Showing papers in "Psychiatric Services in 1986"
TL;DR: Regardless of length of stay, the community residents perceived their living conditions more favorably, had more financial resources, and were less likely to have been assaulted in the past year than the inpatients.
Abstract: Amidst the controversy about the effects of deinstitutionalization, the well-being of the chronic mentally ill in different treatment settings remains unclear. This study examined objective and subjective quality-of-life experiences of four groups of chronic patients categorized according to whether they were inpatients of a state hospital or residents of a supervised community residence and whether their current length of stay had been less than or greater than six months. Regardless of length of stay, the community residents perceived their living conditions more favorably, had more financial resources, and were less likely to have been assaulted in the past year than the inpatients. The study illuminates the problematic living conditions of state hospitals and the benefits of appropriately designed community-based residences for the chronic mentally ill.
164 citations
TL;DR: In a large-scale study of homelessness in Ohio, data were collected in face-to-face interviews with 979 homeless people in 19 counties and found that homelessness is clearly a multidimensional problem and that service strategies must reflect the multiple needs and varying characteristics of homeless people.
Abstract: The social problem of homelessness is of increasing concern to mental health professionals. In a large-scale study of homelessness in Ohio, data were collected in face-to-face interviews with 979 homeless people in 19 counties. The median length of homelessness was 60 days. Almost half the respondents cited economic factors, such as unemployment or problems paying rent, as the major reason for their homelessness. Thirty percent had been hospitalized at least once for mental health reasons, and 31 percent showed symptoms serious enough to require mental health services. Findings are also presented ir relation to a typology of the homeless—street people, shelter people, and resource people—and urban and rural respondents are compared. These and other findings support the principal conclusions that homelessness is clearly a multidimensional problem and that service strategies must reflect the multiple needs and varying characteristics of homeless people.
101 citations
100 citations
TL;DR: Common presentations of AIDS-related organic mental syndromes may mimic functional disorders such as chronic mild depression and acute psychosis, and diagnostic and management guidelines are provided.
Abstract: Psychiatric symptoms among patients with acquired immune deficiency syndrome (AIDS) may be functional reactions to contracting a fatal and stigmatizing disease or may be secondary to malignancies and opportunistic infections in the central nervous system (CNS). More recent evidence indicates that HTLV-III, the virus that causes AIDS, directly infects the CNS and may cause psychiatric symptoms before signs of immunodeficiency, cognitive impairment, or neurological abnormalities emerge. AIDS-related organic mental syndromes may mimic functional disorders such as chronic mild depression and acute psychosis. Both of these common presentations are illustrated with detailed case reports, and diagnostic and management guidelines are provided.
80 citations
73 citations
TL;DR: The hospital records of the nongeriatric population of a state hospital were examined to identify the institution's worst recidivists; six patients with a total of 276 admissions were found; six were diagnosed as schizophrenic and six as having a personality disorder.
Abstract: The hospital records of the nongeriatric population of a state hospital (N=191) were examined to identify the institution's worst recidivists. Twelve patients with a total of 276 admissions were found; six were diagnosed as schizophrenic and six as having a personality disorder. The two diagnostic subpopulations differed most strongly on reasons for their admissions and on treatment received in the hospital. The author proposes that other treatment approaches be applied to the two groups while further research is done.
71 citations
TL;DR: The author discusses several programs that have successfully used continuous treatment teams, the theoretical considerations supporting use of the teams, and the problems be encountered after trying to implement such teams at a public psychiatric hospital in Washington, D.C.
Abstract: Since deinstitutionalization began, the model of service delivery for the chronic mentally ill has been characterized first by the mere availability of services and then by continuity of care as coordinated through the case manager system. However, there is increasing evidence that the continuity of care model has neglected an element crucial to its success--continuity of caregivers. Continuity of caregivers means that a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings. The author discusses several programs that have successfully used continuous treatment teams, the theoretical considerations supporting use of the teams, and the problems be encountered after trying to implement such teams at a public psychiatric hospital in Washington, D.C.
68 citations
TL;DR: Following a review of several studies of homeless populations, a survey of 68 homeless adults in eight urban emergency shelters in Hennepin County, Minnesota indicated impressive rates of mental illness, alcoholism, minor criminality, and chronic medical and dental problems.
Abstract: Following a review of several studies of homeless populations, the authors describe a survey of 68 homeless adults in eight urban emergency shelters in Hennepin County, Minnesota. The results indicated impressive rates of mental illness, alcoholism, minor criminality, and chronic medical and dental problems. More significant, the authors believe, both for the homeless and for public policy planners, is that a majority of the interviewees were disconnected from supportive social networks and were underutilizing medical and welfare programs for which they were eligible. Almost 40 percent of those with chronic health problems were receiving no medical care, and only 6 percent were receiving mental health services, although more than 50 percent needed such care. The authors compare the findings with those of studies discussed in the literature review.
53 citations
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TL;DR: HIV/AIDS has now taken hold in the most populous countries of the world—the number of people infected with HIV has reached one million in China and six million in India; the destructive effects of the epidemic are already beginning to be felt in those countries.
Abstract: HIV/AIDS is the deadliest epidemic of our time. Over 22 million people have already lost their lives and more than 42 million are currently living with HIV/AIDS. Even if a vaccine for HIV were discovered today, over 40 million people would still die prematurely due to AIDS. In many countries, especially in Africa and the hardest-hit countries such as Botswana, Swaziland and Zimbabwe, the AIDS epidemic has spread rapidly, leaving illness, death, poverty and misery in its wake. In other countries the disease is still in its early stages. Notably, HIV/AIDS has now taken hold in the most populous countries of the world—the number of people infected with HIV has reached one million in China and six million in India; the destructive effects of the epidemic are already beginning to be felt in those countries.
51 citations
TL;DR: A review of changes and excesses of the past 30 years--including deinstitutionalization, relocation of patients to nursing homes, the domination of psychodynamic concepts, and the naivety and partial successes of the community mental health movement--is used as a basis for outlining manageable ways to meet this challenge.
Abstract: The challenge of chronic mental illness lies in developing effective service delivery systems that will preserve patients' functioning and limit their disability. The author uses a review of changes and excesses of the past 30 years—including deinstitutionlization, relocation of patients to nursing homes, the domination of psychodynamic concepts, and the naivety and partial successes of the community mental health movement—as a basis for outlining manageable ways to meet this challenge. Care for the chronic patient must be developed within a long-term rehabilitatives context and with wiser use of available benefits and funds, induding consolidation of funding sources. Mental health advocates should coordinate activities rather than compete with one another and case management should be based on more sophisticated concepts and training.
TL;DR: Outpatients with AIDS or AIDS-related complex benefit from clarification, abreaction, and support if the therapist accepts the regression associated with the sick role, focuses initially on somatic rather than on psychological concerns, and overcomes unwarranted fears of contagion.
Abstract: Although the medical and psychosocial problems posed by acquired immune deficiency syndrome (AIDS) are unique, interventions to treat AIDS-related psychiatric disorders are currently available. The depression, delirium, and denial that occur in medically hospitalized patients with AIDS respond to standard psychotherapeutic and psychopharmacological approaches. Outpatients with AIDS or AIDS-related complex benefit from clarification, abreaction, and support if the therapist accepts the regression associated with the sick role, focuses initially on somatic rather than on psychological concerns, and overcomes unwarranted fears of contagion. Patients with AIDS-related dementia are helped considerably by early diagnosis and planning, and patients with antibodies to the AIDS virus require a psycho-educational approach that includes stress inoculation and problem-solving techniques. The authors describe the above interventions as well as common countertransference responses that impede their implementation.
TL;DR: Interviews with 62 outpatients with chronic schizophrenia and schizoaffective disorder indicated that many patients monitor symptoms that they associate with changes in their illness and alter their behavior based on their symptoms.
Abstract: Interviews with 62 outpatients with chronic schizophrenia and schizoaffective disorder indicated that many patients monitor symptoms that they associate with changes in their illness and alter their behavior based on their symptoms. Ninety-eight percent of the subjects identified symptoms, two-thirds of which were nonpsychotic, that indicated to them they were getting worse. Eighty-two percent of those who identified symptoms of decompensation responded by altering their behavior, either by selftreatment (such as self-medicating, engaging in a diversionary activity, or attempting to ignore the symptoms), by seeking mental health assistance, or both. The authors compare their findings with those of other studies and discuss the study's implications for research on and care of schizopbrenic patients.
TL;DR: A reanalysis of data from the 1977 National Nursing Home Survey, including data not available earlier, led to an estimate that 668,000 chronic mentally ill patients reside in nursing homes, and showed that mentally ill residents were more likely to have behavior problems and to have much longer stays.
Abstract: A reanalysis of data from the 1977 National Nursing Home Survey, including data not available earlier, led to an estimate that 668,000 chronic mentally ill patients reside in nursing homes. Several subpopulations of nursing home residents were also identified and compared, which showed, for instance, that residents with only mental disorders were younger, were less likely to need the help of another person in daily activities, and were much less likely to be totally dependent than residents with only physical disorders. However, not surprisingly, mentally ill residents were more likely to have behavior problems and to have much longer stays. Residents diagnosed as senile, with or without a physical disorder, more closely resembled the purely physically ill than the purely mentally ill patients. The data illustrate the wide range of needs of mentally ill nursing home residents and reinforce the importance of assessing and improving the appropriateness of care offered.
TL;DR: The right to treatment should be implemented beginning with established constitutional minimums of providing reasonable care and safety, reasonably nonrestrictive confinement, and treatment to prevent clinical deterioration.
Abstract: Three areas of legal change have had major effects on the chronic mentally ill: substantive and procedural alterations in civil commitment laws, the limited implementation of a constitutionally based right to treatment, and the partial recognition of a right to refuse treatment. After discussing these changes, the authors make recommendations they believe would be beneficial. Revised civil commitment laws should allow greater access to both emergency and ongoing involuntary treatment, including reintroduction of a need-for-treatment standard and use of informal rules of evidence. The right to treatment should be implemented beginning with established constitutional minimums of providing reasonable care and safety, reasonably nonrestrictive confinement, and treatment to prevent clinical deterioration. Legislation should permit medication of involuntarily committed patients without their consent.
TL;DR: This study presents the results of an investigation of the occurrence of delusions during prior psychiatric hospitalizations of 70 patients with recurrent illness, finding significant differences between delusional and nondelusional patients in the clinical characteristics of past depressive episodes.
Abstract: Recent studies have examined the evidence for considering delusional and nondelusional unipolar major depressions as two distinct dinical entities ( 1 ,2). Supporting this hypothesis are important differerices that exist in patient response to treatment and in biochemical characteristics of patients with these disorders (3,4). Spiker and associates (5) and others (6,7) have demonstrated that delusiorially depressed patients respond more completely to treatment with neuroleptic and tricyclic drugs cornbined than to tricyclics alone. Chancy and Nelson (8) found significant differences between delusional and nondelusional patients in the clinical characteristics of past depressive episodes. They reported that 95 percent of delusional patients with recurrent illness had a previous episode of delusional depression, compared with only 8 percent of noridelusional patients. This study presents the results of an investigation of the occurrence of delusions during prior psychiatric hospitalizations of 70
TL;DR: It is found that repeat visitors to psychiatric emergency services are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness.
Abstract: Repeat visitors to psychiatric emergency services constitute 7 to 18 percent of the total patients and account for up to a third of the visits. This frequently difficult-to-treat group has been described in six controlled and two uncontrolled studies. In a critical review of findings and methodology the authors interpret and compare the available data about repeaters. Their major conclusions are that repeaters are more likely to lack social supports, to be currently in psychiatric treatment, and to have a chronic illness. Research approaches to further elucidate these patients' characteristics are suggested.
TL;DR: Italy's mental health law of 1978 mandated the closing of state mental hospitals to new and former patients and the creation of comprehensive community-based service systems, which created the South Verona Community Psychiatric Service, which serves a population of 75,000.
Abstract: Italy's mental health law of 1978 mandated the closing of state mental hospitals to new and former mer patients and the creation of comprehensive community-based service systems. The authors descri...
TL;DR: Several prescriptions for inpatient psychotherapy of schizophrenia are offered: modest, well-defined goals; gentle, supportive, educational interactions with the patient; inclusion of the patient's support system and outpatient caregivers in the treatment; and attention to long-term adjustment as well as to short-term symptom removal.
Abstract: In the inpatient psychosocial treatment of schizophrenia, therapies that are intense and over-stimulating often promote or prolong regression and negatively affect long-term adjustment. These approaches fail to take into account the chronicity of the disorder, the special vulnerabilities of the schizophrenic patient, and the appropriate goals of an inpatient admission. Based on a review of these problems, the authors offer several prescriptions for inpatient psychotherapy of schizophrenia: modest, well-defined goals; gentle, supportive, educational interactions with the patient; inclusion of the patient's support system and outpatient caregivers in the treatment; and attention to long-term adjustment as well as to short-term symptom removal.
TL;DR: A new federal entitlement program for the chronic mentally ill that would pool all existing funds regardless of the source is proposed and States would be empowered to develop a single administrative agency with responsibility for coordinating a comprehensive program of services.
Abstract: The estimated 1.7 to 2.4 million Americans who suffer from chronic mental illness are poorly served by the current nonsystem of services. No agency at any level is responsible for coordination of funding, treatment, and care. Since the mid-1950s funding has become increasingly fragmented as state mental hospitals have been depopulated, community services have been developed, and federal entitlement programs such as Medicaid, Medicare, and Social Security Disability Insurance have been introduced. To overcome the problems of fragmented funding and uncoordinated services, the authors propose establishment of a new federal entitlement program for the chronic mentally ill that would pool all existing funds regardless of the source. States would be empowered to develop a single administrative agency with responsibility for coordinating a comprehensive program of services.
TL;DR: The findings of this study support previous reports documenting a high rate of chronic medical illness among the chronic mentally ill and indicate that different psychiatric groups have different needs that must be considered when planning possible interventions.
Abstract: The findings of our study support previous reports documenting a high rate of chronic medical illness among the chronic mentally ill. More than 42 percent of CSP clients were reported to have at least one chronic medical problem severe enough to limit functioning. This finding was not attributable to age. The data indicate that different psychiatric groups have different needs that must be considered when planning possible interventions. The medical problems associated with OBS and retardation are so much a part of these syndromes that prevention efforts would have to focus on the psychiatric disorder itself. However, the high rate of illness from medication side effects might be prevented by more careful treatment regimens (8). The clients categorized as having other nonpsychotic disorders are the most puzzling. Research needs to be done on the link between limiting medical conditions and a "career" as a chronic mental patient (7). Longitudinal data are required to understand the complex interaction betw...
TL;DR: In a study of 127 long-term psychiatric hospital patients perceived as difficult to treat, investigators used hierarchical grouping analysis to differentiate ten profile groups of patients based on four dimensions or clusters of characteristics previously derived by factor analysis.
Abstract: In a study of 127 long-term psychiatric hospital patients perceived as difficult to treat, investigators used hierarchical grouping analysis to differentiate ten profile groups of patients. The groups are based on four dimensions or clusters of characteristics previously derived by factor analysis: withdrawn psychoticism, severe character pathology, suicidal-depressed behavior, and violence-agitation. The ten profile groups are described and are related to staff ratings of overall treatment difficulty, prognosis, sex, diagnosis, and other variables. The main conclusion is that treatment difficulty stems in large part from the compounding of different dimensions of severe psychopathology. Thus a pan-symptomatic group, with high scores on all four dimensions, ranks highest in overall treatment difficulty.
TL;DR: It is essential that the state mental hospital be seen not as a facility of last resort but as one of many agencies that meet the varied needs of the chronic mentally ill.
Abstract: The author reviews the status of the state mental hospital and the chronic mental patient within the psychiatric service system and then examines the hospital's evolution from a systems perspective. She predicts that the state mental hospital will survive as an integral part of the service system, that it will be one of several loci of care for the chronic mentally ill, and that it will continue to experience financial and identity crises in the near future. She considers it essential that the state mental hospital be seen not as a facility of last resort but as one of many agencies that meet the varied needs of the chronic mentally ill.
TL;DR: The authors conclude that the increased number of mentally ill prison inmates does not reflect a greater incidence of serious criminal activity in this group but an increase in the criminalization of psychotic behavior.
Abstract: Following deinstitutionalization, several studies have documented an increase in the number of mentally ill inmates in prisons. The authors reviewed all referrals to a mental health clinic in a county prison and categorized each case as psychotic or nonpsychotic. The psychotic inmates were four times more likely to have been incarcerated for less serious charges such as disorderly conduct and threats, and they committed fewer sex offenses, property crimes, and drug offenses than nonpsychotic inmates. The authors conclude that the increased number of mentally ill prison inmates does not reflect a greater incidence of serious criminal activity in this group but an increase in the criminalization of psychotic behavior.
TL;DR: The author presents his and others' recommendations about ways to treat black veterans with PTSD and explains why diagnosis and treatment of PTSD in black veterans is complicated.
Abstract: Because of racism in the military and racial and social upheaval in the United States during the Vietnam War years, as well as limited opportunities for blacks in the postwar period, black veterans of the Vietnam War often harbor conflicting feelings about their wartime experiences and have difficulty rationalizing brutality against the Vietnamese. As a result, black veterans suffer from posttraumatic stress disorder (PTSD) at a higher rate than white veterans. Diagnosis and treatment of PTSD in black veterans is complicated by the tendency to misdiagnose black patients, by the varied manifestations of PTSD, and by patients' frequent alcohol and drug abuse and medical, legal, personality, and vocational problems. The author presents his and others' recommendations about ways to treat black veterans with PTSD.
TL;DR: How the staff of a voluntary acute-stay psychiatric unit progressed over a two-year period from having difficulty treating AIDS patients within the usual therapeutic milieu to directly confronting the issues raised by the disease both among themselves and in the patient community is discussed.
Abstract: As more patients with AIDS and AIDS-related syndromes are admitted to psychiatric units, staffs must meet new diagnostic and therapeutic challenges while adapting to the unique stresses of treating these patients. The authors discuss several case vignettes to illustrate how the staff of a voluntary acute-stay psychiatric unit progressed over a two-year period from having difficulty treating AlDS patients within the usual therapeutic milieu to directly confronting the issues raised by the disease both among themselves and in the patient community. The authors believe that the staff's ability to cope with AIDS patients may have strongly influenced the patient community's ability to cope, and that clinical experience and educational programs were major contributors to the staff's adaplation. They conclude with several recommendations for psychiatric staffs beginning to treat AIDS patients.
TL;DR: Using data from a study of a publicly funded mental health aftercare system in a major urban county, the authors reconceptualize beliefs that patients fall between the cracks in the transition from hospital to community services, and the aftercare population is shut out of community mental health agencies.
Abstract: Beliefs that patients fall between the cracks in the transition from hospital to community services, that the aftercare population is shut out of community mental health agencies, and that services are duplicated to a high degree continue to be widely accepted. Using data from a study of a publicly funded mental health aftercare system in a major urban county, the authors neconceptualize these and similar assumptions about mental health aftercare. It appears that the primary focus of concern should be on the nature and quantity of the services being delivered rather than on increasing the proportion of patients connecting with them. Current services appear to be largely oriented toward helping the patient maintain a borderline existence in the community. instead, much more emphasis is needed on meaningfully rehabilitating patients and reducing their chronic need for professional support.