Showing papers in "Psychiatric Services in 1993"
TL;DR: Results support the use of clozapine in treating chronic, residually symptomatic schizophrenic outpatients and determine the length of medication trial needed to identify responders and nonresponders and show improvement in positive symptoms, general symptomatology, and levels of functioning.
Abstract: The purpose of the study was to examine the effects of clozapine in treating moderately ill schizophrenic outpatients and to determine the length of medication trial needed to identify responders and nonresponders. Methods: Rates of clinical response, relapses and hospitalizations, and levels of symptomatology and functioning were assessed for 30 chronic schizophrenic outpatients who received clozapine for one year. For some patients, data on relapse and hospitalization during treatment were compared with data from the year before treatment. Results: Eighteen of the 30 patients met criteria for sustained response; 1 7 of the responders were identified within the first four months of treatment. Patients experienced significantly fewer relapses and hospitalizations during treatment than in the previous year. Improvement in positive symptoms, general symptomatology, and levels of functioning reached a plateau during the first six months of treatment and remained at that level during the second six months. Ne...
117 citations
72 citations
TL;DR: The study supports the efficacy of an intensive day treatment program for patients who manifest significant difficulties associated with affective and personality disorders.
Abstract: Objective: The outcome of a day treatment program for psychiatric outpatients with affective and pesonality disorders was evaluated. The program was dynamically oriented, intensive, group focused, and time limited (18 weeks). Methods: The prospective trial used a randomized treatment-versus-control (delayed-treatment) design to examine 1 7 outcome variables covering five areas: interpersonal functioning, symptomatology, selfesteem, life satisfaction, and defensive functioning. Those variables, plus individualized treatment objectives, were monitored before and after the treatment and control periods and at follow-up an average of eight months later. Results: Treated patients showed significantly better outcome than control patients for seven of the 1 7 outcome variables: social dysfunction, family dysfunction, interpersonal behavior, mood level, life satisfaction, self-esteem, and severity of disturbance associated with individual goals of treatment as rated by an independent assessor. The findings could ...
71 citations
TL;DR: The preliminary findings suggest that involving consumers as surveyors in satisfactions studies produces findings that differ from those in studies by staff surveyors, and consumer involvement may help improve research validity and needs to be explored further.
Abstract: The preliminary findings suggest that involving consumers as surveyors in satisfactions studies produces findings that differ from those in studies by staff surveyors. Consumer involvement may help improve research validity and needs to be explored further. These initial attempts are encouraging and provide a basis for identifying consumers' concerns in order to help them become more effectively involved in their own care. Development of methods to validly assess consumer satisfaction can also have wide-ranging beneficial effects on the psychiatric community's ability to provide more appropriate services. Consumer involvement in satisfaction surveys can help us provide better services. To achieve optimal outcomes, treatment of mental illness must be a cooperative venture.
59 citations
52 citations
TL;DR: Patients with comorbid diagnoses of a substance use disorder and at least one other axis I mental disorder have low rates of compliance with aftercare, and predictors of noncompliance among dual diagnosis inpatients are identified.
Abstract: Objective: Patients with comorbid diagnoses of a substance use disorder and at least one other axis I mental disorder have low rates of compliance with aftercare. The purpose of the study was to identify predictors of noncompliance among dual diagnosis inpatients. Methods: Characteristics of 48 dual diagnosis inpatients were examined. Compliance was defined as visiting the aftercare site at least three times. Results: Persons with a diagnosis of cocaine dependence were significantly more likely to be noncompliant with aftercare than those with a diagnosis of cocaine abuse. Patients with a discharge diagnosis of any type of depression were more likely to be noncompliant than those without such a diagnosis. During inpatient treatment, patients who were subsequently noncompliant with aftercare showed more erratic patterns of privilege loss and gain. Conclusions: Knowledge of factors related to noncompliance with aftercare may lead to better intervention with dual diagnosis patients.
52 citations
TL;DR: Patients in the multiple-family format had substantially lower risk of relapse than patients in single-family treatment, and agency clinicians in the model training was successful across the state.
Abstract: The New York Family Support Demonstration Project was begun in 1984 to translate the results of research on family psychoeducation in the treatment of schizophrenia into general practice. Goals were to compare experimentally a single-family psychoeducation model with a multiple-family group format, to replicate successful outcomes in ordinary clinical settings, and to train agency clinicians in the model. A total of 172 schizophrenic patients and their families from six sites across the state were followed for two years. Relapse rates comparable to those in more narrowly focused research studies were obtained in ordinary clinical settings. Patients in the multiple-family format had substantially lower risk of relapse than patients in single-family treatment. Over the next three years, the multiple-family approach was successfully disseminated across the state using a strategy based on five central assumptions of the psychoeducational model.
48 citations
TL;DR: The authors recommend providing intermediate and long-stay hospitalization to the extent needed for the new generation of chronically and severely mentally ill persons who have reached adulthood since deinstitutionalization.
Abstract: The number of state hospital beds nationwide has been reduced to 40 per 100,000 population; in California, nonforensic state hospital beds have decreased to 8.3 per 100,000. The main effects of this reduction are becoming more evident. Most seriously affected have been the new generation of chronically and severely mentally ill persons who have reached adulthood since deinstitutionalization. Those who need intermediate or long-term hospitalization and cannot receive it may become even more desperate and psychotic; may avoid treatment entirely; and may turn to drug abuse and become homeless or incarcerated in jail. Moreover, the small number of long-stay beds can lead to a breakdown in the public mental health system and attempts to avoid responsibility for persons who need both acute and long-term hospitalization. This avoidance can be manifested by raising admission criteria for acute treatment or shifting responsibility to other systems. The authors recommend providing intermediate and long-stay hospita...
45 citations
TL;DR: At the time of the study in April 1989, the clinic’s depot neuroleptic program had an active census of 69 patients with diagnoses of chronic schizophrenia or schizoaffective disorder, which included one combat veteran with chronic psychosis who had never been hospitalized.
Abstract: itary service. Forty-seven percent have schizophrenia, 30 percent have anxiety disorders, including posttraumatic stress disorder, and 1 5 percent have primary affective disorders, including bipolar disorder. The clinic’s depot neuroleptic program is managed by psychiatric nurses. Patients in the program are seen at least monthly by a clinical nurse specialist who monitors their mental status and general health. Using a standardized protocol, complete blood count and relevant biochemical profiles are obtained annually or when clinically indicated. A physician also follows each patient, periodically reviewing the patient’s condition and treatment. At the time of the study in April 1989, the clinic’s depot ncunoleptic program had an active census of 69 patients with diagnoses of chronic schizophrenia or schizoaffective disorder. Sixty-seven of the patients were men, and two were women. The patients had a history of noncompliance with oral medication megimens. All had a history of long-term hospitalization lasting two years or more or a history of three on more psychiatric hospitalizations. The group also included one combat veteran with chronic psychosis who had never been hospitalized. Most patients in the depot neuroleptic program reliably kept their scheduled appointments at the dinic. Between eight and 1 7 patients were hospitalized each year for recurrences or exacerbation of schizophrenia. Although we were aware of sig. nificant alcohol abuse and dependence in this patient population, we were not aware ofothem substance use disorders. An increase in the number of dual
41 citations
TL;DR: Although the hospital had a successful survey outcome and received accreditation with few contingencies, the authors question whether quality of care was improved by the survey process and whether the high cost of the survey constitutes an appropriate use of resources.
Abstract: Objective: The 1 989 survey conducted by the joint Commission on Accreditation of Healthcare Organizations (JCAHO) at the UCLA Neuropsychiatric Hospital was the hospital's first using standards outlined in the 1989 edition of JCAHO's Accreditation Manual for Hospitals. The authors' goal was to calculate the cost of preparing for and undergoing the 1989 survey. Methods: Costs associated with planning for the survey and conducting a mock survey and the actual survey were based on records of staff time spent on those activities, fees for consultant services, and fees for the actual survey. Costs associated with follow-up of the mock survey, preparation for the actual survey, and additional staff time spent in record keeping and treatment planning to meet accreditation standards were based on staff estimates of time spent in these activities. Results: Documented and estimated costs for the survey process totaled $326,784, which represented about 1 percent of the hospital's operating budget for 1989. Conclusio...
36 citations
TL;DR: The results suggest that treatment modality has little impact on compliance and that compliance may be increased by letter and phone prompts and by staff awareness of patients' problems such as transportation and finances.
Abstract: Objective: The purposes of the study were to determine rates of compliance with appointments among patients with schizophrenia who had been treated for more than four years in an outpatient clinic, to explore reasons for missed appointments, and to determine whether treatment modalities affected compliance rates. Methods: Chi square analysis was used to compare attendance rates over a 12-month period of 55 patients who were nonrandomly assigned to a monthly group and 56 patients who were nonrandomly assigned to be seen in individual treatment every one to two months. Patients were asked to give reasons for missed appointments. Results: From 71 to 86 percent of the patients kept their clinic appointments each month. Forgetting the appointment and transportation difficulties were the most common reasons for nonattendance. Compliance rates of patients in the two treatment modalities differed during only three of the 12 months: during two of those months subjects in individual treatment bad higher compliance ...
TL;DR: Great distance between the family home and the residential treatment center and low socioeconomic status greatly limit a family's accessibility for involvement with children in out-of-home placements, and obstacles are more likely to occur in families of dually diagnosed children.
Abstract: Objective: The goals of the study were to determine the extent of family involvement with children in residential treatment settings, to examine whether involvement diminishes over time, and to examine the relationship between involvement and the child's diagnosis as well as the demographic characteristics of the child and the family. Methods: Staff rated the level and frequency of family involvement with 234 children, aged five to 19 years, living in three residential treatment centers. The children were grouped according to three diagnostic categories: psychiatric disorder, mental retardation, and dual diagnosis of psychiatric disorder and mental retardation. Result :Almost one-third of the children had no family contact, and about 5Opercent had three or fewer contacts per year. The level of family involvement was lower with dually diagnosed children than with children who had only psychiatric disorder or mental retardation. Level of involvement was also related to the driving time between the family ho...
TL;DR: This study showed that both a single educational session and an educational review process were effective in increasingstable schizophrenic patients' knowledge about the side effects of neuroleptic medication.
Abstract: This study showed that both a single educational session and an educational review process were effective in increasingstable schizophrenic patients' knowledge about the side effects of neuroleptic medication. In addition, neither intervention resulted in clinical deterioration or decreased compliance. Structured informing processes using printed information and a multiple-choice questionnaire have several advantages. Allowing patients to read the information while it isbeing read aloud facilitates learning. Physicians can use the standardized printed information form to document more precisely what was said to patients during the informed consent process. In addition, the printed information provides a core to which other educational materials may be added. The questionnaire can be used to assess which information should be reinforced. Printed information may also be translated into other languages, can be reviewed by patients at home, and can be shared with relatives and other advisers and support persons
TL;DR: Case managers appeared able to overcome job pressures and persevere in their professional commitment and what difficulties they had appeared to level off after one year, at least among those who continued in their positions.
Abstract: Objective: The health, personal life, and attitudes of case managers providing intensive services to severely mentally ill clients were evaluated to see bow the managers changed over their first 18...
TL;DR: Results suggest that use of a urine toxicology screen and the BPRS early in treatment may aid in assessing the acute course of several psychiatric disorders and the effect of comorbidity.
Abstract: The study investigated whether chronic mentally ill patients whose psychiatric relapse was complicated by active substance abuse recovered from relapse at a different rate than similar patients with no comorbid substance abuse. Methods: A total of 401 patients involuntarily hospitalized on a short-term psychiatric treatment unit received a urine toxicology screen on admission; the severity of their psychiatric symptoms was rated on the fifth day of hospitalization using the Brief Psychiatric Rating Scale (BPRS). Differences in scores between patients who bad positive screens and those who had negative screens were evaluated for various diagnostic groups. Results: Patients who had a positive screen and a primary discharge diagnosis of psychoactive substance abuse had a BPRS total score indicating less psychopathology than similarly diagnosed patients with negative screens. Patients who had positive screens and a diagnosis of personality disorder had some BPRS subscale scores indicating greater psychopathol...
TL;DR: Roles of consumer staff Through a national survey of supported housing programs conducted in 1989, the center obtained detailed information about program operations and client and staffing charactenistics from 78 organizations throughout the United States that were primarily operated by professionals.
Abstract: Roles of consumer staff Through a national survey of supported housing programs conducted in 1989, the center obtained detailed information about program operations and client and staffing charactenistics from 3 78 organizations throughout the United States that were primarily operated by professionals (6). A totalofl45 (38 percent) of these organizations reported haying mental health consumers as paid staff(6). About two-thirds ofthc 145 organizations provided information about the specific jobs and salary ranges for the consumers they cmployed.
TL;DR: Self-harm behaviors, violence toward others, and behaviors that sabotage treatment were identified by both nurses and residents as characteristics of difficult patients, although these characteristics contributed less to residents' perceptions of patient difficulty than to nurses'.
Abstract: Objective: Characteristics attributed by nurses and by psychiatric residents to difficult-to-treat inpatients in a short-stay setting were compared to determine whether her discipline-specific perceptions of such patients existed. Methods: A total of 117 patients consecutively admitted to a short-stay inpatient unit were assessed by both psychiatric residents and nurses during the third week of hospitalization using subscales of the Hospital Treatment Rating Scales. The degree of management difficulty presented by each patient in 28 areas was rated, and an overall rating was calculated. Two separate regression analyses were used to examine characteristics of patients rated difficult. Results: Self-harm behaviors, violence toward others, and behaviors that sabotage treatment were identified by both nurses and residents as characteristics of difficult patients, although these characteristics contributed less to residents' perceptions of patient difficulty than to nurses'. For nurses, the most important addi...
TL;DR: The authors articulate 18 basic assumptions that have been helpful in clinical practice in building an integrative ideology among professionals with disparate training and orientations and attempt to balance the reality of psychiatric disorders with a fundamental interest in maintaining the autonomy and dignity of people with severe mental disorders.
Abstract: Most practitioners working in community support settings understand the need to provide a comprehensive array of well-coordinated services to individuals with severe mental disabilities. However, a lack of consensus about the conceptual basis of mental health care, especially between advocates of psychosocial rehabilitation and psychiatric practitioners who favor a more medically oriented approach, has hindered efforts to optimize the effectiveness of the multidisciplinary teams found in most community support programs. The authors articulate 18 basic assumptions that have been helpful in their clinical practice in building an integrative ideology among professionals with disparate training and orientations. The assumptions attempt to balance the reality of psychiatric disorders with a fundamental interest in maintaining the autonomy and dignity of people with severe mental disorders.
TL;DR: Quality of care in three types of facilities in which chronic mentally ill patients reside was examined to determine how it was related to patient functioning and how patients' dependency on others for self-care moderated relationships between quality of care and patient functioning.
Abstract: Quality of care in three types of facilities in which chronic mentally ill patients reside was examined to determine how it was related to patient functioning and to determine bow patients' dependency on others for self-care moderated relationships between quality of care and patient functioning. Methods: Discriminant function analyses and multiple regression analyses were used to examine 12-month follow-up data from a Department of Veterans Affairs (VA) study of 294 chronic mentally ill patients in 52 community nursing homes, nine VA nursing home care units, and 43 VA hospital psychiatric units. Results: The three types of facilities were best differentiated by staff and resident characteristics and facility policies. Residents of community nursing homes were more impaired, and staff were less well trained, than in the VA facilities. The community nursing homes had less restrictive policies. Patients who lived in facilities that gave them more control over their daily lives and that bad larger proportion...
TL;DR: The authors suggest that an important factor in the successful affiliation of patients with AA is their capacity to separate their alcohol-related problems and treatment from their PTSD symptoms and treatment and to accommodate dual identities as both an alcoholic and a traumatized soldier.
Abstract: Alcohol use is prevalent among Vietnam veterans who suffer from chronic combat-related posttraumatic stress disorder (PTSD). Although Alcoholics Anonymous (AA) is the mainstay of ambulatoty alcoholism treatment, adherence to particular components of the AA philosophy may prove especially challenging for alcoholic Vietnam veterans with PTSD. The authors describe elements of AA's philosophy, such as "surrendering" to a "higher power," making amends to persons one has harmed, and sharing one's story publicly, that may be difficult for the Vietnam veteran with PTSD. The authors suggest that an important factor in the successful affiliation of these patients with AA is their capacity to separate their alcohol-related problems and treatment from their PTSD symptoms and treatment and to accommodate dual identities as both an alcoholic and a traumatized soldier. Preparing such patients for AA by reframing some of thxe 12 steps is recommended.
TL;DR: Peer-led milieu treatment and professional services can be combined in the general hospital to provide intensive ambulatory care for socioeconomically disadvantaged substance abusers.
Abstract: Objective: Cocaine abuse, particularly in crack form, is highly prevalent among patients with severe socioeconomic disadvantages who are treated in municipal general hospitals. The authors describe and evaluate a day treatment program for 30 such patients that combines peer-led self-help and professional care provided by a general hospital psychiatric service. Methods: Treatment outcomes at one year for 92 patients referred to the day program from the hospital's psychiatric services and 58 perinatal patients referred from the obstetric services were examined using chi square and regression analyses to determine whether certain variables, especially referral source, were related to outcome. An acceptable treatment outcome was def med as three successive negative urinalyses before termination or at the end of one year of treatment. Results: Almost all the patients were unemployed members of ethnic minorities, and most abused at least one substance in addition to cocaine. The l50 patients attended the progra...
TL;DR: The authors call for a more central role for rehabilitation, which integrates treatment in the three domains of patients' lives and uses group methods to formulate plans and enhance client involvement.
Abstract: The authors describe the development of modern psychiatric rehabilitation, from its early association with occupational therapy to its present state as a discipline with an armamentarium of treatment strategies. Psychiatric rehabilitation addresses difficulties in three domains of patients' lives: clinical status, functional status, and quality of life. The authors suggest that the acceptance of rehabilitation as a separate discipline has been slow due to boundary conflicts between these domains and between the disciplines that traditionally represent them. The authors call for a more central role for rehabilitation, which integrates treatment in the three domains and uses group methods to formulate plans and enhance client involvement.
TL;DR: It is shown that severely mentally ill homeless patients who were offered an assertive community outreach approach with comprehensive services were largely able to adhere to treatment recommendations in most domains except for daily structure, suggesting the importance of low-demand housing and drop-in centers for these individuals.
Abstract: Although these data are preliminary, they show that severely mentally ill homeless patients who were offered an assertive community outreach approach with comprehensive services were largely able to adhere to treatment recommendations in most domains except for daily structure. Patients were least compliant in the domain of daily structure, suggesting the importance of low-demand housing and drop-in centers for these individuals. The correlation of noncompliance in the domain of substance abuse with noncompliance in other domains underlines the importance of developing innovative approaches to substance abuse in this population. Poorer housing outcomes were particularly associated with noncompliance in the domains of both housing and daily structure. Patients' compliance with housing recommendations and their housing outcome were linked. However, the need for daily structure, or something to do all day, was also related to poor housing outcomes and clearly needs to be addressed in this population. A great...
TL;DR: Foreword from Dr. Bachracb: Attempts at reaching consensus in service planning and service delivery depend on partisans' ability to listen to, and hear, one another's views.
Abstract: Foreword from Dr. Bachracb: Attempts at reaching consensus in service planning and service delivery depend on partisans' ability to listen to, and hear, one another's views. Only then can compromis...
TL;DR: The authors suggest that general hospital staff strengthen the treatment alliance between patients and outpatient clinicians, aggressively pursue community supports, work to ensure patients' follow-up with outpatient care, and consider depot medications and patient education to promote medication compliance.
Abstract: Objective: To improve treatment of schizophrenic patients in short-term inpatient units, the authors review studies of interventions that have been implemented with schizophrenic patients during brief hospitalizations and suggest areas for future research. Methods: The review is organized around seven general treatment domains, including the therapeutic alliance, continuity of care, family involvement, procurement of community services, psychosocial rehabilitation, medication compliance, and substance abuse treatment. Results and conclusions: Because schizopbrenic patients have traditionally been treated in long-term settings, little literature exists to inform interventions on short-term units. The authors suggest that general hospital staff strengthen the treatment alliance between patients and outpatient clinicians, aggressively pursue community supports, work to ensure patients' follow-up with outpatient care, and consider depot medications and patient education to promote medication compliance.
TL;DR: Ten clinical principles emphasize cooperation between the patient and the treatment agencies in creating a comprehensive, consistent, and enforceable plan to reduce unnecessary hospitalizations.
Abstract: Treatments applicable to the frequently rehospitalized psychiatric patient-the so-called revolvingdoor patient-have been poorly delineated. One subgroup of these patients includes those for whom recidivism has become a way of life; they may be said to suffer from "hospitalpbilia". Neither refractoriness to treatment nor noncompliance with medications explains their frequent admissions. The author presents ten clinical principles to guide treatment planning for this subgroup of patients. The principles emphasize cooperation between the patient and the treatment agencies in creating a comprehensive, consistent, and enforceable plan to reduce unnecessary hospitalizations. Four treatment strategies based on the principles are outlined: unlimited access to hospitalization, a chit or voucher system, a rationing system, and an approach centered on the patient's expressed ability to avoid hospitalization.
TL;DR: The need for substance use treatment may be underestimated if discharge planners consider only DSM-III-R diagnoses and a brief screen for recent regular use may be a better way to assess treatment needs in a state hospital population.
Abstract: Objective: Identifying substance use disorders in persons with mental illness is often difficult. in this study prevalence rates of substance use disorders among state psychiatric hospital patients were obtained by six different methods: DSM-III-R substance use diagnoses and five additional strategies based on frequency of use and past substance abuse treatment. Overlaps and differences between patients identified by the six methods were examined. Methods: Chart review and a structured substance use screening interview were used with a random sample of 20percent (N= 474) of the population of the Maryland state hospital system. Comparisons focused on cohorts identified by two of the methods: DSM-III-R substance use diagnoses and recent regular use (any past period of daily or weekly use plus any use during the 30 days before hospitalization). Results: The prevalence rates of substance use identified by the six strategies ranged from 23 percent to 55 percent. The recentregular-use criteria identified 176 pa...