Showing papers in "Psychiatric Services in 1989"

Treatment of patients with psychiatric and psychoactive substance abuse disorders.

Abstract: The treatment of individuals with coexisting psychoactive substance abuse and severe psychiatric disorders requires an integration of principles from the mental health and chemical dependency fields. The authors outline a conceptual model for treating dually diagnosed patients that consists of four treatment phases—engagement, persuasion, active (or primary) treatment, and relapse prevention. The components of these phases include case management, group therapy, psychopharmacology, toxicologic screening, detoxification, family involvement, and participation in self-help groups. Due to the high morbidity and mortality associated with dual daignoses, the authors encourage the development, implementation, and scientific evaluation of integrated treatment models targeted toward this population.

An integrated treatment model for dual diagnosis of psychosis and addiction

Abstract: A model that integrates the treatment of patients with a dual diagnosis of psychosis and addiction has been developed on a general hospital psychiatric unit The model emphasizes the parallels between the standard biopsychosocial illness-and-rehabilitation model for treatment of serious psychiatric disorders and the 12-step disease-and-recovery model of Alcoholics Anonymous for treatment of addiction Dual-diagnosis patients are viewed as having two primary, chronic, biologic mental illnesses, each requiring specific treatment to stabilize acute symptoms and engage the patient in a recovery process An integrated treatment program is described, as are the steps taken to alleviate psychiatric clinicians' concerns about patient involvement in AA and addiction clinicians' discomfort with patients' use of medication

Missed diagnosis of substance abuse in psychiatric patients.

Abstract: Like many other studies, our study found that drug users cannot be differentiated from nonusems on the basis of age, sex, or diagnosis. Another more interesting finding is that the drug-related diagnosis is often missed. About 75 percent of the patients in our sample met the critena for diagnosis of drug abuse or drug addiction even after excluding occasional use and the possible abuse of prescription drugs such as antiparkinsonian preparations and other over-the-counter drugs. The drug abuse was detected only on the third level of screening subsequent to evaluations in the emergency rooms of university hospitals and after a complete state hospital evaluation. Therefore our results suggest that drug abuse and addiction are more common in psychotic patients than generally diagnosed and are often missed. Use of multiple drugs may complicate the clinical picture, leading to difficulties in diagnosis and management. We believe that drug abuse and drug addiction were not detected in the emergency rooms and in ...

Housing instability and homelessness among aftercare patients of an urban state hospital.

Abstract: Homelessness as a dimensional concept reflecting instability of community living arrangements was examined in an urban state hospital's sample of 187 aftercare patients with chronic mental illness. According to ratings by outreach clinicians, 17 percent of the patients were predominantly homeless and 10 percent were occasionally homeless over the six months before evaluation. Younger, male patients were more likely to be homeless. Homelessness was strongly associated with abuse of alcohol and street drugs, treatment noncompliance, and a variety of psychosocial problems and psychiatric symptoms. Homeless patients were viewed by their primary clinicians as attracted to the hospital as a living alternative and, during prospective one-year follow-up, had a much higher rate of rehospitalization.

Families of the Seriously Mentally Ill and Their Satisfaction With Services

Abstract: Family members of seriously mentally ill persons were interviewed to determine their satisfaction with services received through a countywide service system based on the community support program (CSP) model developed by the National Institute of Mental Health. Interviews with 56 family members indicated that a majority were dissatisfied with various aspects of the service system. Multiple regression analysis revealed that significant contributors to family satisfaction were sex of respondent, type of relationship to family member, age at onset of illness, and time since onset of illness. Interaction with a case manager, specifically interaction involving emotional support for families, was the strongest factor explaining family satisfaction. That finding confirms the central role of the case manager in the delivery of CSP services.

A follow-up of chronic patients committed to outpatient treatment.

Abstract: Data collected in a statewide study of psychiatric patients involved in civil commitment bearings in North Carolina were used to evaluate the effectiveness of outpatient commitment as a less restrictive alternative to involuntary hospitalization. Six months after the commitment bearings, outcome data for patients who were committed to outpatient treatment were compared with outcome data for patients who were released and patients who were involuntarily hospitalized. All three groups comprised patients who were chronically mentally ill, had previously been hospitalized, and had histories of medication refusal and dangerousness. Patients who were committed to outpatient treatment were significantly more likely than patients with the other two dispositions to utilize aftercare services and to continue in treatment.

Problems of epidemiologic method in assessing the type and extent of mental illness among homeless adults.

Abstract: Because the problem of homelessness has generated such attention and controversy, findings from studies of homeless populations are often received eagerly without appreciation of the significant biases inherent in surveys. Drawing on surveys of the homeless made in the 1980s, the authors review problems in sampling and in measurement of mental disorder. They suggest that within any one study researchers employ alternative sampling strategies and measures of mental disorder to facilitate comparison of results within and across studies.

Factors associated with premature termination from outpatient treatment.

Abstract: A variety of demographic and clinical data collected on 142 new patients treated in an adult psychiatric outpatient clinic were analyzed to determine factors that discriminated between patients who terminated treatment prematurely during the first eight months of therapy and those who did not. High levels of paranoid ideation, lack of health insurance, and living less than 15 miles from the clinic were significantly associated with premature termination. Those factors were combined with three others--substance abuse, divorced marital status, and absence of fee reduction--in a probit regression model that correctly predicted the incidence of premature termination in 75 percent of the patients. The results suggest that patients who may be at risk for premature termination of outpatient therapy can be identified early in the course of their treatment.

AIDS anxiety among health care professionals.

Abstract: House staff physicians and nurses at a major New York City teaching hospital completed a 79-item questionnaire designed to assess AIDS anxiety, fear of contagion, and personal attitudes about homosexuality. Sixty-three percent of respondents were skeptical of or did not believe assurances by experts that health care workers who observe safety guidelines are at minimal risk of contracting AlDS from patients. Respondents from minority groups were significantly less trusting of experts' reassurances of their safety and were more uncomfortable working with homosexual patients. Twenty-six percent of all respondents feared that they would become victims of AIDS if they continued their present work, yet 97 percent expressed a firm commitment to caring for AIDS patients throughout their illness and the dying process. The author suggests that AIDS training and educational programs for health care professionals should consider their cultural background and psychosocial needs.

Factors predicting utilization of acute psychiatric inpatient services by frequently hospitalized patients.

Abstract: A three-month cohort of admissions (N=300) to an acute psychiatric inpatient unit of a county general hospital was studied to identify factors that differentiate patients with multiple admissions over a 12-month period from those with only a single admission. Patients with more than one admission made up 32 percent of the cohort. Compared with single-admission patients, they were significantly more likely to be chronically unemployed and to have a diagnosis of schizophrenic or affective disorder. Regression analyses indicated that the number of prior psychiatric hospitalizations was the strongest predictor of both the number of hospitalizations and the number of days hospitalized; other significant predictors were a secondary diagnosis of personality disorder, chronic unemployment, self-referral, and being black. The findings indicate that many of the problems of multiple-admission patients are rooted in social disadvantage, and efforts to devise effective interventions should not focus on psychopathology...

Use of mental health services by dually diagnosed patients.

Abstract: The results of this study are consistent with those of an earlier study that reported shorter lengths of stay among patients with substance abuse disorders than among other psychiatric patients (7). Furthermore, our results suggest the association between substance abuse and shorter stays is maintained even when substance abuse coexists with a serious mental illness. However, compared with psychiatric patients who do not abuse substances, dually diagnosed patients, particularly those who abuse alcohol, are more likely to be rehospitalized after these initial short stays and spend more days in a state facility during a 90-day follow-up period. This increased recidivism was not associated with decreased linkage with aftercare among the substance abusing patients. A primary limitation of this study is the absence of a reliable diagnosis of coexisting serious mental illness. Given the discordance between chart diagnoses of substance abuse and diagnoses derived from the semistructured interview using the CUAD ...

Impact of Therapeutic Management on Use of Seclusion and Restraint With Disruptive Adolescent Inpatients

Abstract: In the paper entitled "Impact of Therapeutic Management on Use of Seclusion and Restraint With Disruptive Adolescent Inpatients" by Ikar J. Kalogjera, Ashok Bedi, William N. Watson, and Anthony D. Meyer in the March 1989 issue (pp. 280-285), the number of admissions to the three study units from January through May of 1981 was incorrectly stated. Admissions during that period totaled 119. The editors regret the error.

Diagnostic and behavioral characteristics of psychiatric patients who abuse substances.

Abstract: tients but more commonly evidence sociopathy or other character disorders. Demographically, they are younger, more often male, from the lower socioeconomic strata, and from families with adocumented history of sociopathy or alcoholism. In addition, dual-diagnosis patients are usually hospitalized at an earlier age and are more apt to experience a recurring cycle of admissions, particularly in conjunction with the substance ofabuse (2-7). Apart from broad diagnostic and demographic comparisons, however, little research has focused on the behavioral characteristics that distinguish substance-abusing patients from other psychiatric patients and that may therefore have special relevance to the clinician. The study reported here, which was based on a large inpatient survey, makes such comparisons between substanceabusing and non-substance-abusing psychiatric patients.

Characteristics of Community Support Program Clients in 1980 and 1984

Abstract: Results from a survey of 1,053 clients enrolled in the community support program in 1984 were compared with data on 1,471 clients enrolled in 1980. In 1984 the percentages of males and blacks treated was larger than in 1980, and clients made increased use of private homes and apartments and relied less on supported living arrangements. Both the percentage of clients receiving federal income supports and clients' median income as a percentage of the national median declined between 1980 and 1984. Fewer clients with schizophrenia and more clients with affective disorders were treated in 1984 than in 1980, probably due to implementation of DSM-III. Nationwide, the number of clients in the program grew from 4,288 in 1980 to more than 350,000 in 1984. The preponderance of schizophrenia, unemployment, and history of hospitalization in the 1984 cohort suggests the program is meeting its goal of treating the most severely mentally disabled.

Treatment of homosexual alcoholics in government-funded agencies: provider training and attitudes.

Abstract: Alcoholism treatment providers in 36 government-funded agencies in New York City were surveyed for information about their training for and attitudes toward the treatment of homosexual patients. The 164 respondents had limited knowledge about how to evaluate and treat homosexual alcoholics and frequently did not discuss sexual orientation with their clients even though they considered it important. The training and supervision of most providers in the treatment of alcoholic homosexual clients was substandard or nonexistent. About half of the providers believed that treatment programs would benefit from having openly gay staff and felt that being openly gay carried little professional risk. Respondents also reported that development of programs for homosexual alcoholics had little priority in their facilities. Many believed that homosexual alcoholics are less likely to seek help and may have more difficulty achieving sobriety.

Children of psychiatrically ill parents: a prevention perspective.

Abstract: A number of risk factors have been associated with the etiology and pathogenesis of psychiatric disorders in children of psychiatrically ill parents. The author reviews the evidence for genetic transmission of psychopathology in families, particularly depression, schizophrenia, and alcoholism. Genetic factors appear to play less of a role in transmission than the characteristics of the child and the environmental consequences of the parent's illness. Some risk factors, such as ineffective parenting, poor communication patterns, and chaotic environments, may be modified by preventive interventions. Such interventions can improve family stability, foster the parents' ability to meet the child's needs, and minimize the pathology to which the child is exposed. Broad-based preventive interventions for the general population are also discussed.

A comparison of two crisis housing alternatives to psychiatric hospitalization.

Abstract: This study compared outcomes for demographically matched clients four months after their admission to two short-term crisis programs. The programs provided crisis housing and case management services as alternatives to psychiatric hospitalization for clients with severe and persistent mental illness. One program met housing needs by purchasing shelter in hotels and boarding houses, and the other provided lodging in an eight-bed crisis house. In both programs, two-thirds of the clients avoided hospitalization during four-month follow-up, and both programs were effective in stabilizing clients' housing and financial situations. Clients in the purchase-of-housing program showed an increase in substance abuse problems at follow-up. Average client costs were similar in the two programs. A critical program difference was the substantially higher staff turnover in the crisis house, which was later replaced with scattered-site crisis housing.

Drug abuse in schizophrenia.

Abstract: Hospital and Community Psychiatry August 1989 Vol. 40 No. 8 847 ons closely agrees with the 8 percent figure reported by McCulloch and associates (2,3). This percentage, however, is much greater than that reported more recently from the Langley Porter Psychiatric Institute by McNiel and Binder (4). There are several possible reasons for this difference. First is the difference in patient populations studied. Our study was conducted at the emergency psychiatnc services section of an urban university hospital rather than at a general emergency room, as in the McNiel and Binder study. Our emergency room also is located in a neighborhood whose residents are members of lower-socioeconomic and minority groups, rather than in a middle-class, ethnically diverse neighborhood. A second possible explanation for the higher proportion of patients who carried weapons in our study may be that we limited our searching to patients who were admitted to the inpatient service. One might infer that patients in need of inpatient treatment might also carry weapons more frequently. The fact that no significant differences appeared in the incidence of weapon carrying among diagnostic or demographic groups is consistent with the study hypothesis that patients who carried weapons would be a heterogeneous group. That finding is also consistent with those of the other studies (3,4). However, a larger sampie size might yield different resuits and perhaps show statistically significant differences between patients who do and do not carry weapons.

A Smoke-Free Psychiatric Unit

Abstract: The United States is in the midst of reevaluating its attitudes toward the smoking of tobacco. Incontrovertible evidence exists of smoking’s widespread and direct negative effects on health. Increasingly, the effects of passive smoking have been documented (1). There has been a trend to restrict or eliminate smoking in both private and government sectors. General hospitals have begun to acknowledge this trend and are becoming more active in health promotion. Many have stopped the sale of cigarettes, have established nonsmoking aeas, and offer programs to help people stop smoking. Descriptions of some clinical programs are available (2), and guidelines for administration of no-smoking units have been presented (3).

Clinical case management of the dually diagnosed patient.

Abstract: We have presented a treatment model that integrates experience in addressing the symptoms and disabilities of major mental illness with an effective approach to substance abuse. The model is still evolving, but we have found that approaching treatment in stages provides a much-needed structure in the management of this very challenging population.

Medical disorders associated with psychiatric comorbidity and prolonged hospital stay.

Abstract: Our study shows that increased length of stay is associated with the presence of psychiatric comorbidity in inpatients who have certain medical illnesses such as neoplasms; circulatory, digestive, renal, and respiratory disorders; and operative procedures. Our resuits suggest that the effects of psychiatric interventions for such patients should be explored and that studies of the cost-effectiveness of psychiatric interventions should be focused on categories of medical illness in which psychiatric comorbidity is associated with increased length of stay. Collaboration between researchers in medicine and psychiatry is an important approach to containing the cost of hospital care, and by furthering the recognition and treatment of psychiatric comorbidities, such collaboration can also enhance patient's health.

Effects of a smoking ban on a general hospital psychiatric service.

Abstract: After a private general hospital announced plans to ban smoking inside the hospital, the authors initiated a study on the psychiatric units to identify anticipated and actual patient-related problems associated with the ban and to assess staff and patient attitudes toward the ban. Data were obtained through pre- and postban surveys of medical and nursing staff and predischarge interviews with patients. The findings showed that staff anticipated more smoking-related problems than actually occurred and that patients who smoked were able to reduce their tobacco use during their hospital stay. No evidence was found to suggest that hospitalized psychiatric patients are less capable of cutting down on smoking than the general population.

Emerging treatment guidelines for mentally ill chemical abusers.

Abstract: Dr. Miller's Introduction: We are becoming more and more aware that many alcoholics and chemically dependent individuals also suffer from a psychiatric disorder. This reality emerges now after a period in which the possibility of coexisting mental and addictive disorders was often denied by the alcoholism and drug fields. Psychiatrists and other mental health professionals need to be alert to patients with these dual disorders so that relapses of both the dependency and the psychiatric disorder can be averted. This month's column presents useful guidelines to help professionals deal effectively with this difficult problem.

Patients' accounts of stress and coping in schizophrenia.

Abstract: Many current approaches to the management of schizophrenia emphasize the influence of environmental stress on the course of the illness. Relatively neglected is the internal experience of schizophrenic patients as a source of stress and anxiety. The author draws on a wide range of first-person accounts by patients with schizophrenia to identify four internal sources of stress—altered perceptions, cognitive confusion, attentional deficit, and impaired identity—and to reveal the wisdom and creativity with which patients have come to terms with their illness.

Systems issues in serving the mentally ill substance abuser: Virginia's experience.

Abstract: State service delivery systems have had limited success in meeting the needs of persons with major mental illness and substance abuse problems. Systems issues that create barriers to effective services include rigid program boundaries, inadequate assessment and diagnosis, lack of trained staff, the limited array of special services, and inflexible funding patterns. The state of Virginia, which administers mental health and substance abuse services through a single agency, has addressed these issues by clearly communicating that services for mentally ill substance abusers should be given high priority, by instituting a collaborative working relationship between mental health and substance abuse services, and by providing funding incentives. Additional efforts to develop advocacy organizations for mentally ill substance abusers, to train mental health professionals to serve this population, and to improve program evaluation and assessment are needed.

An emergency psychiatry update.

Abstract: A review of trends in emergency psychiatry since 1981 indicates that the scope and complexity of the field have greatly increased. Clinicians have found it useful to identify patient groups with special assessment and treatment needs, including adolescents, the elderly, victims of rape and of domestic violence, and repeat visitors to the emergency service. The spread of AIDS requires greater medical attentiveness by psychiatric emergency clinicians, and two recreational substances of abuse, cocaine and inbalants, have become increasingly popular. The use of psychotropic drugs in the emergency room has received more attention, and new trends in rapid tranquilization are apparent. Also reviewed are current medicolegal controversies related to emergency room practice, findings on prediction and control of violence, and the use of the psychiatric emergency service as a training site.

Community adjustment of chronic schizophrenic patients in urban and rural settings.

Abstract: The influence of environmental conditions on the community adjustment of chronic schizophrenic patients who live in boarding homes and other residential facilities was studied using data from medical records and interviews with patients. Seventyeight patients living in an urban area and 46 patients living in a rural area were included in the study. Compared with rural patients, urban patients were more likely to live in substandard dwellings, to receive less practical support from the home operator, and to report more incongruence with household members and aversive neighborhood conditions. Urban patients showed significantly more psychopathology, functioned more poorly in relationships with others, and had poorer global functioning than rural patients. Except for the physical condition of patients' dwellings, all the environmental conditions measured in the study were significantly associated with some measures of community adjustment regardless of geographic setting.

Psychotropic Drug Use in Pregnancy

Abstract: Treating psychiatrically ill female patients during pregnancy with psychotropic drugs presents the physician with many clinical dilemmas.1 The U.S. Food and Drug Administration (FDA) has not approved any psychotropic use during pregnancy though the use of these medications is common.2,3 Once considered a time of emotional well-being for women, a growing literature suggests that pregnancy may not convey the “protection” against psychiatric disorder once believed.4–7 The marked prevalence of psychiatric disorders during pregnancy and the growing evidence that psychiatric patients may be at high risk for relapse when medications are discontinued8–11 make treatment planning for psychiatrically ill pregnant women and for those who may wish to conceive much more difficult. Balancing the risk of fetal exposure with the risk of untreated psychiatric disorder places the clinician “between a teratologic rock and a clinical hard place.”12