Showing papers in "Psychiatric Services in 1982"

Young Adult Chronic Patients: An Analytical Review of the Literature

Abstract: This article analyzes the periodical and "fugitive" literature concerned with an emerging psychiatric service entity, young adult chronic patients. The increasing prominence of a young adult patient population results from the confluence of two primary forces: deinstitutionalization policies and demographic factors. The author discusses the clinical diversity and program requirements of these patients. Young adult chronic patients are best served when their uniqueness as a patient population is acknowledged and heeded and when special services for them are integrated into the total system of care, the author concludes.

Young Adult Chronic Patients: The New Drifters

Abstract: Young chronic patients are faced with the same concerns and life-cycle stresses as others in their age group. They strive for independence, satisfying relationships, a sense of identity, and a realistic vocational choice. Lacking the ability to withstand stress and intimacy, they struggle and often repeatedly fail. The result is anxiety, depression, psychotic episodes, and hospitalizations; gradually many begin to give up the struggle. Such concerns may become intensified during the reassessment of life that takes place at about age 30. Denial of illness, the rebelliousness of youth, and issues of control and violence compound the problems. Since deinstitutionalization, patients can no longer take asylum from stresses in a lifetime of hospitalization. Many patients drift from one city to another, or from one living situation to another. Some ways of approaching these problems, such as working with younger patients while they may still be motivated to make changes, helping them develop appropriate rational...

Self-Help and Mental Health

Abstract: Over the past decade self-help groups have become an important way of helping people cope with various life crises. Groups have organized to help individual members deal with a wide range of health-related and other problems. The authors define the meaning of self-help in such groups and describe the range of groups now available, including a number of mental-health-related groups. The part self-help groups play in providing social support, preventing illness and death, and reducing the need for hospitalization is discussed. The authors also examine the role of professionals in initiating and working with such groups. They point to self-help groups as one means of meeting the increasing demands placed on health and mental health service systems during the 1980s.

Young Adult Chronic Patients: Three Hypothesized Subgroups

Abstract: Shortly after the 1963 passage of the Community Mental Health Centers Act, New York State launched the construction of four new psychiatric centers, including the Richard H. Hutchings Psychiatric Center in Syracuse. The Hutchings acute care crisis stabilization model was intended to significantly diminish the phenomenon of chronic psychiatric disability. After a decade of operation, however, the Hutchings Center must deal with a caseload of young and chronically disabled individuals who are contributing to the build-up both in the hospital and in the community of the new long-stay patient. The idiosyncratic needs of this chronic group must be defined so that prescriptive programs can be built to meet their needs. The Hutchings Center's original goal of returning patients to and serving them in the community remains the same, but the process of treatment, rehabilitation, and long-term community support must change.

Psychiatric rehabilitation as a deterrent to recidivism.

Abstract: An experiment was conducted to evaluate the effectiveness of a comprehensive rehabilitation program in deterring the rehospitalization of severely disturbed psychiatric outpatients. A total of 102 ...

The optimal length of hospitalization for psychiatric patients: a review of the literature.

Abstract: In recent years, several controlled studies have evaluated the value of different lengths of psychiatric hospitalization and of alternatives to hospitalization. The author reviews such studies, noting that most findings suggest that longer stay does not decrease subsequent hospitalization, and does not clearly improve social adjustment or diminish psychopathology. Longterm hospitalization may increase the patient's commitment to continued psychiatric care, but short stay with optimal aftercare planning may be just as beneficial. Long-term hospitalization is necessary clinically for some patients, but the evidence is consistent and convincing in indicating that hospitalization should be kept as short as feasible.

Factors Affecting Adjustment to Community Living

Abstract: The authors draw on sociological writings to develop a theoretical model of adjustment to community living in terms of personal attributes, and test the model with data descriptive of a representative sample of 1,471 chronically mentally ill adults participating in the National Institute of Mental Health community support program. According to the model, poor community adjustment results from deficits in basic living skills, from behaviors and traits that offend others, and from somatic problems that restrict independent activity. The model is used in the prediction of four distinct facets of community adjustment: clients' work status, social activity, and need for hospitalization and for crisis assistance. In addition, the model is also used to explain work performance of a subsample of 371 clients who had jobs at the time of the study. While in most instances only a modest amount of the variance is explained, the results provide some empirical support for the theoretical model, and suggest that differen...

Case Management for the Chronic Mentally III: Models and Dimensions

Abstract: Community-based care of the chronic mentally ill requires the integrative efforts that generally fall under the rubric of case management. The authors describe models of case management according to three dimensions: the manager's degree of involvement in direct service, the type of caseload, and the source and extent of the manager's control over services and resources. The last dimension can be affected by such factors as contracts with private service providers and the case manager's rapport with clinical service providers. Various systemic problems, such as insufflcient funds and duplication of services, may impede case management. Effective case management depends on adequate resources and clear communication among the components of the system.

The medical care of psychiatric patients.

Abstract: Longitudinal and cross-sectional data have demonstrated a high incidence of physical illness among psychiatric patient populations. Problems involved in the treatment of medically ill psychiatric patients include the nonspecificity of psychiatric symptoms, the inadequacy of previous examinations by a nonpsychiatric physician to rule out the possibility of physical disease causing psychiatric symptoms, and the patient's lack of awareness of current or pre-existing physical disease when consulting the psychiatrist. The following review examines nine categories of medical disorders that are known to produce psychiatric symptoms, with discussion of the psychiatric manifestations. Implications for current practice and training are briefly considered.

Diagnosis and Assessment of the Older Patient

Abstract: Despite the enormous medical and psychiatric importance of mental illness among the elderly, clinicians generally are not trained in the phenomenology and presentation of the major mental disorders that occur primarily in this age group. The authors describe the presenting symptoms and course of four conditions—senescent forgetfulness, primary degenerative dementia (considered as the confusional phase and dementia phase), geriatric depression, and multi-infarct dementia—with emphasis on differential diagnosis. The clinical examination of the patient is the most important feature of any diagnostic and assessment program; because of the wide prevalence and in many ways unique aspects of mental illness among the elderly, all but the smallest psychiatric programs should have at least one clinician who specializes in assessment of geriatric problems.

Fifty years of psychiatric services: 1940-1990.

Abstract: Using data from the National Institute of Mental Health and the Census Bureau, the authors examine trends in the delivery of mental health services over the past 40 years as they relate to number and types of facilities, utilization of services, diagnosis, and maintenance expenditures. The data show that during this period access to psychiatric services has been broadened, and there has been increasing use of outpatient and community-based services. More recently there has been increasing reliance on the private sector to provide services, with the help of third-party reimbursement. In addition, the types of facilities have become more varied, providing a broader range of options for mental health care. The authors consider the future of mental health services in light of these trends.

Family Treatments of Schizophrenia: Background and State of the Art

Abstract: Schizophrenia, as a failure to achieve maturity and independence, has always had distressing effects on a patient's family. Unfortunately, scientific theories that propose the family itself as a contributing factor have eroded the alliance between professionals and family members and added to the burden of family guilt. The initiative in designing family therapy for schizophrenia began among an early group of innovators who subscribed to strong family-theory ideologies. Today a more pragmatic group, trained in various research methodologies, has taken the lead. The authors discuss the historical development of family therapy for schizophrenia and review new programs including relatives' groups, psychoeducational family therapy, and strategic and systemic approaches.

Culturally syntonic family therapy for migrant Puerto Ricans

Abstract: Puerto Ricans and other Hispanics have traditionally used the nuclear and extended family as vital support systems to deal with stress. Some Puerto Rican migrant families living in the United States have been suspected of being at high risk for mental health problems precisely because they lack extended family supports. Working together as bilingual co-therapists, the authors found that a systems-oriented family therapy approach is effective and syntonic with the culture of Hispanic migrants. They provide a clinical vignette and warn therapists about the potential problems in differentiating dysfunctional family patterns from culturally sanctioned behaviors.

Apocalypse Terminable and Interminable: Operation Outreach for Vietnam Veterans

Abstract: In 1979 a program called Operation Outreach began to provide comprehensive and integrated psychosocial services to Vietnam veterans. The 136 vet centers, housed in storefronts and other nongovernment buildings, are staffed by Vietnam veterans and others knowledgeable about the horrors of that war; many of them are not mental health professionals. To date the centers have treated approximately 100,000 veterans out of the several hundred thousand who may be experiencing the effects of posttraumatic stress disorders. The author briefly discusses the history of the centers and describes the theoretical and clinical aspects of the program. Based on his clinical experience with veterans and on reports from vet center staff members, he outlines current information available on stress disorders of Vietnam veterans and explores their origins in war experiences and in the reception many veterans received when they returned home. He also describes which treatment methods are successful with troubled veterans and whi...

Cost measurement and cost data in mental health settings.

Abstract: Costs play a major role in determining the types of mental health services that are delivered and thus are a key factor in any discussion of the future of mental health services. The author presents some of the available cost data for care provided in three kinds of settings: hospitals; nonhospital settings such as halfway houses, health maintenance organizations, and community mental health centers; and comprehensive community programs. He discusses the methodological and measurement problems in the estimation of costs and the difficulties in comparing costs across settings. He emphasizes the need for cost data that permit accurate and comparable predictions of costs that will assist policymakers in making intelligent choices between types of services.

The Postwar Healing of Vietnam Veterans: Recent Research

Abstract: The author discusses four themes in the literature on Vietnam veterans' readjustment to civilian life: the unique characteristics of the war; postwar malaise and clinical syndromes; different response patterns to combat experience; and the unique aspects of psychological recovery and healing among Vietnam veterans. After examining literature related to each theme, he warns that therapists and researchers must recognize the diversity of veterans' experiences and of their responses to combat. He points out that the majority of veterans suffer from a subclinical malaise rather than from a diagnosable disorder, and that these veterans could benefit greatly from some form of intervention. Finally, to advance postwar healing, the author stresses the importance of more subtle conceptualizations of stress, more varied forms of intervention, and greater efforts to rehabilitate national respect for service.

Vietnam Veterans and Posttraumatic Stress Disorder

Abstract: As many as four million Americans were stationed in Indo-china during the Vietnam War; some 800,000 were assigned to the combat zone. These individuals are at especially high risk for developing posttraumatic stress disorder, a diagnostic category that appeared for the first time in DSM-III. The authors explore the reasons why many Vietnam veterans have developed the disorder. They discuss four broad types of disorders now being found among veterans, the problems in diagnosing and treating the disorder, and the theoretical basis in ego psychology for the behavior of veterans with the disorder. Also briefly outlined are some clinical considerations for therapists treating Vietnam veterans.

The chronically mentally III in community support systems.

Abstract: This paper presents the results of a 1980 survey of a random sample of 1,471 chronically mentally disabled adults in community support systems sponsored by the National Institute of Mental Health. Drawing on data reported by 248 case managers using the Uniform Client Data Instrument, the authors describe the clients' entry into the program, demographic characteristics, clinical histories, and level of functioning. The paper also presents utilization data corresponding to the ten essential components of a community support system, and examines the relationship between client need and use of services. The authors conclude with a discussion of the changing political environment for mental health services and some of the emergent issues for public policy.

An Inpatient Program for Vietnam Combat Veterans in a Veterans Administration Hospital

Abstract: The Veterans Administration's first inpatient program for Vietnam War veterans was opened in January 1978 at the VA Medical Center in Palo Alto, California. The unit treats a range of psychiatric disorders; however, the typical patient is a 34-year-old white male with a diagnosis of posttraumatic stress disorder and at least one previous hospitalization. The program is designed as a three-phase therapeutic community based on mutual support and group solidarity. Medication is minimized. The program also reflects the assumptions that a debriefing, however belated, from military experience is essential, and that the clinical regimen should enable veterans to resume the transition to adulthood that the war interrupted. The average stay is five months; preliminary evaluation indicates that 60 per cent of the veterans achieve relief from acute psychological distress, resolve a crisis with a spouse or significant other, and begin a job or schooling.

The long-term patient in the community: life style patterns and treatment implications.

Abstract: A sample of 99 long-term patients at an urban community mental health-mental retardation center were interviewed to determine how they spent their time and their degree of happiness with their lives and the services they received at the center. More than half the patients were considered by center staff to be only mildly or moderately impaired, but as a group they were distinguished by low levels of educational, financial, and vocational achievement; only 13 per cent were working more than half time. Most of the patients considered themselves happy, but their life style was oriented toward health and social relationships and lacked a work-task orientation. The authors conclude that the patients' life style meshes closely with the orientation of the treatment system; neither places emphasis on achievement of noninterpersonal tasks or enhancement of a work orientation. The authors believe that many chronic users of community mental health services have the potential to work and that practically all could be...

Changing Trends in CMHCs: Keys to Survival in the Eighties

Abstract: Since 1970 community mental health centers have been seeing greater percentages of less seriously ill patients in spite of the growing numbers of seriously and chronically ill patients in the community. CMHC staffs are composed of less highly trained individuals at all levels, centers appear to be used less for psychiatric training, and federal funds have decreased substantially. To survive the 1980s, centers must make some drastic adjustments, the author believes. They must develop closer relationships with other health facilities, including state hospitals, and they must reprofessionalize their staffs, offering incentives that attract and retain more psychiatrists and doctoral-level psychologists. Centers must market their services more competitively to consumers in the private sector. They must continue to care for the indigent, becoming more adept at participating in third-party insurance programs.

Civil commitment: is the pendulum changing direction?

Abstract: lIt has become a commonplace to observe that commitment law in the United States rides a pendular course. In the last century and a half, as the public has alternately occupied itself with rights of the mentally ill and attention to their treatment needs, substantive and procedural standards for civil commitment have grown in turn more and less stringent (1). There are now several telltale signs that we are approaching another turning point. The current reversion to rigorous civil commitment standards and procedures-what some term the “enminalization” of the mental health system-began nearly 15 years ago. California’s passage in 1969 of the Lanterman-Petris-Short Act (2) and the 1972 Wisconsin case of Lessard v. Schmidt (3) are often cited as landmarks in the process. During this period the nation has witnessed an almost total abandonment of the “need for care and treatment” standard that previously governed commitment in favor of reliance upon determinations of dangerousness (4). We have also seen the construction of multiple legal safeguards against improper commitment, including rights to court hearings, representation by counsel, and the use of more demanding standards of proof. Although the United States Supreme Court has repeatedly declined the opportunity to endorse most of these changes, the lower courts continue to extend these rights. Thus recent decisions have granted patients the right to remain silent at commitment hearings (5), and the right to an abrogation of their commitment for the failure of their counsel to challenge hearsay testimony (6). Many psychiatrists have opposed these changes from the beginning. But psychiatric remonstrations appear to have had little effect on either legislators or judges, who have, because of civil-libertarian or economic concerns, continued to push for more restrictive commitment policies. The current signs of a change in those approaches to civil commitment are tentative ones. Nevertheless,

Needs for psychiatry in the general hospital.

Abstract: Thirty to 60 per cent of the patients in general hospitals suffer from significant psychological dysfunction or psychological dysfunction secondary to their medical illness. In addition to helping medically ill patients adapt to their illness and hospitalization, psychiatrists who work in general hospitals should develop the biopsychosocial model of diagnosis and management and improve the staff's capacity to detect, diagnose, and manage their patients' psychological problems. The author discusses specific needs for consultation-liaison psychiatry in the general hospital such as development of prevention schema, case detection, continuing education programs for staff, and education groups for patients and families. He also describes structural innovations to meet the increasing demands for psychiatric services in the general hospital setting. These innovations include the establishment of a biopsychosocial data-base system and the use of screening devices, medical-psychiatric inpatient units, and medical-...

Measuring Restrictiveness of Psychiatric Care

Abstract: "Restrictiveness" is neither a narrow legal concept nor a clinical concept that encompasses all aspects of a patient and his treatment; it refers to several features of treatment that can infringe on individual freedoms. As part of a study to develop a reliable method to measure restrictiveness, 31 mental health professionals were asked to rate the restrictiveness of six dimensions of treatment, such as legal status, and 33 treatment alternatives. Interrater reliability was high for both the importance of dimensions (alpha = .92) and the restrictiveness of alternatives within dimensions (alpha = .99). The treatment dimension judged most important in assessing restrictiveness was "limitations of physical freedom." The scale resulting from these judgments offers a plausible measurement of the restrictiveness of treatment configurations for use in evaluation research. The authors caution that restrictiveness is not in itself a comprehensive index of the quality of psychiatric care.

Psychiatric Manpower and Public Mental Health: Maryland's Experience

Abstract: From July of 1976 through December 1981, 67 psychiatrists who graduated primarily from American medical schools and who bad completed university residency training programs were recruited into Maryland's state mental health system. As of 1981, 43 of these psychiatrists still worked in inpatient facilities; they represented 33 per cent of all state hospital psychiatrists in Maryland. The Maryland Mental Hygiene Administration and the University of Maryland have used two general strategies to develop psychiatric manpower and improve employment conditions. They established close linkages between academia and the public sector and demonstrated positive, effective leadership by psychiatrists within the state mental health system.

Attitudes of Nonpsychiatric Physicians Toward Psychiatric Consultation

Abstract: The authors report on an opinion survey of 200 nonpsychiatric attending physicians at a university teaching hospital about the process and outcome of consultation psychiatry. Over-all, physicians felt that 37 per cent of their patients had problems with significant psychological components, but that consultation was indicated for only 11 per cent. Physicians reported a high level of global satisfaction with consultations; 68 per cent were satisfied frequently or almost always. Factor analysis reduced consultees' evaluations of 18 different consultation activities to five dimensions, with patient disposition consistered the most important and services to medical and ward staff the least important. Analysis of differences by specialty revealed that family medicine physicians seemed the most oriented to psychological issues and surgeons the least.

A comparison of AMA and non-AMA patients on a short-term crisis unit.

Abstract: Nineteen patients who left a short-term psychiatric crisis unit against medical advice were compared with 109 patients who received a regular discharge during a six-month period. Demographic, historic, assessment, and diagnostic variables of both groups were examined. Results indicated that patients diagnosed as having personality or substance use disorders and patients judged abnormal on a mental status examination were more likely to be AMA patients. However, AMA patients indicated fewer social problems as rated on Linn's Social Dysfunction Scale. It was concluded that diagnostic variables best differentiated patients leaving the treatment unit against medical advice from those who completed treatment.