Background: Assertive community treatment (ACT) is an intensive and comprehensive treatment for clients with severe mental illness (SMI) who do not readily benefit from clinic-based services. Monitoring the implementation of such programs is critical, because better-implemented programs have been found to be effective in improving client outcomes.

Objective: We tested the hypothesis that fidelity to the ACT model would be positively correlated with improved client outcomes, as measured by reduction in psychiatric hospital use.

Methods: A scale measuring fidelity of program implementation, the Dartmouth ACT Scale, was examined in 10 newly formed ACT teams. Using the team as the unit of measure, the mean reduction in state hospital days for a 1-year period before and after program admission was calculated. Mean effect size in reduction in hospital days was used as the outcome measure in a correlational design.

Results: Pre/post comparisons showed a 43% reduction in hospital days for 317 clients (t=8.61, P<.001). The Pearson correlation between DACTS fidelity and reduction of state hospitaldays was .49, P=.08, one-tailed.

Conclusion: Several possible reasons are offered for why the study hypothesis was not confirmed. However, even if predictive validity of the Dartmouth ACT Scale is limited, it continues to be a useful tool for program monitoring and for providing corrective feedback.

Techniques such as positron emission tomography and single photon emission computed tomography allow for the imaging of neurotransmitter receptors and transporters in the brain. These tools have been used to investigate serotonergic, dopaminergic, and opioidergic function in healthy subjects as well as in patients with major depressive disorder, bipolar disorder, and other mood disorders. Pharmacologic challenges, such as amphetamine challenge, and physiologic stressors, such as pain challenge, have been used to further examine the function of these neurotransmitter systems. Neuroimaging of patient populations before and after medication treatment may be useful to understand changes in neurotransmission that accompany disease remission. As new radiotracers with higher selectivity for the various receptors and transporters are developed, imaging techniques may provide new insights into the pathophysiolagy of mood disorders, leading to improved diagnosis and treatment.

Premenstrual dysphoric disorder (PMDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as the presence of at least 5 of 11 symptoms with at least one of the symptoms being depressed mood, anxiety, affective lability, or irritability. The other symptoms include decreased interest in usual activities, poor concentration, fatigue, increased appetite, change in sleep, a sense of being overwhelmed or out of control, and physical symptoms such as breast tenderness. The symptoms must be present in the luteal (premenstrual) phase of the menstrual cycle, must resolve during the first few days of menses, and must have been present for at least 1 year. The symptoms should be severe enough to disrupt social and role functioning. The DSM-IV PMDD criteria include the recommendation that women prospectively rate their symptoms daily for two menstrual cycles to confirm the timing of the symptoms and the absence of a chronic underlying Axis I disorder. Many studies have identified irritability as the most frequently reported premenstrual symptom. It has been proposed that women with PMDD may comprise two subsets; one with predominant depressive symptoms, and another with predominant irritability.

Perinatal depression is widely considered to be a major public health problem. Anxiety disorders are also common among women of childbearing years, but the course and consequences of anxiety during pregnancy have not yet been established.

Almost all studies of the prevalence and consequences of perinatal anxiety have used questionnaire measures of anxiety. Unlike the Edinburgh Postnatal Depression Scale, questionnaire measures of anxiety symptoms have not been validated for pregnant or postpartum patients, thus it is unclear to what degree these measures are detecting anxiety versus typical physical symptoms associated with pregnancy and infant care. For example, many items on the Beck Anxiety Inventory, including difficulty breathing, facial flushing, unsteadiness, light headedness, sweating, and indigestion, commonly occur during pregnancy. In a study of >8,000 women, more women scored above a cut-off score on the anxiety subscale of the Crown-Crisp Index during weeks 18 and 32 of pregnancy compared to 8 weeks and 8 months postpartum. Three studies have administered selected modules from the Structured Clinical Interview to postpartum women. All three studies found that >50% of women with postpartum anxiety disorders were not depressed and that anxiety disorders were at least as common postpartum as major depression. Antenatal anxiety was associated with an increased risk of postpartum depression, even after controlling for antenatal depression.

Coronary heart disease (CHD) remains the leading cause of death in women in the United States and other industrial countries. CHD accounts for 250,000 female deaths per year, and in contrast to men, there is no indication of declining death rates. Women <65 years of age are twice as likely to die from myocardial infarction (MI) as men and have a poorer prognosis if they survive. Nevertheless, CHD has long been considered a “male” disease and many of the guidelines for prevention, diagnosis, and treatment of CHD are extrapolated from data of predominantly middle-aged men to women. It was only in the early 1990s that the National Institute of Health required that researchers report outcome analyses separately by sex. Since then, data has emerged showing that the magnitude of risk conferred by traditional risk factors for CHD (eg, hypertension, diabetes, and smoking) differs between men and women. Sex differences in molecular and cellular mechanisms, and genetics as well as responses to treatment are still vastly understudied.

Increasing evidence suggests that besides traditional CHD risk factors, negative emotions are independent prognostic risk factors for CHD. Recently published guidelines by an expert panel for cardiovascular disease prevention in women mention depression as a target for potential psychosocial interventions. Anxiety has also been shown to predict CHD incidence, acute coronary syndromes (ACS), morbidity and mortality post-ACS, and sudden cardiac death. Studies on the relationship between anxiety and CHD have shown mixed results.

Key Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for obsessive-compulsive disorder (OCD) include the presence of either obsessions or compulsions, some recognition by the individual that their symptoms are excessive or irrational (except in children), duration of at least 1 hour/day, and association with marked distress or functional impairment. OCD patients report that somatic, religious, and sexual obsessions as well as those concerning contamination, aggression, symmetry, and hoarding are most common. The most frequent compulsions reported in OCD patients involve checking, cleaning, counting, repeating, and hoarding behaviors. Factor analyses of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) symptom checklist have also identified five primary symptom dimensions: aggression/checking; contamination/cleaning; symmetry/repeating, counting, or ordering rituals; hoarding; and a sexual/religious symptom dimension.

Results from a large, 2-year prospective study suggest that symptoms of adult OCD are much more stable than previously thought, with any changes more likely to occur within, rather than between the symptom dimensions. Prevalence estimates based on the Epidemiologic Catchment Area survey and the Cross-National OCD Collaborative Group study indicate a worldwide lifetime prevalence rate for OCD of 2% to 3%. Females have a slightly higher risk (1.5 times) for OCD (Slide I). OCD onset is relatively early, generally during adolescence or young adulthood. The clinical course of OCD is generally chronic and complicated by comorbidities.