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Summary Seventy-three student therapists (psychologists, psychiatrists and social workers) at a psychoanalytic training center responded to a survey questionnaire on attitudes and behavior relating to psychodiagnostic reports. Factor analysis of the questionnaire yielded three substantive dimensions: (a) General Diagnostic Utility, (b) Independent Action, and (c) Cry for Help. The latter two factors related to age and profession of the respondent. In general the respondents indicated psychodiagnostics could be of significant utility, though some evidence suggested they may serve primarily a confirmatory function. Conflicts between teaching and service roles of a training clinic were discussed.

Despite evidence that sexual problems may play a role in the dissatisfaction of heroin addicts with methadone hydrochloride treatment, little is known about their drug-free sexual adjustments or the effects of opiates. We surveyed 136 heroin-addicted veterans for problems of impotence, premature ejaculation, and retarded ejaculation when the subjects were drug free and when they were using heroin. Forty-five were In methadone treatment and also reported on methadone effects. Premature ejaculation was a surprisingly common complaint when subjects were drug free, but it remains unclear whether this finding represents true base line levels or subtle abstinence reactions. Heroin and methadone both increased the frequency of impotence and retardation, though the effects of heroin were substantially more dramatic.

Malan has argued forcefully that meaningful measurement of outcome in psychoanalytically oriented psychotherapy requires a complex clinical-judgment process by an expert clinician that is based on a psychodynamic hypothesis. Information pertaining only to symptom status before and after treatment was abstracted from each of 18 case summaries published by Malan. Each of these abstracted "cases" was related by a nonprofessional judge for global improvement and by me for symptomatic improvement. Correlations among these simple outcome ratings, "dynamic assessments" of treatment outcome made by the Tavistock group, and several theoretically important variables measuring transference manifestations during treatment were examined. Simple symptomatic improvement was an important component of the complex Tavistock outcome rating. The results raised questions as to the importance of the expert clinician and the psychodynamic hypothesis in the assessment of treatment outcome.

Male veterans applying for outpatient treatment of narcotic addiction were interviewed as to symptoms of withdrawal and overdose using a two-phase procedure. First they were asked how they felt, with no specific symptoms mentioned by the interviewer. Then a list of 28 symptoms was read. Symptoms reports increased dramatically. Every symptom was reported more frequently when patients were specifically asked. Correlations indicated fairly good agreement on severe symptom levels, but poor agreement on mild and moderate symptoms. Standardization of method of inquiry seems essential for valid comparison of studies of addiction.

The emotional climate within the home is a powerful predictor of relapse and remission in schizophrenic disorders. Research has focused on "expressed emotion" (EE), a measure of relatives' expressed attitudes about the patient. Recently, EE has become a focus of controversy. Correcting a misperception that EE research blames families of schizophrenic patients, we clarify the concepts and data base that underlie EE research, provide an operational definition of EE, and briefly review the history of EE research in schizophrenia and other disorders. Then, methodological and conceptual issues in the interpretation of these data are discussed, and implications for clinical practice and mental health policy are considered.

HE VALUE of methadone in treating narcotic addiction has been demonstrated by numerous studies.‘-4 Many patients who become engaged in treatment have been shown to decrease or stop their involvement with the drug culture and to make meaningful progress toward vocational and social rehabilitation. Despite its proven efficacy, a substantial proportion of known addicts are not in treatment. Estimates of the percentages of addicts in methadone treatment include 15%40% in Kansas City,5 about 50% in New Orleans,6 and 20% in Philadelphia. * Many of these patients may never seek treatment; others drop out after just a few visits. Program policies may exert strong effects on whether patients seek or continue treatment. The Massachusetts General Hospital drug program, which offers methadone detoxification, reports program changes improving their drop-out rate from a staggering 97% of patients failing to come for a second appointment’ to 76% coming twice and 57% coming 3 or more times.8 These motivational and dropout problems have been experienced at the Philadelphia VA Drug Dependence Treatment Center since its opening 255 years ago. Some delays and administrative red-tape are probably an inevitable feature of treatment in large institutions such as ours. We considered it likely that any negative consequences produced by delays might be maximized in a group of patients such as ours since many observers describe addicts as being impulsive, passive, having a low frustration tolerance and an inability to postpone gratification.e~‘O~ll These character traits would make addicts extremely sensitive to delays. We hypothesized therefore that changing our intake procedure so as to decrease delays would increase retention rates. This paper reports on the consequences of one such change: contact with a physician and other treatment staff on the day of arrival at the clinic.

Blood pressure measurements were collected from 36 depressed geriatric outpatients (ages 55 to 81 years) enrolled in a double-blind, placebo-controlled study of the efficacy of doxepin and imipramine. Mean systolic postural changes were 25.9 mm Hg for imipramine, significantly higher than the 10.5 mm Hg for doxepin, and 12.4 mm Hg for placebo. The orthostatic drop in the imipramine group was only weakly related to dose and did not correlate with amount of pretreatment orthostatic hypotension or with duration of treatment. The increased orthostatic hypotension occurred early in treatment and at low doses of imipramine. Accordingly, caution is advised in the use of imipramine for the elderly.

Clinical evidence suggests the possibility of conditioning of narcotic abstinence symptoms. Addicts report subjective and objective signs of withdrawal/craving when exposed to certain stimuli. This may partially explain the high rate of relapse to drug seeking behavior when treated addicts return to their home environment. Conditioning of narcotic abstinence symptoms was produced experimentally in five of eight volunteer subjects. Brief naloxone precipitated abstinence was the unconditioned response. The conditioned stimulus was a tone and odor. After an average of seven training trials, the tone and odor produced a conditioned abstinence response. The conditioned response consisted of subjective components (feelings of sickness, nausea, cramps, craving) and objective components (yawning, tearing, rhinorrhea, irregular respiration and transiently increased blood pressure). These laboratory findings support the anecdotal evidence regarding the existence of conditioned abstinence phenomena.

To the Editor.— The article by Smith et al 1 on the relation between plasma haloperidol levels and clinical response suggests a "therapeutic window" relationship with a therapeutic plasma level range between 7.0 and 17.0 ng/mL for hospitalized schizophrenic patients. That is, above 17.0 ng/mL the patient's condition may either fail to improve or even worsen. If this is true (and if it applies to the usual newly [re]admitted schizophrenic patient), our work 2 and that of Itoh et al 3 would indicate that the majority of inpatient schizophrenics in the western world are in the psychotoxic plasma-level range! Itoh and colleagues, 3 in a series of 135 schizophrenic patients, and our group, 2 in a series of 70 patients, found respective correlations of.77 and.82 between dose and haloperidol plasma level. We attribute these high and very comparable correlations to good compliance (we will not enter a patient into the

Re-analyses of data presented by Macmillan et al (1986b) challenge their conclusions that high expressed emotion is not prognosticate significant for the course of schizophrenia or unrelated to the level of behavioural disturbance prior to admission. Several equally plausible models of causal relationships between EE and duration of untreated illness are presented. We conclude that our re-analyses of the Macmillan data do not warrant premature closure regarding the significance of the EE variable.

This is a report on the double-blind study on EMG biofeedback for 37 narcotic addicts in an outpatient methadone clinic. Patients were randomly assigned to either the experimental group (N = 24) receiving a contingent EMG biofeedback or a control group (N = 13) receiving non-contingent preaped “pseudo-biofeedback”. All patients were stabilized on a study dose of methadone and the mean daily amount did not differ between groups. All were experiencing a significant degree of anxiety at the time of evaluation. The evaluation consisted of the patient's self-report, which comprised the Beck Depression Inventory, anxiety checklist, withdrawal sickness rating, drug references, and the psychiatrist's rating of depression, namely the Hamilton Depression Scale, Hamilton Anxiety Scale, and BPRS. In addition, an evaluation of progress was obtained from the patient and his counselor which included the current job or school status and brief ratings of drug use, psychiatric symptoms, social adjustment, and illegal activity. All patients had at least one urine sample analyzed weekly for illicit drug use. Evaluation was done at the beginning, and at the end of the treatment and at a follow-up one month later. Termination status was assessed only for subjects who completed the course of 15 biofeedback sessions (N = 19). Patients attended five sessions per week for thirty minutes just prior to receiving the methadone. Fifteen sessions were scheduled over a three-week period. The results indicated that the two study groups did not differ and there was a significant improvement (p < 0.05) on several variables for the total patient sample. All the psychiatric ratings of anxiety, depression, psychopathology were significantly reduced. In addition, self-rated craving for narcotics and self-rated anxiety were lower and there were fewer drug avoidance responses on the sentence completion test. But there were no meaningful differences in the two groups in improvement as reflected in the psychometric instruments.

Our study of predictability of outcomes of psychotherapy used predictions of two kinds: (1) direct predictions by patients, therapists, and clinical observers; and (2) predictive measures derived from the same sources. Seventy-three nonpsychotic patients were treated in psychoanalytically oriented psychotherapy (mean, 44 sessions). Two thirds of the therapists were residents in psychiatry; one third were more experienced. The two main composite outcome measures, measured at termination, were Raw Gain (residualized) and Rated Benefits, which intercorrelated at .76. Most patients improved and showed a considerable range of benefits. The clinical observers' direct predictions of Rated Benefits were highest (.27, P less than 905). The success of the predictive measures were generally insignificant, and the best of them were in the .2 to .3 range meaning that only 5% to 10% of the outcome variance was predicted. The Prognostic Index Interview variables did the best (eg, emotional freedom composite, .30; a crossvalidation for 30 patients was .39 (P less than .05). Neither the therapist measures nor the early psychotherapy session measures predicted significantly. Reanalysis of the similar Chicago Counseling Center study, in our terms, showed a similar low level of prediction success, eg, adequacy of functioning, marital status match, and length of treatment predicted significantly in both studies.

• Two studies compared propoxyphene napsylate (Darvon-N) with methadone hydrochloride as maintenance treatment for narcotic addicts. Most measures indicated that methadone was more effective than propoxyphene as a maintenance drug. Patients receiving propoxyphene reported more withdrawalrelated symptoms early in treatment, tended to drop out sooner than patients receiving methadone, and were more likely to abuse heroin. Nevertheless, follow-up interviews at one and six months after treatment indicated no between-group differences in adjustment.

A subsample was drawn from an earlier collection of data in order to answer a number of questions related to "acid" (LSD, STP) flashbacks. Acid users who reported flashbacks also reported significantly more marijuana use than those who did not; the two groups did not differ on use of other drugs, including acid. Simple correlations and multiple regression analyses both showed extent of marijuana use to be the only drug variable significantly related to acid flashbacks. No optimal combination of marijuana and acid improved flashback prediction. Among acid users, correlations between amounts of use for various drugs were high and significant, excepting only the marijuana-acid correlation.

• We evaluated the effectiveness and the side effects of what we defined as low (5-mg) and conventional (25-mg) doses of fluphenazine decanoate administered every two weeks in a double-blind comparison. Subjects were 66 patients who fulfilled DSM-III criteria for schizophrenic disorder. Evaluation of the survival with each dose revealed no significant difference at one year, but significantly better survival was seen with the 25-mg dose (64%) than the 5-mg dose (31%) at two years. There was no significant difference in survival when the clinician was permitted to make a dosage adjustment up to 10 mg in the lowdose group and 50 mg in the higher-dose group when the patient demonstrated evidence of a symptomatic exacerbation. Patients assigned to the higher dose appeared to feel more uncomfortable during the early months of the study, as indicated by significantly higher scores on subscales of the Hopkins Symptom Checklist-90R and higher side effect scores for retardation and akathisia. Implications for clinical practice are discussed.

Depression presents a serious problem for many schizophrenic patients. However, little is known about the nature and course of this depression. Van Putten and May (1) suggested that some of the observed depression in schizophrenia may be a drug-induced akinesia syndrome. It has been proposed that depression in schizophrenia can be a “reactive” depression to the disruptive effects of the psychotic episode (2). McGlashan (3) introduced the term “aphanisis” to describe the residual schizophrenic defect state that might be confused with depression. It has also been argued that postpsychotic depression actually begins concurrent with psychotic symptoms but that the depressive symptoms are not noticeable until the florid symptoms begin to remit (4,5). In addition, Herz and Melville (6) demonstrated that depression is commonly reported in the prodromal period, suggesting that “prepsychotic” or prodromal depression may be an addition relevant type of depression.

This study evaluated the effectiveness of a skills training program designed to teach disease management to Latinos with schizophrenia treated at a community mental health center. Ninety-two Latino outpatients with schizophrenia and their designated relatives were randomly assigned to 3 months of skills training (ST) versus customary outpatient care (CC) and followed for a total of 9 months. The skills training approach was culturally adapted mainly by including the active participation of key relatives to facilitate acquisition and generalization of disease management skills into the patients' natural environment. There was a significant advantage for the ST group over the CC group on several symptom measures, skill acquisition and generalization, level of functioning, and rates of rehospitalization. There were no significant differences between the groups on quality of life or caregiver burden. Skills training had a direct effect on skill acquisition and generalization, and utilization of disease management skills led to decreased rates of rehospitalization. Incorporating an intensive, culturally relevant generalization effort into skills training for Latinos with schizophrenia appeared to be effective in teaching disease management and viable in a community mental health center.

She informed consent projects (ICPs) we describe here were designed to produce (1) new and improved methods for the informed consent process, (z) methods for confronting the challenges of obtaining consent for special or vulnerable populations, and (3) data to help inform and guide public policy development (Table 1). From the outset, the project investigators identified a number of conceptual and practical concerns and challenges in conducting empirical research on informed consent. These concerns and challenges were shared by all the investigators, despite the significant variability in the research methods used and the populations studied. Experienced researchers will recognize that some of these concerns and challenges are common to many kinds of research involving human subjects. Some, however, are unique to research on informed consent. We describe these matters for the purpose of fostering ongoing dialogue about the challenges researchers face in studying the informed consent process. Common Research Challenges

• In a randomized controlled study, the affective style (AS) of parents of schizophrenics in clinic-based individual treatment groups and home-based family treatment groups was compared prior to treatment and again three months after treatment had begun. Affective style is an index reflecting the quality of the family emotional climate, measured from face-toface discussion. Pretherapy and posttherapy measures of negative AS were significantly predictive of relapse within the nine-month treatment period for patients in individual treatment. In addition, for both treatment groups, a negative AS pattern at the posttherapy reassessment was significantly associated with decreased patient social functioning, reduced ability of the family to absorb the family intervention, and lower capacity of the family to cope with everyday family stresses. The results suggest that AS is an important intrafamilial attribute, with implications for treatment strategy and planning.

• The relative costs and benefits of low- and conventionaldose neuroleptic maintenance therapy were evaluated in a double-blind comparison of 5 and 25 mg of fluphenazine decanoate administered every two weeks. Subjects were 50 patients fulfilling DSM-III criteria for schizophrenic disorder who had been successfully maintained with 25 mg or less of fluphenazine decanoate. A one-year survival analysis disclosed that there were no statistically significant differences between the two doses insofar as preventing relapse. Patients receiving the higher dose appeared to feel more uncomfortable, as indicated by higher scores on subscales of the Hopkins Symptom Checklist-90. In addition, patients receiving the higher dose had higher side-effect scores. These findings suggest that a substantial proportion of patients who are presently maintained with 25 mg or less of fluphenazine decanoate every two weeks will do just as well with as little as 5 mg.

• Measures of family attitudes (expressed emotion [EE]) and interactional behaviors (affective style [AS]), both of which have been found to predict relapse in schizophrenia, were obtained from key relatives of 23 hospitalized recently manic bipolar patients. Patients were then followed up for a period of nine months after hospital discharge and rated on measures of clinical course, social adjustment, and medication compliance. Levels of intrafamilial EE and AS were found to predict likelihood of patient relapse at follow-up, especially when used as conjoint predictors of patient outcome status. Levels of AS also predicted degree of social adjustment at follow-up. The predictive relationships observed were independent of patient medication compliance, treatment regimen, baseline symptoms, demographics, and illness history. Results suggest that the emotional atmosphere of the family during the postdischarge period may be an important predictor of the clinical course of bipolar disorder.

• This study was designed to assess the relative prognostic importance of patient factors, therapist characteristics, and treatment mode. The sample was 100 schizophrenic outpatients referred to a community mental health center following psychiatric hospitalization. Patients were randomly assigned to either group (N=50) or individual (N=50) psychotherapy. Criteria were rehospitalization and two clinician ratings—adjustment and social effectiveness—at a two-year follow-up. The best predictor of rehospitalization was the number of previous hospitalizations. The best predictor of adjustment status at two years was pretreatment adjustment level. Also, patients with good prognostic indices made relatively large gains. Predictors of outcome for group-treated patients did not differ from those for individually treated patients. Controlling for initial status, treatment mode was almost as good as predictor of adjustment gains as were other patient factors.

This paper reports on surveys of illicit drug usage by medical students during 1970 and 1972. A high rate of response from each of the four classes in both years revealed a large increase in the number of students who used cannabis between 1970 and 1972. Despite this greater occurrence of use, there was a marked decline in the current frequency of use among the two classes studied in both years, evidently due to loss of interest in taking the drug. Over the two years there was also a decrease in the number of students favoring legalization of marihuana. In both studies relatively few students had ever taken LSD, mescaline, amphetamines, and barbiturates, and here too interest decreased by 1972. These findings suggest that a wave of cannabis use passed through the medical school irrespective of the age of the student and has now subsided.

One hundred schizophrenic patients, newly discharged from a state mental hospital, were randomly assigned to group or to individual psychotherapy. The patients in each treatment category were initially equivalent on measures of illness severity and on prognostic indices. Outcome after 12 and 24 months of treatment, based on social effectiveness and psychiatric ratings, was significantly better for group therapy, but rehospitalization rates did not differ significantly. Analysis of therapist variables failed to account for the differences in outcome. Thus, in this population, the type of treatment was able to influence the outcome.