Showing papers in "Psychiatric Services in 1984"
TL;DR: During the six-month posttreatment period patients who had received social skills training either continued to improve or maintained their gains on most measures, while the patients receiving day hospital treatment alone either maintained gains or lost them.
Abstract: To study the efficacy of social skills training and day hospital treatment for schizophrenic patients, the authors treated 20 chronic schizophrenic patients in a 12-week day hospital program and 44 patients in the same program supplemented by comprehensive social skills training. While both groups of patients who completed treatment showed improvement immediately following treatment, during the sixmonth posttreatment period patients who bad received social skills training either continued to improve or maintained their gains on most measures, while the patients receiving day hospital treatment alone either maintamed gains or lost them. The authors discuss the implications of these findings as well as the finding that almost half of the patients in both groups were hospitalized at least once in the year following treatment.
130Â citations
TL;DR: The results of a preliminary outcome study of 60 former patients who completed a survey form rating various aspects of their lives one year postdischarge support the contention that pathological gambling is a treatable disorder.
Abstract: In 1972 the Brecksville Unit of the Cleveland Veterans Administnation Medical Center began the first inpatient treatment program for pathological gambling in the United States. The 30-day, highly structured gambling treatment program aims for abstinence from gambling, reduction of the urge to gamble, and restonation of a maximum level of social functioning. The authors report the results of a preliminary outcome study of 60 former patients who completed a survey form rating various aspects of their lives one year postdischange. Fifty-five percent of the nespondents reported complete abstinence from gambling since dischange. Chi-square analyses demonstrated significant relationships between abstinence from gambling and improved interpensonal relationships, better financial status, decreased depression, and participation in professional aftercare and Gamblers Anonymous. The authors believe that their initial results support the contention that pathological gambling is a treatable disorder.
93Â citations
TL;DR: Most striking among the findings was the low priority respondents accorded to the psychiatric and social services currently offered by community mental health agencies; instead the respondents often blamed their inability to avoid readmissions on their lack of basic resources for survival.
Abstract: Efforts to alter the repeated use costly hospital-based psychiatric services and the underuse of community mental health services by some homeless adults have yielded few successes. To better understand these failed efforts, the authors interviewed 112 self-identified homeless recidivists in San Francisco on several demographic variables, the problems they face in living in the community, and the resources they feel they need to be able to remain in the community. Most striking among the findings was the low priority respondents accorded to the psychiatric and social services currently offered by community mental health agencies; instead the respondents often blamed their inability to avoid readmissions on their lack of basic resources for survival. The authors discuss the relevance of the findings for mental health research, funding policies, and programming.
85Â citations
TL;DR: Using the literature on chronic pain, the authors discuss the evolution of the chronic pain concept into the multidisciplinary multimodal approach used by pain clinics today, and the factors identified in the literature that influence a patient's perception of pain.
Abstract: In the past ten years developments in social psychology, neurochemistry, learning theory, and psychophysiology have expanded the concept of chronic pain into a biopsychosocial model, in which pain is viewed as a form of abnormal illness behavior influenced by a wide range of biological, social, and psychological factors. Using the literature on chronic pain, the authors discuss the evolution of the chronic pain concept into the multidisciplinary multimodal approach used by pain clinics today, and the factors identified in the literature that influence a patient's perception of pain. Finally, based on their experiences in setting up a pain clinic and on the literature on leading pain management programs, they discuss in detail the evaluation, treatment, and management strategies of a comprehensive chronic pain management program.
84Â citations
TL;DR: The author, who was diagnosed as having chronic process schizophrenia, describes her experiences as a patient in the treatment world of the chronic mentally ill, beginning at age 17, and attributes her recovery to multiple, sometimes nontraditional, treatment approaches and to the coping techniques she learned with the help of others.
Abstract: The author, who was diagnosed as having chronic process schizophrenia, describes her experiences as a patient in the treatment world of the chronic mentally ill, beginning at age 17. Over the next six years she was seen by four psychiatrists, was hospitalized eight times, attended day hospitals, lived in a foster care home, and received shock treatments, megavitamin therapy, and a variety of neuroleptic and antidepressant drugs. Eventually she developed a drinking problem and was forced to enter a chemical dependency treatment program. The first of many turning points in her illness came when a psychiatrist associated with the program believed she could recover and persuaded staff to work with her. The author defines hope as an essential element in the recovery process and emphasizes the importance of instilling hope for recovery in physicians, patients, and patient care staff. She attributes her recovery to multiple, sometimes nontraditional, treatment approaches and to the coping techniques she learned with the help of others.
66Â citations
TL;DR: The authors conclude that the more disaffiliated members of the homeless population, such as those served by Project HELP, need even more extensive services than the homeless who use some kind of existing sheltered care, and they suggest various kinds of services to meet their needs.
Abstract: Project HELP was established in New York City in 1982 as a mobile outreach unit providing crisis medical and psychiatric services to impaired homeless persons. The authors describe the demographic characteristics of the population served, the disposition of patients accepting treatment or shelter services, and the adaptation of the homeless to weather extremes. They discuss the difficulties in providing services to a population whose members are distrustful of authority and are unwilling to provide information about themselves. They conclude that the more disaffiliated members of the homeless population, such as those served by Project HELP, need even more extensive services than the homeless who use some kind of existing sheltered care, and they suggest various kinds of services to meet their needs.
59Â citations
TL;DR: The author examines three studies of the major monetary costs and benefits of psychosocial rehabilitation of the mentally ill, focusing on hospitalization costs, costs of community treatment, and earnings from competitive employment, and concludes that these studies offer substantial evidence for the economic advantages of psychOSocial rehabilitation.
Abstract: The author examines three studies of the major monetary costs and benefits of psychosocial rehabilitation of the mentally ill; he focuses on hospitalization costs, costs of community treatment, and earnings from competitive employment. In the first study, which compared the effects of psychosocial rehabilitation with those of a support group over a nine-month period, an estimated savings of $1,880 per client was found among the clients receiving psychosocial rehabilitation. In the second study of treatment costs for 40 chronic psychiatric recidivists who were involved in an aggressive home outreach program, an estimated annual savings of $5,000 per client was found. In the third study 101 clients were interviewed six months after they had left a psycbosocial rehabilitation program. Their earnings from competitive employment were linearly related to their length of participation in the program. The author concludes that these studies offer substantial evidence for the economic advantages of psychosocial re...
57Â citations
TL;DR: It is proposed that psychiatric hospitals will have difficulty adjusting to a reimbursement system based on diagnosis alone, and four major aspects of the prospective payment system are reviewed: efficiency, equity and access for patients, quality of care, and practicality.
Abstract: Can prospective payment control the cost of Medicare treatment without seriously affecting the quality of care? The authors pose this question and then explore the new system's implications for the mental health field. Because psychiatric diagnoses do not adequately describe the reasons for hospitalization, and because treatment of mental disorders is not standardized throughout the country, the authors posit that psychiatric hospitals will have difficulty adjusting to a reimbursement system based on diagnosis alone. They also review four major aspects of the prospective payment system: efficiency, equity and access for patients, quality of care, and practicality. Other issues, such as prospective payment's financial impact on medical research and technology development, are also discussed.
45Â citations
TL;DR: The results confirm the existence of a prodromal period before relapse and the importance of prompt therapeutic interventions during such periods and present a literature survey of the role of stress, the family, and psychotropic medication in relation to the relapse process.
Abstract: Although clinicians know that the acute symptoms of schizophrenia exacerbate and remit during the course of the illness, few studies detail the process leading to psychotic episodes. As an introduction to the problem of recognizing relapse in schizophrenic outpatients, the author discusses interviews that were conducted with one group of family members and two groups of schizophrenic patients, one whose psychotic episodes had just occurred and one whose episodes had occurred more than six months previously. The results confirm the existence of a prodromal period before relapse and the importance of prompt therapeutic interventions during such periods. Finally, the author presents a literature survey of the role of stress, the family, and psychotropic medication in relation to the relapse process, and discusses comprehensive therapeutic strategies that aim to either prevent or mitigate full-blown relapse.
34Â citations
TL;DR: The authors describe the use of diagnostic supervision to identify common errors made by trainees in the application of DSM-III to multiaxial evaluations in an outpatient clinic, and discusses the implications for training residents and psychology interns.
Abstract: The authors describe the use of diagnostic supervision to identify common errors made by trainees in the application of DSM-lII to multiaxial evaluations in an outpatient clinic. Errors on all five axes were due primarily to misapplications ofdiagnostic criteria and conventions. Errors on axes I, IV, and V were most frequent. Axis I errors were cornrnonly due to confusion about the relationship of dysthyrnic disorder to major depression, neglect of substance use disorder diagnoses, and misuse of the adjustment disorder and V-code categories. On axis JV, the severity of psychosocial stressors was frequently overrated, based on severa! misconceptions. Axis V ratings were often erroneously over estimated because they were individualized rather than made on a uniform scale. No differences were found in the error rates of psychiatric residents compared with psychology interns except on axis 1, where interns made more errors. The authors discuss the implications of these errors for training residents and psycho...
32Â citations
TL;DR: It is pointed out that while many chronic patients eventually attain high levels of social and vocational functioning, many cannot meet simple demands of living, even with long-term rehabilitative help.
Abstract: Deinstitutionalization of the chronically mentally ill does not mean they no longer need social support, protection, and relief from the pressures of life--in other words, asylum and sanctuary The authors address the questions of why asylum should be provided, for what patients, the relationship between asylum and rehabilitation, and the implications for mental health professionals They point out that while many chronic patients eventually attain high levels of social and vocational functioning, many cannot meet simple demands of living, even with long-term rehabilitative help Many consciously limit their exposure to stimuli and pressure not from laziness but from a well-founded fear of failure Professionals must realize that whatever degree of rehabilitation is possible for each patient cannot take place unless support and protection--whether from family, treatment program, board-and-care home, or public hospital--are provided at the same time
TL;DR: It is concluded that instructions and feedback are an effective and inexpensive way to reduce the use of restrictive treatment procedures and that the approach used in their facility merits further investigation.
Abstract: Restrictive procedures are frequently used in residential facilities for the mentally illand developmentally disabled despite bumanitarian, professional, and legal concerns. Administrators in a regional residential facility for the developmentally disabled instructed staff to reduce the use of seclusion, mechanical restraint, andpsychotropic drugs in the facility and set clearly defined policies and procedures on the use of such restraints. Data were gathered on the prevalence of restrictive procedures before and after the new policies were implemented, and staff received frequent feedback. The data showed that in the two and a half years following the adoption of the new policies, the use of seclusion, mechanical restraint, and psychotropic drugs dropped significantly without a concomitant increase in violent incidents, staff turnover, or use of other restrictive procedures. The authors condude that instructions and feedback are an effective and inexpensive way to reduce the use of restrictive treatment ...
TL;DR: The findings suggest that the case managers, by focusing on management of reality rather than on symptomatology, foster their clients' community adjustment.
Abstract: Case managers have been assigned a key role in community support systems (CSS) for deinstitutionalized chronic mental patients, yet little research has been published on how case managers actually work with clients. In separate intensive interviews the authors questioned 30 CSS clients and their 15 case managers about how the case managers helped or failed to help clients with their daily functioning. Results are discussed in terms of the case managers' general role, and their role in linking clients to activities, providing social support, and preventing rehospitalization. The findings suggest that the case managers, by focusing on management of reality rather than on symptomatology, foster their clients' community adjustment.
TL;DR: A needs assessment was conducted to determine the existence and extent of differences between Vietnam-era veterans and other veterans residing within the catchment area of the Northport Veterans Administration Medical Center, and a greater percentage of Vietnam- era veterans reported experiencing the symptoms of posttraumatic stress disorder.
Abstract: A needs assessment was conducted to determine the existence and extent of differences between Vietnam-era veterans and other veterans residing within the catchment area of the Northport Veterans Ad...
TL;DR: This study included 58 of the 110 patients who had been released from the clinical research unit from one to five years previously, and included patients discharged to other Camarillo State Hospital units, other hospitals, community placement facilitics, or their own homes.
Abstract: gram on the clinical research unit at Camarillo State Hospital. Prcvious studies had amply documented the short-term benefits accrued by patients treated on the unit during its 12 years of operation (3-5). This study included 58 of the 110 patients who had been released from the unit from one to five years previously. The patients had been discharged to other Camarillo State Hospital units, other hospitals, community placement facilitics, or their own homes. Their length of stay on the unit had ranged from two weeks to five years, and averaged six months. They were released from the program without benefit of systematic
TL;DR: The results indicate that while the 18- to 34-year-old patients in their study did exhibit many of the problematic characteristics associated with young chronic patients, these characteristics applied to a relatively small minority of the young patients as well as tomany of the older patients.
Abstract: Using data from a 1981 survey of 844 clients in seven selected programs of New York State's community support system, the authors assess the relationship of client age to a wide range of individual characteristics. They are particularly concerned with whether the young adult chronic patients in their study (those aged 18 to 34) share the same negative characteristics increasingly applied to young chronic patients in the literature, and whether these characteristics also apply to older patients. Their results indicate that while the 18- to 34-year-old patients in their study did exhibit many of the problematic characteristics associated with young chronic patients, these characteristics applied to a relatively small minority of the young patients as well as to many of the older patients. In addition, the results highlight several significant strengths of young patients that have received little attention. The authors conclude by discussing the important clinical and programmatic implications of their findings.
TL;DR: Physicians must, the author believes, enter the public debate to protect the goal of medical care: the maximization of the health status of the population.
Abstract: The author argues that for-profit hospitals threaten the integrity of the health care system because they are designed to maximize charges and profits rather than equity and quality. He discusses the most detrimental results of an unrestrained profit motive: higher costs, skimming off of patients on whom money can be made and dumping of poor patients onto public hospitals, consumption of the products of medical education and research without contribution to their costs, stockholders who are unanswerable to the community of users, and undue political and economic power. Physicans must, the author believes, enter the public debate to protect the goal of medical care: the maximization of the population.
TL;DR: The authors suggest that the average restrictiveness experienced by this population of severely mentally disabled individuals has been reduced since the initiation of deinstitutionalization.
Abstract: Restrictiveness of care was assessed among 286 severely mentally disabled individuals known to an urban community mental health center. By examining dinical records, the authors rated each subject for each month during a period of up to 85 months on four dimensions of restrictiveness: physical freedom, time constraints, legal status, and conservatorship. The maximum restrictiveness experienced by most of the subjects was high, reflecting periodic involuntary hospitalization. The average restrictiveness they experienced, however, was well below the level represented by state hospital care. Thus the authors suggest that the average restrictiveness experienced by this population has been reduced since the initiation of deinstitutionalization.
TL;DR: The author concludes that in approaching current policy issues mental health professionals must forge solutions that meet the needs of patients rather than those of the external environment.
Abstract: Too often mental health care professionals consider bureaucratic constraints rather than patient needs when making clinical, administrative, and public policy decisions. This sort of "top-down" decision-making leads to solutions that emphasize procedures and regulations rather than clinical results. After examining the disastrous effects of top-down planning in areas such as care of the chronic mental patient, the author concludes that in approaching current policy issues mental health professionals must forge solutions that meet the needs of patients rather than those of the external environment.
TL;DR: A modification of the proportionate scaling method developed by Holmes and Rahe is used to measure and rank the stress-producing potential of 60 items identified by psychiatrists at Saint Elizabeths Hospital in Washington, D.C., as sources of stress.
Abstract: Although state mental hospitals face a critical shortage of psychiatric manpower, there have been no studies of how psychiatrists view their roles and responsibilities within the public mental health system. in this study, a modification ofthe proportionate scaling method developed by Holmes and Rahe is used to measure and rank the stress-producing potential of 60 items identifled by psychiatrists at Saint Elizabeths Hospital in Washington, D. C., as sources of stress. Results of the analysis show that most of the events rated as highly stressful fall into the category of administrative and organizational shortcomings.
TL;DR: The data indicate that day care is possible for at least some severely demented clients and it is hoped that the data demonstrating successful management in day care will encourage some centers to accept more clients with dementia.
Abstract: Day care is a vitally needed form of respite within the continuum of resources required by demented clients and their families over the course of the illness. The benefits provided to clients and caregivers by this form of respite are important topics for further study. Our data indicate that day care is possible for at least some severely demented clients. We hope that the data demonstrating successful management in day care will encourage some centers to accept more clients with dementia. The urgent need of caregivers for relief also justifies efforts to develop special centers for demented clients and to overcome the difficulties involved in caring for them.
TL;DR: The authors found that the VRP patients had very low dropout and relapse rates;VRP patients also had better recidivism and employment rates compared with baseline rates and with patients in two comparison programs, suggesting that integrating rehabilitation into hospital psychiatry improves patient care.
Abstract: Psychosocial rehabilitation services, while sorely needed by patients with prolonged mental illness, are not usually offered as part of hospital psychiatry. The authors describe the Veterans Resource Program (VRP), a hospital-based psychosocial rehabilitation program, as a model for introducing rehabilitation services into a hospital psychiatry system. Its perceived residential treatment environment was found to be more practically oriented and to provide more autonomy for patients than did an intensive treatment unit, while still possessing many supportive relationship characteristics. The authors found that the VRP patients had very low dropout and relapse rates; VRP patients also had better recidivism and employment rates compared with baseline rates and with patients in two comparison programs. These results suggest that integrating rehabilitation into hospital psychiatry improves patient care.
TL;DR: Policymakers can learn a great deal from the personal experiences of Miss Frumkin, whose story clearly illustrates the challenges faced by chronically mentally ill people in the United States.
Abstract: Unfortunately Miss Frumkin's story is not unique. There are an estimated 1.7 to 2.4 million chronically mentally ill persons in the United States. Like Miss Frumkin, many have drifted in and out of hospitals as the symptoms of chronic mental illness fluctuate unpredictably. They have failed to find a caretaker or treatment setting that will assume primary responsibility for their care. They have fallen between the cracks of different agencies when seeking help in the community. They are taking various kinds of antipsychotic drugs to help control the symptoms of chronic mental illness and are developing adverse effects. They are leading lonely marginal lives in but not of the community. They are becoming overwhelmed by the cost of the illness. They are experiencing frustration and despair in attempting to deal with an illness "stronger than I am," in Miss Frumkin's words. Policymakers can learn a great deal from the personal experiences of Miss Frumkin and her family. Her story clearly illustrates the prof...
TL;DR: The author presents key concepts of the asylum related to codes of conduct, management of restraint, and social amenities from the perspective of Tuke and other reformers, and challenges some interpretations of the early asylums made by Michel Foucault.
Abstract: The author explores the initial intent of the asylum, a reform designed to ensure humane care of the mentally ill, drawing especially on Samuel Tuke's account of the York Retreat. He presents key concepts ofthe asylum related to codes of conduct, management ofrestraint, and social amenities f rom the perspective of Tuke and other reformers, and challenges some interpretations oftbe early asylums made by Michel Foucault.
TL;DR: After a preliminary study of foreign patients treated on the psychiatry service, the department of psychiatry established a program of seminars and didactic sessions intended to familiarize staff and trainees with cultural patterns of the largest groups of foreign students attending the university.
Abstract: Cultural and linguistic barriers have long been problems in establisbing an effective therapeutic alliance between patients and therapists from different cultural, ethnic, and racial backgrounds. The current emphasis on cultural psychiatry has stimulated the inclusion of culturally relevant material in the curricuia of American psychiatric residency programs, such as the program at Howard University Hospital in Washington, D.C. After a preliminary study of foreign patients treated on the psychiatry service, the department of psychiatry established a program of seminars and didactic sessions intended to familiarize staff and trainees with cultural patterns of the largest groups of foreign students attending the university. The department also participated in a transcultural fellowship program for medical students sponsored by the American Psychiatric Association and the National Institute of Mental Health. After describing the programs, the authors briefly discuss such culturally related issues as foreign ...