Showing papers in "Psychiatric Services in 1990"
TL;DR: The authors reframe compliance as a collaborative relationship in which both the patient and practitioner assume responsibility for producing a treatment regimen to which the patient can adhere.
Abstract: Although effective treatment for schizophrenia is available, patients' compliance with treatment prescriptions is notoriously poor. The authors reframe compliance as a collaborative relationship in which both the patient and practitioner assume responsibility for producing a treatment regimen to which the patient can adhere. Barriers that prevent a partnership in treatment may be related primarily to treatment techniques, to characteristics of the patient and his family, to the patient-clinician relationship, or to the treatment delivery system. A comprehensive approach to addressing these sources of noncompliance includes specific skills that can be acquired by the patient, family members, and the practitioner.
208 citations
TL;DR: Across the service settings and patient populations studied, assertive community treatment reduced hospital utilization and provided evidence that the approach was more effective than conventional treatment in controlling symptoms, promoting social functioning, and improving occupational performance.
Abstract: Experimental studies of assertive community treatment programs based on the Training in Community Living model are reviewed. In most of the programs studied, interdisciplinary treatment teams met with patients in the community, taught them to take care of basic needs, and ensured that they received adequate material support and medical care. Across the service settings and patient populations studied, assertive community treatment reduced hospital utilization. Although early researchers provided evidence that the approach was more effective than conventional treatment in controling symptoms, promoting social functioning, and improving occupational performance, recent studies have generally not replicated these findings. Defining the conditions under which assertive community treatment achieves superior functional outcomes remains an important challenge for future research.
191 citations
TL;DR: Data gathered from the medical record and in interviews with staff and patients in an inpatient psychiatric setting at a Veterans Affairs medical center were used to examine events preceding 73 episodes in which patients were placed in four-point restraints.
Abstract: Data gathered from the medical record and in interviews with staff and patients in an inpatient psychiatric setting at a Veterans Affairs medical center were used to examine events preceding 73 episodes in which patients were placed in four-point restraints. The behaviors leading to restraint included physical aggression, verbal threats, and threats with an object as a weapon. These behaviors were more likely to relate to external situations than to the patient's internal psychiatric symptoms. Staff were most frequently the target of patients' aggression, and patients were more likely to view the events leading to restraint as conflict with staff. No differences in the subsequent number of restraint episodes or hours in restraints were found between patients with positive and negative responses to the index restraint episode.
141 citations
TL;DR: The relationship between use of alcohol and street drugs and compliance with prescribed medication before admission to an acute psychiatric inpatient setting was studied in 42 schizophrenic patients, more than half of whom had a history of alcohol abuse or dependence.
Abstract: The relationship between use of alcohol and street drugs and compliance with prescribed medication before admission to an acute psychiatric inpatient setting was studied in 42 schizophrenic patients, more than half of whom had a history of alcohol abuse or dependence. Most patients, even those without a history of alcohol abuse, admitted to drinking alcohol in the month before admission. Alcohol abusers drank significantly more often and drank significantly greater quantities than nonabusers. The majority of patients were noncompliant with prescribed medication before admission, and most of these patients specifically reported being noncompliant when drinking alcoholic beverages.
135 citations
TL;DR: Clozapine therapy for treatment-resistant schizophrenic patients resulted in decreases in psychopathology and reductions in mental health service costs and economic benefits were observed after two years of clozAPine therapy.
Abstract: Clozapine therapy for treatment-resistant schizophrenic patients resulted in decreases in psychopathology and reductions in mental health service costs. The majority of these savings were due to reduced use of inpatient hospital services. Reduction of the need for hospital services improves the quality of life of this group of chronic patients, as long as necessary aftercare services are available. An additional advantage of clozapine is the increased clinical contact that results from frequent monitoring for possible hematologic effects. This contact may contribute to a more appropriate level of care for schizophrenic patients in a community setting. Although community service costs for these patients might increase, improved quality of care and early intervention in the event of an acute schizophrenic episode may result in improved patient functioning and decreased total costs. Economic benefits were observed after two years of clozapine therapy. If these findings are generalizable beyond two years, clo...
126 citations
TL;DR: Use of seclusion and restraint in 23 adult public psychiatric hospitals in New York State was examined by comparing demographic and diagnostic characteristics of 657 patients who were secluded or restrained during a four-week period with characteristics of 22,939 patients who weren't.
Abstract: Use of seclusion and restraint in 23 adult public psychiatric hospitals in New York State was examined by comparing demographic and diagnostic characteristics of 657 patients who were secluded or restrained during a four-week period with characteristics of 22,939 patients who were not. Logit analysis was used to calculate the probability of seclusion and restraint of individual patients with various combinations of characteristics. Characteristics associated with high probabilities included age less than 26 years, length of stay from 30 to 365 days, involuntary legal status, female gender, a diagnosis of mental retardation, and residence in a hospital with a high rate of seclusion and restraint. The rate of seclusion and restrain in the 23 hospitals ranged from .4 to 9.4 percent of patients. Both patient characteristics and the hospital of residence were needed to explain the case-by-case probability of a patient's being secluded or restrained.
113 citations
TL;DR: In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia, and these patients also had a higher level of aggression at referral.
Abstract: In an effort to improve the prediction of violence among psychiatric inpatients, the authors retrospectively studied 25 patients who were violent and 34 who were not violent after admission to a psychiatric emergency ward in Norway. The only demographic variable that discriminated between the two groups was violence in the family of origin; the violent group had experienced significantly more. The best single predictor of violence was a history of previous violence by the patient, which correctly classified 80 percent of the patients. The combined information about patients' level of aggression rated at referral and level of anxiety rated at admission correctly classified 78 percent. In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia. These patients also had a higher level of aggression at referral.
99 citations
TL;DR: Treatment for pregnant mentally ill women who denied their pregnancies should take place in a setting that integrates comprehensive psychiatric and obstetrical care and may include pharmacotherapy, supportive psychotherapy, and evaluation of the patient's parenting skills and support network to assess whether she is able to keep her baby.
Abstract: Psychotic denial of pregnancy in chronic mentally ill women may place the women and their fetuses at high risk of postpartum emotional disturbance, precipitous or unassisted delivery, fetal abuse, and neonaticide. Psychotic denial of pregnancy is illustrated with case reports from an inpatient program for pregnant mentally ill women. Women who denied their pregnancies tended to have a diagnosis of chronic schizophrenia, to have previously lost custody of children, and to anticipate separation from the baby they were carrying. The author suggests that treatment for such patients should take place in a setting that integrates comprehensive psychiatric and obstetrical care and may include pharmacotherapy, supportive psychotherapy, and evaluation of the patient's parenting skills and support network to assess whether she is able to keep her baby.
98 citations
TL;DR: If the sample was representative of the Washington State inmate population, the group who were interviewed were corn pared with a larger sample of 1,409 consecutive admissions to the necep iion center, no significant diffenenc es between the groups in age, eth nicity, marital status, offense, on IQ were found.
Abstract: entering the Washington State pni son system. A total of 109 male of fenders were interviewed. The study was conducted in accordance with the institution's policy stipulating that inmates must give informed consentto participate in any research activity. To determine if the sample was representative of the Washington State inmate population, the group who were interviewed were corn pared with a larger sample of 1,409 consecutive admissions to the necep iion center. No significant diffenenc es between the groups in age, eth nicity, marital status, offense, on IQ were found. In addition, no differ ences between groups were found in scores on the Minnesota Multiphasic Personality Inventory, the Buss Durkee Hostility Inventory, the Sui cide Probability Scale, the Veterans AlcoholScneeningTest,onthe Mon roe Dyscontrol Scale. Individuals who show extremely violent on psy chotic behavior are sent directly to a prison psychiatric ward. Thus in mates with severe psychiatric distur bance are probably undenrepresent ed in the sample discussed in this paper. Measures. Responses to ques iions on the Diagnostic Interview Schedule (DIS) (5) were used to de tenmine lifetime prevalence of the following DSM-IH-R axis I or axis II diagnoses: depression, dysthymia, alcohol abuse on dependence, drug abuse on dependence, schizophre nia, schizophreniform disorder, mania, and antisocial personality dis order. To assess intenraten reliability, pairs of interviewers drawn from a group of five interviewed 24 in mates. The diagnoses made in each joint interview were analyzed using an extension of kappa (kappa v) (6), John A. Chiles, M.D. Elizabeth Von Cleve, Ph.D. Ron P. Jemelka, Ph.D. Eric W. Trupin, Ph.D.
94 citations
TL;DR: The Mental Illness Version of the Texas Inventory of Grief, adapted from the Texas Revised Inventory ofGrief, is devised to assess family members' initial and present feelings about their relative's loss of mental health.
Abstract: Investigations of the grief reactions experienced by families when a relative develops a serious mental illness have been hampered by the lack of an appropriate instrument to measure such reactions. The authors devised the Mental Illness Version of the Texas Inventory of Grief, adapted from the Texas Revised Inventory of Grief, to assess family members' initial and present feelings about their relative's loss of mental health. A test of the instrument with 58 family members of patients with schizophrenia or bipolar disorder revealed a surprisingly low level of initial grief but higher levels of present grief.
89 citations
TL;DR: For the study group, the disabling functional deficits of major mental illness appeared to be important contributing factors to homelessness.
Abstract: Fifty-three homeless mentally ill patients were studied by two psychiatrists in a treatment setting in which data could be gathered from family members and other third parties as well. All the patients were severely mentally ill when the homelessness immediately preceding the current admission began. For the study group, the disabling functional deficits of major mental illness appeared to be important contributing factors to homelessness. These deficits included disorganized thinking and actions, poor problem-solving skills, inability to mobilize oneself depression, and paranoia that prevented acceptance of help. Other important factors contributing to homelessness were the lack of a comprehensive and effective system of mental health care, substance abuse combined with severe mental illness, and the tendency for chronically and severely mentally ill persons, especially during their youth, to pursue their life goals in an unrealistic or irrational way.
TL;DR: An AIDS prevention program in a large inner-city mental health center that serves primarily black and Latino patients is developed, arguing that stereotypes of the mentally ill as asexual or neutered have had dangerous consequences.
Abstract: Some chronic mentally ill populations are at high risk for infection with human immunodeficiency virus. The authors argue that stereotypes of the mentally ill as asexual or neutered have bad dangerous consequences, namely the absence of sex education and AIDS prevention as an integral part of treatment. To counter this neglect, the authors developed an AIDS prevention program in a large inner-city mental health center that serves primarily black and Latino patients. Prevention efforts include individual risk assessments and an innovative drop-in group. Central to effective patient education are the distribution of condoms and concrete instruction in their use.
TL;DR: A high rate of pathological gambling was found among patients with a secondary diagnosis of psychoactive substance use disorders, including schizoaffective disorder, paranoid schizophrenia, major depression, and organic personality disorder.
Abstract: A total of 105 patients admitted to a psychiatric admissions service for adults were screened for pathological gambling using the South Oaks Gambling Screen, a valid, reliable instrument for identification of this disorder. Seven of the 105 patients were identified as pathological gamblers, and ten were children of problem gamblers, rates that are higher than those for the general population. Pathological gamblers identified in this study had a broad range of primary diagnoses, including schizoaffective disorder, paranoid schizophrenia, major depression, and organic personality disorder. A high rate of pathological gambling (11 percent) was found among patients with a secondary diagnosis of psychoactive substance use disorders.
TL;DR: Experimental severely mentally ill adults in an inner-city area of Atlanta participated in a study to determine if intensive outreach by case managers would result in decreased use of mental hospitals and improved community living.
Abstract: Twenty-eight severely mentally ill adults in an inner-city area of Atlanta participated in a study to determine if intensive outreach by case managers would result in decreased use of mental hospitals and improved community living. The experimental group of 14 clients received intensive support from case managers in the community who helped them anticipate and prevent crises, maintain medication schedules, and address problems in living. Fourteen clients in the control group received some of these same services but at a less intensive level and only at the offices of the case managers. Compared with control clients, experimental clients had an average of ten fewer hospital days and better adherence to medication regimens and agreed-upon service plans during the project.
TL;DR: Patients on clozapine showed marked clinical improvement as measured by the Brief Psychiatric Rating Scale and had significantly lower rates of rehospitalization and hospitalization costs than a comparison group of schizophrenic patients who received standard neuroleptic treatment and who were considerably less psychotic at hospital admission.
Abstract: The long-term efficacy of clozapine therapy and its effect on health care costs were examined over a two-year period. Patients on clozapine showed marked clinical improvement as measured by the Brief Psychiatric Rating Scale. They also had significantly lower rates of rehospitalization and hospitalization costs than a comparison group of schizophrenic patients who received standard neuroleptic treatment and who were considerably less psychotic at hospital admission. By the second year of the study, savings on mental health care costs averaged $20,000 for each patient on clozapine therapy. The savings were due largely to the patients' change in residence from costly inpatient facilities to less expensive settings in the community.
TL;DR: The author discusses the origins, actors, and major issues involved in managed health care in terms of prevailing myths and future realities and calls for more and better research to answer important clinical and policy questions about managed care and for improved communication between mental health professionals and managed care organizations.
Abstract: Managed care may be viewed as the most recent attempt to control the rate of increase of health and mental health care costs in the United States. The majority of people who receive insured mental health services do so through some form of managed care program. Now increasing concerns are being raised about whether managed care really reduces costs, whether it adversely affects the quality of care, and whether it restricts access to care. The author discusses the origins, actors, and major issues involved in managed health care in terms of prevailing myths and future realities. He calls for more and better research to answer important clinical and policy questions about managed care and for improved communication between mental health professionals and managed care organizations.
TL;DR: The authors believe more rigorous studies of the assertive community treatment programs are needed before policymakers can properly evaluate their role in the overall mix of services.
Abstract: Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements—alone and in combination—on diffe...
TL;DR: Findings agree with those of other European studies and suggest that when hematological and other variables are carefully controlled, the benefits of clozapine therapy outweigh the risks.
Abstract: The efficacy and adverse effects of clozapine for patients who cannot be treated with conventional neuroleptics were evaluated by means of a retrospective chart review. The review showed that 85 percent of 503 inpatients experienced slight to nearly complete reduction in symptoms. Adverse effects occurred in 59 percent of patients, although only 7 percent had side effects severe enough to warrant discontinuation of the drug. Data for 70 outpatients treated with clozapine showed that the rate of rehospitalization was significantly lower than before treatment with the drug. These findings agree with those of other European studies and suggest that when hematological and other variables are carefully controlled, the benefits of clozapine therapy outweigh the risks.
TL;DR: Ten sequential guidelines are developed that can help clinicians identify patients who are appropriate for involuntary outpatient treatment that assume that the patient has a chronic mental illness and a history of dangerousness to self or other because of that illness.
Abstract: Successful involuntary psychiatric outpatient treatment requires identifying patients who are suited to such treatment and ensuring that the service system is able to deliver the treatment. Based on his clinical experience, the author has developed ten sequential guidelines that can help clinicians identify patients who are appropriate for involuntary outpatient treatment. The sequential order of the guidelines means that a patient must meet the criteria for each guideline before being evaluated on subsequent guidelines. The guidelines assume that the patient has a chronic mental illness and a history of dangerousness to self or other because of that illness. The author believes that achieving consensus about who should receive involuntary outpatient treatment is an important first step in permitting evaluation of the efficacy of the approach.
TL;DR: Overall costs showed a nonsignificant decrease, dropping by about $1,500 per patient per year, and the staff time and resources gained were used to treat a larger number of chronic patients seeking services.
Abstract: Seventy-two patients who received five years of intensive case management services were transferred into mainstream community mental health center services with a much higher patient-to-staff ratio. At the end of a two-year follow-up, 91 percent of the patients were still receiving treatment. Compared with the previous five years, hospitalizations during the follow-up period increased, but not significantly so. Contacts with mainstream CMHC services increased significantly. Overall costs in constant 1979 dollars showed a nonsignificant decrease, dropping by about $1,500 per patient per year. The staff time and resources gained by the programmatic changes were used to treat a larger number of chronic patients seeking services.
TL;DR: A survey that explored the housing histories, problems, needs, and preferences of a sample of 38 chronically homeless women contacted in metropolitan Toronto hostels and drop-in centers found that despite having multiple mental and physical health problems, the women showed a strong preference for a normal, independent living situation.
Abstract: Consumer preference surveys can provide valuable information on which to base the planning and development of housing for groups with special needs. The authors describe a survey that explored the housing histories, problems, needs, and preferences of a sample of 38 chronically homeless women contacted in metropolitan Toronto hostels and drop-in centers. Despite having multiple mental and physical health problems, the women showed a strong preference for a normal, independent living situation. However, they acknowledged the need for a range of supportive services to maintain themselves in such a situation. The women strongly opposed being housed in settings with mentally ill persons, with alcohol or drug abusers, and with those involved in criminal activities.
TL;DR: The author describes the numerous ways in which patient care review negatively affects the therapeutic relationship between the doctor and the patient and the need for setting standards for review organizations that will help overcome these and other problems.
Abstract: Some form of patient care review has become an integral component of most health insurance plans. The author describes the numerous ways in which such review negatively affects the therapeutic relationship between the doctor and the patient. Pressured to cut costs, reviewers are unlikely to be objective in their evaluation of the need for treatment. Many are not qualified to review particular types of treatment. Avenues for appeal of reviewers' decisions are weak. The intensity and frequency of review are often disruptive both to the treatment and to the psychiatrist's practice. Some patients discontinue treatment after learning that their care is being reviewed because of fears about loss of confidentiality or other reasons. Informed consent procedures relating to release and protection of confidential information are inadequate. The author emphasizes the need for setting standards for review organizations that will help overcome these and other problems.
TL;DR: Strong antipsychiatric attitudes throughout the mental patient movement suggest that mental health professionals who approach former-patient groups with narrow clinical conceptions of mental illness are likely to fail in establishing partnerships.
Abstract: Data from a national survey of 104 self-help groups for former mental patients were examined to assess actual and potential partnerships between these groups and mental health professionals. The groups' level of interaction with and attitudes toward professionals varied with the structure, affiliation, and service model of the groups. The majority were moderate "supportive" groups in which partnerships with professionals could occur but were problematic. Less common were radical "separatist" groups, with which professional partnerships were almost guaranteed to fail, and conservative "partnership" groups, with which partnerships were likely to succeed. Strong antipsychiatric attitudes throughout the mental patient movement suggest that mental health professionals who approach former-patient groups with narrow clinical conceptions of mental illness are likely to fail in establishing partnerships.
TL;DR: The authors describe how the cities were selected and how the program operates, and provide a case example of the problems one city faced in establishing a central authority.
Abstract: In 1985 the Robert Wood Johnson Foundation implemented the Program on Chronic Mental illness, which provides grants and assistance to nine cities across the country in their efforts to improve services to persons with chronic mental illness. A basic premise of the program is that a central mental health authority is the cornerstone of improved systems of care. To be eligible for participation in the program, each city had to develop a service system incorporating a central authority and four other features: continuity of care, a full range of services, a housing plan, and new sources of financing. The authors describe how the cities were selected and how the program operates. They also provide a case example of the problems one city faced in establishing a central authority.
TL;DR: The findings suggest that primary medical care settings serving the poor and homeless may present an excellent opportunity for delivering mental health services and that psychiatrists should expand their involvement in such settings.
Abstract: Data were collected on indicators of mental health status and substance abuse among 214 homeless and 250 domiciled but impoverished patients who sought care in a community medical clinic in a california beach community. Although both groups had a high prevalence of problems, homeless patients were significantly more likely to have been hospitalized for alcohol or mental problems, to have been arrested because of drinking, and to have experienced delirium tremens. Homeless persons were also more likely to have made a suicide attempt, to have experienced recent psychotic symptoms, and to be dissatisfied with life. The findings suggest that primary medical care settings serving the poor and homeless may present an excellent opportunity for delivering mental health services and that psychiatrists should expand their involvement in such settings.
TL;DR: The authors were able to account for an increased amount of variance in length of stay for the major diagnostic categories of mental disorder and substance abuse for Medicare and Blue Cross/Blue Shield patients by constructing a weighted least squares regression model.
Abstract: Medicare's use of diagnosis-related groups and the frequent acceptance of lengt of stay as an indicator of resource utilization has caused a surge of interest in the predictability of length of hospital stay for psychiatric inpatients. By constructing a weighted least squares regression model using data from the 1980 Hospital Discharge Survey, the authors were able to account for an increased amount of variance in length of stay for the major diagnostic categories of mental disorder and substance abuse for Medicare and Blue Cross/Blue Shield patients. The enhanced ability to predict length of stay is attributed to a carefully constructed data base and an increased number of predictor vanables, particularly comorbidity. Knowledge of the presence or absence of a chemical dependency unit in the hospitals from which patients were discharged substantially increased the proportion of variance accounted for in the analysis.