Showing papers in "Psychiatric Services in 1992"

Clinical factors associated with better quality of life in a seriously mentally ill population.

Abstract: improving the quality of life of persons with chronic mental illness is becoming an important treatment goal. in this study, 101 former acute care psychiatric inpatients with serious mental illness who were living in Mississippi communities were interviewed using portions of Lehman's Quality of Life interview. A particular focus was whether clinical characteristics, such as medication compliance and social skills, that could be changed by interventions were associated with patients' ratings of their quality of life. Self-reports of better quality of life were associated with fewer depressive symptoms, fewer medication side effects, and better family interactions. Results indicate that clinical interventions to improve quality of life in this population should include family psychoeducational programs and better detection, evaluation, and treatment of both depressive symptoms and side effects of medication.

Case management, quality of life, and satisfaction with services of long-term psychiatric patients.

Abstract: Two scales developed in Great Britain, the QOL Profile and the General Satisfaction Questionnaire, were used to examine the relationship between type of case management services and quality of life and satisfaction with treatment of 68 long-term psychiatric patients in Colorado. Factor analysis identified three types of case management activities that tended to occur together: assertive outreach (direct help, out-of-office visits, and monitoring), brokerage (referral to other agencies), and counseling and assessment. Monitoring was the only variable positively associated with quality of life for all patients; brokerage was the only variable negatively associated with acceptability of services. The number of case management contacts was negativtly associated with treatment satisfaction.

A consumer-operated case management project.

Abstract: Introduction by Dr. Bachrach: The idea that patients and former patients might themselves be involved in service delivery has become increasingly popular in recent years. Once viewed as an expression of patient protest without clinical merit, self-help services are now, at least in some places, accepted and endorsed by mental health planning authorities. This month's guest columnists describe the philosophical underpinnings of a statefunded consumer-operated case management program in Oregon and discuss both the hope and some of the potential difficulties that such an experimental effort may generate.

An overview of mental health services for American Indians and Alaska Natives in the 1990s.

Abstract: Native Americans appear to be at higher risk than other U.S. ethnic groups for mental health problems, including depression, substance abuse, domestic violence, and suicide. Despite recent increases in the federal budget for mental health services for Native Americans, less than 50 percent of the estimated need for ambulatory services is being met. Initiatives to improve the quantity and quality of mental health services for Native Americans in the 1990s include development of a national mental health plan, increased technical assistance to Native American communities, additional training and research, and continued attention to standards that promote high-quality, culturally relevant care. Tribes themselves are seen as the most appropriate locus for initiation of programs for preventing emotional problems in their communities.

Correlations between psychiatric disabilities and vocational outcome.

Abstract: Eighty-nine subjects were recruited from inpatient and community psychiatric treatment programs in the Los Angeles area to participate in the Brentwood Job Finding Club. They were trained in job-seeking skills and were given logistical support during their job search. Thirty-six percent either obtained a job or entered a job training program. Persons with good work histories, good job interviewing skills, and monpsychotic diagnoses were more likely to find employment. Persons with psychotic diagnoses and poor work histories and those receiving Supplemental Security Income were the least successful.

Homelessness and indicators of mental illness among inmates in New York City's correctional system.

Abstract: Data from three cross-sectional samples of inmates in the New York City correctional system (N= 299, 236, and 151) were analyzed to determine the prevalence of homelessness among detainees. One-fourth to one-third of each sample had been homeless at some time during the two months before arrest, and 20 percent of the primary sample of 299 inmates had been homeless the night before arrest. Further analysis of the primary sample showed that homelessness was strongly associated with mental illness: 50 percent of those who had ever been homeless during the past three years responded positively to at least one mental illness screening question, compared with 25 percent of the never-homeless inmates. More than a third of the ever-homeless group had received mental health treatment, compared with a fifth of those who had never been homeless.

The Promise of Partial Hospitalization: A Reassessment

Abstract: In this review of trends in partial hospitalization since 1987, the authors provide a brief overview of the field, summarize recent research findings, examine the data on the growth of partial hospitals, and outline recent changes in public- and private-sector use of this treatment modality. Support for intermediate and long-term partial hospitalization is diminishing rapidly, while support for short-term partial hospitalization as an alternative to inpatient care is increasing in the private sector and diminishing in the public sector. The future for partial hospitals seems uncertain, as the treatment functions of these programs are being assumed by psychosocial and vocational rehabilitation programs and assertive community treatment teams. In light of these trends, the authors recommend new directions for partial hospital research involving comparisons between short-term day hospitalization and intensive outpatient interventions.

Building systems of care for youth with serious mental illness.

Abstract: In 1990 the Robert Wood Johnson Foundation's Mental Health Services Program for Youth awarded grants to eight state-community partnerships to develop systems of care for mentally ill children and adolescents. The authors describe approaches to system building in the program's first two years of implementation. The evolving systems consist of government agencies in child welfare, mental health, public health, education, and juvenile justice, as well as privatesector health and mental health care providers. Basic system features include interagency steering committees and long-term intensive case management. Fundamental principles guiding system development are individualization of care to meet the needs of the specific child, organization of care to empower families to manage care over the long term, flexible financing of care, and normalization of care in family and community settings.

Factors Predicting Referral to Inpatient or Outpatient Treatment From Psychiatric Emergency Services

Abstract: Dispositional decisions in ten psychiatric emergency rooms in New York State were examined using logistic regression. Variables influencing recommendations for inpatient or outpatient psychiatric treatment were fairly consistent across the hospitals. All terms used in the regression model were interactions formed from five variables: dangerous behavior as a reason for referral, severity of the mental disorder, the hospital where the patient presented, current signs of psychosis, and a diagnosis of major mental illness. A sixth variable, assaultive behavior in the emergency room, also influenced disposition decisions but could not be considered in the model because all patients with that characteristic were referred for inpatient treatment. A model of disposition decisions based on interactions of variables may be especially powerful because it captures the dynamic combination of factors clinicians encounter.

Involvement in productive activities and satisfaction with living situation among severely mentally disabled adults.

Abstract: Eighty-three adults with severe mental disabilities participated in a study examining effects on life satisfaction of having nothing to do, receipt of a housing subsidy, and enrollment in an intensive case management program. The clients were divided into four groups receiving subsidized bousing and intensive case management, subsidized housing and nonintensive case management, intensive case management and nonsubsidized housing, and nonintensive case management and nonsubsidized housing. Initially and at ten months, clients reported how much time they spent with nothing to do and their level of satisfaction with supported-living arrangements. A significant association was found between time spent with nothing to do and both satisfaction and change in satisfaction and between having a housing subsidy and satisfaction. Results suggest that getting clients involved in activities of their own choosing would result in much greater increases in satisfaction.

Psychiatric inpatients' knowledge of medication at hospital discharge.

Abstract: Results of a survey of 253 psychiatric inpatients on the day of discharge from a short-stay hospitalization indicated that more than half did not know the name and dosage of the psychiatric medications prescribed for them and why they were taking them, even though they had received both group and individual medication instruction during hospitalization. Sixty-eight percent of the patients knew the names of all their psychiatric medications, but only 53 percent knew when to take them. Sixty-three percent felt that they had some understanding of why the medications were prescribed, while 37 percent said they did not know. Younger, better-educated patients who had an affective illness (as opposed to schizophrenia) were more likely to have adequate knowledge of their medication regimen. Results suggest the need for more active forms of medication education, such as supervised self-administration in the final days of hospitalization.

Homelessness and Drug Abuse in New Haven

Abstract: The prevalence of drug abuse among homeless people in New Haven, Connecticut, was examined using questionnaire data collected from 80 percent of all homeless persons (N= 181) residing in the city's five emergency shelters during a four-week study period in 1990. Fifty-four percent of the sample had used drugs during the 30 days before the interview, and almost two-thirds during the previous year. Cocaine was reported to be the most frequently used drug. Almost one-fourth of the sample identified drug use as the primary reason for their homelessness. Drug use was most prevalent among people who had been homeless for six months to three years and less prevalent among newly homeless people and people who had been homeless four years or more.

The Myth of the Typical Dual Diagnosis Patient

Abstract: Clinicians who treat patients with comorbid substance abuse and psychiatric disorders need both the expertise involved in treating each of the patient's individual disorders and the specialized knowledge required to help the patient cope with having more than one illness Programs treating dually diagnosed patients should include sophisticated psychopharmacologic and psychotherapeutic treatment, offer the capability of safely detoxifying patients from a variety of different agents, include relapse prevention and 12-step techniques, and provide long-term treatment to help patients work through the difficulties they will experience at various stages of the recovery process By combining excellent psychiatric and chemical dependence treatment, such specialized programs may be able to substantially improve the prognosis of a patient population that has traditionally been very difficult to reach

A conceptual framework for understanding self-help groups.

Abstract: Although self-help groups are recognized as an important part of the continuum of services in the mental health system, confusion about what constitutes a self-help group remains. The authors outline seven criteria for defining the self-help group and differentiating it from other types of groups, such as advocacy or support groups. Self-help groups are distinguished by their supportive and educational aims, focus on a single life-disrupting event, primary purpose of supporting personal change, anonymous and confidential nature, voluntary membership, member leadership, and absence of a profit orientation. Eight basic principles underlying successful self-help groups are discussed, including the shared experience of members, their acceptance of responsibility for themselves, and their commitment to personal change.

Psychotic Depression: Advances in Conceptualization and Treatment

Abstract: Psychotic depression is a unique subtype of depressive illness in which mood disturbance is accompanied by delusions, ballucinations, or both. Once considered relatively uncommon, it is frequently encountered in clinical practice, particularly in treatment-resistant depressed patients. Psychotically depressed patients respond poorly to antidepressants, but remission is likely with neuroleptic-antidepressant combinations or electroconvulsive therapy. Psychotic depression may be unipolar or bipolar with early or late onset and may be more likely to occur in patients with a history of childhood psychic trauma. Much is known about the course and treatment response of obvious presentations of psychotic depression, but more must be learned about depressed patients who have intermittent, subtle, or mild psychotic symptoms and about the ways in which the capacity to become psychotic interacts with the capacity to become depressed to produce a syndrome greater than the sum of its parts.

Confidentiality and the family as caregiver.

Abstract: Many families provide mentally ill relatives with a residence and other support. Although professionals increasingly acknowledge the importance of the supportive role families play, families continue to report that they receive too little information from professionals about the patient, particularly when the family acts as caregiver. The authors suggest that mental health professionals' views about confidentiality may prevent them from providing information to families and urge professionals to rethink the issue of confidentiality and its application to families acting as caregivers. The authors conclude that certain information about a patient can—and should—be shared with families who are in a caregiver role without violating clinical, legal, or ethical principles.

Comorbid mental disorders in patients with AMA discharges from alcoholism treatment.

Abstract: Discharge against medical advice (AMA) from alcoholism treatment, whether formal rehabilitation or detoxification, may indicate the patient’s failure to participate in treatment or the failure of the treatment environment to respond to the patient’s needs and circumstances. Completion ofthc treatment protocol is required for patients to benefit fully from available services. Prior research, mostly conducted with general psychiatric patients, has identified variables such as age (1,2), personality characteristics (3), length ofstay (4), and lack ofsocial stability (1 ,5) as risk &ctors for AMA discharges. Some studies have identified patients with substance abuse disorders as especially liable to leave treatment against advice (2,6). However, a broad range of psychiatric diagnoses have not yet been evaluated as risk

Rehabilitation and quality of life.

Abstract: The relationships between rehabilitation and quality of life are complex. Rehabilitation , first used to describe the act of restitution of privileges that, for some reason, had been taken away, or the restoration of one's reputation damaged by slander or error, came into psychiatry as describing actions undertaken to return the patient to some previously well-established position altered or lost because of mental illness.

Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans.

Abstract: Clinical data were gathered on 627 homeless Vietnam veterans evaluated in a Department of Veterans Affairs clinical program for homeless mentally ill veterans. More than two-fifths (43 percent) of the 627 veterans showed evidence of combat stress that was associated with more severe psychiatric and substance abuse problems, although not with greater social dysfunction. In comparison with Vietnam veterans assessed in a national epidemiological study, homeless veterans were severely socially and vocationally dysfunctional. While homeless mentally ill veterans with combat stress used VA mental health services more frequently than did homeless mentally ill Vietnam veterans with other disorders, many received no mental health services. Combat stress appears to be a significant problem among homeless mentally ill Vietnam veterans.

The Educational Implications of Managed Mental Health Care

Abstract: Our own experience in training psychiatric residents and psychology interns reflects a general consensus between disciplines and among participants of all persuasions ( payers, insurers, providers, and educators) that managed mental health care can provide an excellent framework around which to build an educational curriculum. The field of managed mental health care badly needs the knowledge base and academic core that professional training programs have the ability and the responsibility to provide.

Homelessness in a Mentally Ill Urban Jail Population

Abstract: Researchers have sought to establish the proportion of persons with serious and persistent mental illness among homeless adults. Related studies have found rates of homelessness or the risk of homelessness among psychiatric inpatient populations to be between 9 and 1 3 percent (1,2). Belcher (3), who followed a cohort of state hospital patients, found that 36 percent became homeless within six months after discharge. Others have found that many mentally ill homeless adults have been involved with police or have been incarcerated (4). Prevalance of severe mental disorder among jail detainees has been found to be two or three times greater than in the general population (5). The criminal justice system provides, by default, primary care to many homeless mentally ill persons (4). Some evidence indicates that homeless persons are not more prone

The role of general hospitals in the privatization of inpatient treatment for serious mental illness

Abstract: For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated most...

Substance use disorders in a sample of Canadian patients with chronic mental illness.

Abstract: In a study designed to investigate the pattern of substance use disorders among a group of chronic mentally ill patients in Toronto, 102 patients completed the Structured Clinical Interview for DSM-111-R and a modified substance-use-disorder module of the Diagnostic Interview Schedule. Forty percent of the sample met criteria for substance use disorders, and 49 percent for personality disorder. Among patients with personality disorder, all those with a personality disorder in cluster B (that is, with antisocial, borderline, histrionic, or narcissistic personality disorder) had a substance use disorder, while the majority of patients in cluster A and cluster C were not substance abusers. in the overall sample, the group with substance use disorders was significantly younger than the group without. In contrast to findings of previous studies, women met criteria for substance use disorders as often as men did.

A Profile of Problem Drinkers in Public Mental Health Services

Abstract: Psychiatric patients with alcohol problems are generally considered more challenging to treat and more demanding of public psychiatric services than other patients. This study of new admissions to a county mental health system in California examined differences between problem drinkers and nonproblem drinkers in clinical and demographic characteristics and in the demands they placed on services. Problem drinkers experienced more severe emotional distress at intake; were more likely to have financial, legal, and employment problems; and were more likely to be involved with illicit drugs. They made greater demands on clinical resources and also required more social services, such as income supports, case management, and vocational services. The study indicates that to meet the varied needs of psycbiatric patients with drinking problems, public mental health services should develop stronger ties not only with substance abuse services but also with social service and criminal justice agencies.

Clinical presentation of PTSD in World War II combat veterans.

Abstract: Clinicians have increasingly recognized posttraumatic stress disorder (PTSD) among Vietnam veterans, but the disorder may be easily over looked among World War II combat veterans. The authors review recent studies of PTSD in older veterans and describe five cases that illustrate the diverse clinical presentations of PTSD in this population. Symptoms included anxiety, cognitive and somatic complaints, depression, alcohol dependence, and amnestic periods. Despite the variedpresentations, a fairly consistent patient profile emerged. Patients avoided reminders of war, showed an exaggerated startle response, and experienced restless sleep and chronic anxiety. Factors associated with exacerbations of symptoms were retirement and reminders of war experiences. Although past studies have emphasized resuppression of the trauma, the authors encourage a flexible approach to treatment, including exploratory techniques.