the z = 1.477 system is the GRB host galaxy itself. The spectral index of the OT is relatively steep, beta = 0.89 +/- 0.03, and this cannot be caused by dust with a standard Galactic extinction law in the z = 1.477 absorption system. This spectroscopic identification of the redshift of GRB 010222 shows that prompt and well-coordinated followup of bright GRBs can be successful even with telescopes of modest aperture.Comment: 12 pages, 3 figures; ApJ Letters accepted version, only minor change