Showing papers in "Psychiatric Services in 1995"

Assertive community treatment: an update of randomized trials.

Abstract: OBJECTIVE Results of randomized clinical trials of assertive community treatment for seriously mentally ill patients published between 1990 and 1994 are reviewed to synthesize the state of knowledge about this research and to clarify continuing research directions. METHODS Randomized trials of interventions that used treatment principles and practices consistent with the Program for Assertive Community Treatment model or close adaptations whose results were published since 1990 were identified by literature searches using MEDLINE and PsychLit and by contact with investigators of ongoing trials. RESULTS Controlled clinical trials have been conducted with a wide range of severely mentally ill populations, including patients in Great Britain, patients with recent-onset schizophrenia, veterans, dually diagnosed clients, and homeless persons. Methodological improvements in some studies include increased attention to monitoring the experimental and comparison interventions, as well as larger sample sizes and longer duration of the clinical trials than in earlier efficacy trials. Strong positive effects of assertive community treatment on hospital days and on patient and family satisfaction were found. Gains in functional outcomes, such as employment, may require interventions specifically targeted to these outcomes. CONCLUSIONS Questions about the role of assertive community treatment as time-limited treatment, as an adjunct to other services and treatment, or as a comprehensive and continuous service system for adults with severe mental illness require further research. The growing research base should provide valuable information on costs, outcomes, and indications for assertive community treatment that can be evaluated by policy-makers.

Therapeutic alliance and outcome in a VA intensive case management program.

Abstract: A total of 143 clients and their case managers in a Veterans Affairs (VA) intensive case management program modeled on the Program for Assertive Community Treatment rated their therapeutic alliance after two years in the program. Strong case-manager-rated alliance was associated with reduced symptom severity and improved global functioning as rated by independent assessors; it was also associated with higher client ratings of community living skills and more positive outcome as perceived by both clients and case managers. Strong client-rated alliance was associated only with more positive client-perceived outcome. Alliance ratings were not associated with use of inpatient psychiatric hospitalization. The case manager-client alliance appears to be a significant component of therapeutic effectiveness.

Psychopathology among children placed in family foster care.

Abstract: OBJECTIVE: The literature on psychopathology among children in family foster care published in the last 20 years was reviewed to estimate prevalence and types of psychopathology in this population. METHODS: A comprehensive computerized database was searched for the period 1974 through 1994, with emphasis on recent literature. RESULTS AND CONCLUSIONS: Available evidence suggests that the prevalence of psychopathology among children in family foster care is higher than would be expected from normative data, even when this population is compared with children who have backgrounds of similar deprivation. As for the types of psychopathology in this population, the only apparent trend is the predominance of externalizing disorders, such as disruptive behavior disorders. A combination of social, psychological, and biological factors may render children in family foster care highly vulnerable to psychopathology.

Evaluating Use of Continuous Treatment Teams for Persons With Mental Illness and Substance Abuse

Abstract: Objective Continuous treatment teams serving persons with co-occurring severe mental disorders and substance abuse disorders at seven sites in New Hampshire were evaluated to determine their fidelity to a model based on the Program for Assertive Community Treatment. Methods Continuous treatment teams and standard case management programs at the seven sites were evaluated on 13 criteria for fidelity to the continuous treatment team model over a 27-month period. Data sources included clinicians' activity logs, agencies' management information systems, interviews, observation of staff activity and practices, and clinical records and other documents. Results The continuous treatment teams scored significantly higher than the case management programs on ten of the 13 criteria. The teams were more effective than the case management programs in implementing substance abuse treatment. Conclusions Evaluation of the programs' fidelity to the model criteria allowed differentiation of successfully implemented continuous treatment teams from standard case management and from an unsuccessfully implemented team. The results confirm the need for careful measurement of model implementation and for investigation of organizational issues such as administrative support and clarity of program mission.

Consumers as peer specialists on intensive case management teams: impact on client outcomes

Abstract: Objective The study examined whether employing mental health consumers as peer specialists in an intensive case management program can enhance outcomes for clients with serious mental illness. Methods A quasiexperimental, longitudinal, nonequivalent control group design was used to compare outcomes of clients assigned to three case management conditions: teams of case managers plus peer specialists, teams of case managers plus nonconsumer assistants, and case managers only. Outcomes were measured at baseline and at three six-month intervals. Repeated-measures analysis of variance was used to assess between-group differences. Results Complete data were available for 104 clients. Compared with clients in the other two groups, clients served by teams with peer specialists demonstrated greater gains in several areas of quality of life and overall reduction in the number of major life problems experienced. They also reported more frequent contact with their case managers and the largest gains of all three groups in the areas of self-image and outlook and social support. No differences in outcomes were found between clients served by teams with nonconsumer assistants and those served by case managers only. Conclusions Integration of peer specialists into intensive case management programs appears to lead to enhanced quality of life for clients and more effective case management.

Relationships between psychiatric symptomatology, work skills, and future vocational performance

Abstract: Objective Experts do not agree on what, if any, relationships exist between diagnosis, symptomatology, work skills, and the future vocational performance of persons with severe mental illness. The objective of this study was to longitudinally examine such relationships, using a sample of clients who were attending psychosocial rehabilitation programs. Methods Subjects were 275 clients of three psychosocial rehabilitation programs who had expressed a vocational goal. They were assessed at intake into the study and then quarterly until they left the rehabilitation program. The variables examined included symptoms, measured by the Brief Psychiatric Rating Scale; diagnosis; work skills, measured by the Griffiths Work Behavior Scale; and vocational status at end-point. Results Among subjects remaining in the study for one year, both symptomatology and work skills improved significantly. Moderately significant negative correlations were found between symptoms and work skills; subjects who became employed had lower symptom scores and higher work skills than persons who never became employed. Conclusions Although a moderate relationship was found between symptomatology and work skills, symptoms should not be considered a proxy measure for vocational functioning among persons with severe mental illness. Participation in psychosocial rehabilitation programs appeared to have a salutary effect on symptoms and work skills.

Outcome for psychiatric emergency patients seen by an outreach police-mental health team

Abstract: OBJECTIVE: The study examined whether outreach teams of mental health professionals and police officers could assess and make appropriate dispositions for psychiatric emergency cases in the community, even in situations involving violence or potential violence. The study also assessed whether such teams could reduce criminalization of mentally ill persons. METHODS: One hundred and one consecutive referrals to law enforcement-mental health teams in Los Angeles were studied through records review. Subjects' status during a six-month follow-up period was also examined. RESULTS: Referral had a high rate of past criminal arrests, violence, and major psychopathology. Sixty-three had a history of violence against persons, 59 had a criminal arrest history, 79 had prior psychiatric hospitalizations, and 66 were serious substance abusers. At referral, 70 manifested severe psychiatric symptoms, 20 were overtly violent, and 29 others exhibited threatening behavior. However, only two of the group were arrested; 80 were taken to hospitals. At six-month follow-up of 85 referrals, 22 percent had been arrested (12 percent for crimes of violence), and 42 percent had been rehospitalized. CONCLUSIONS: Outreach emergency teams composed of a police officer and a mental health professional are able to deal appropriately with persons who have acute and severe mental illness, a high potential for violence, a high incidence of substance abuse, and long histories with both the criminal justice and mental health systems. Such teams apparently avoid criminalization of the mentally ill. Language: en

Use of a Brief Behavioral Skills Intervention to Prevent HIV Infection Among Chronic Mentally Ill Adults

Abstract: OBJECTIVE Research shows that many chronic psychiatric patients are at risk for infection by the human immunodeficiency virus (HIV) This study investigated the effects of a behavioral skills training program designed to prevent HIV infection among chronic mentally ill adults living in an inner-city area METHODS Twenty-seven men and 25 women were randomly assigned either to a four-session AIDS prevention program emphasizing risk education, sexual assertiveness, condom use, risk-related behavioral self-management, and problem-solving skills or to a waiting-list group, who later received the same intervention RESULTS Compared with the waiting-list control group, participants in the prevention program demonstrated significant gains in AIDS-related knowledge and intentions to change risk behaviors The prevention program also significantly reduced rates of unprotected sexual intercourse and increased the use of condoms over a one-month follow-up period A subset of participants who provided two-month follow-up data maintained some behavior changes CONCLUSIONS A relatively brief, skills-focused AIDS prevention program for chronic psychiatric patients produced reductions in HIV risk behaviors Such HIV risk reduction intervention programs may be of use in inpatient, outpatient, and community-based settings

Long-term course of substance use disorders among patients with severe mental illness.

Abstract: Objective This study assessed the long-term course of substance abuse and dependence among severely mentally ill patients. Methods A prospective, naturalistic, seven-year follow-up of severely mentally ill outpatients (most with schizophrenia and schizoaffective disorder) successfully located and reassessed 79.1 percent (N = 148) of the patients from the original study group. The follow-up study group was assessed for alcohol and drug use at baseline and seven-year follow-up by their case manager or primary clinician using the Case Manager Rating Scale (CMRS) for the assessment of substance-related problems among severely mentally ill patients. Results The prevalence of active substance use disorder changed little from baseline to follow-up. Alcohol abuse or dependence was present in 24 percent of the patients at baseline and 21 percent at follow-up, and drug abuse or dependence was present in 20 percent at baseline and 17 percent at follow-up. However, those with initial alcohol abuse had a higher rate of remission (67 percent) than those with initial alcohol dependence (33 percent). Similarly, those with initial drug abuse had a higher rate of remission (54 percent) than those with initial drug dependence (31 percent). Conclusions The higher rates of change for those with initial substance abuse compared with substance dependence suggest that distinguishing between abuse and dependence may have important implications for assessment and prognosis of individuals with a dual diagnosis of a substance use disorder and severe mental illness.

Who cares? Pathways to psychiatric care for young people experiencing a first episode of psychosis.

Abstract: OBJECTIVE The authors reviewed the literature to better understand pathways to psychiatric care among young persons experiencing a first episode of psychosis. Because no discrete body of literature exists about how young people with psychotic illness gain access to psychiatric services, the authors examined three related areas: illness recognition, help-seeking, and referral pathways. METHODS Automated and manual searches of primarily medical and psychological sources from 1977 to 1995 were conducted. RESULTS The review found evidence of delay in obtaining early treatment among young people with an emerging psychosis, although comparisons between studies are difficult. Early psychiatric intervention is believed to significantly aid recovery and is an increasingly important clinical issue. Recognizing psychiatric illness is problematic for professionals and nonprofessionals. CONCLUSIONS Understanding of help seeking by patients experiencing a first psychotic episode and of their referral pathways is limited. Taken together, studies suggest factors affecting access to treatment but provide neither sufficient empirical information nor an adequate conceptual framework to better target secondary prevention strategies. Formulation of a pathways-to-care model appears to offer a useful way of understanding mental health care use. Exploration of consumer experiences would enrich the model. Strategies to reduce treatment delay could then be developed and evaluated. Increased consumer involvement might help ensure that services are better tailored to patients' needs.

Command Hallucinations and the Prediction of Dangerousness

Abstract: OBJECTIVES Recent studies have supported the belief that command hallucinations can induce dangerous behavior. This study tried to replicate previous findings that compliance with the command was associated with delusions related to hallucinations and the ability to identify the hallucinated voice. This study also assessed the association between compliance and the dangerousness of the command, chronicity of illness, a diagnosis of schizophrenia, and past compliance with hallucinated commands. METHODS The most recent command hallucination reported by 93 psychiatric inpatients was rated for level of dangerousness and level of compliance with the command. RESULTS Subjects who experienced less dangerous commands or who could identify the hallucinated voice reported higher levels of compliance, although reported compliance with more dangerous commands was not uncommon. Commands experienced in the hospital were less dangerous than those experienced elsewhere and tended to be specific to the hospital environment. Subjects were less likely to comply with commands experienced in the hospital. CONCLUSIONS Based on their self-reports, psychiatric patients who experience command hallucinations are at risk for dangerous behavior. Ability to identify the hallucinated voice is a fairly reliable predictor of reported compliance. Level of dangerousness resulting from compliance with command hallucinations may be a function of the patient's environment.

Characteristics of violence in the community by female patients seen in a psychiatric emergency service

Abstract: OBJECTIVE: This study examined differences in factors associated with violence toward others by female and male patients evaluated in a psychiatric emergency service. METHODS: A sample of 812 psychiatric patients recruited in the emergency service of an urban psychiatric hospital were followed in the community over a six-month period. Patients provided self-reports of violent incidents, and collateral informants also provided reports of the incidents. Official records were also reviewed. During the followup period, 369 patients (213 male and 156 female patients) engaged in violence, defined as laying hands on another person in a threatening manner or threatening another person with a weapon. RESULTS: Male and female patients did not differ significantly in frequency and seriousness of violence, but they did differ on who the co-combatant was and where the incident took place. CONCLUSIONS: Gender is not a strong predictor of involvement in violence by psychiatric patients. The observed gender differences in location in which violence took place and identity of the co-combatant may be related to differences in the social worlds of men and women, with men having more opportunity for public violence with strangers. Language: en

A national survey of the use of outpatient commitment.

Abstract: OBJECTIVE To determine the extent of use of outpatient commitment, a survey was undertaken of each state and the District of Columbia. METHODS One of the authors, an attorney, reviewed pertinent state statutes, then conducted telephone interviews with individuals in each state who were knowledgeable about the use of outpatient commitment. RESULTS Thirty-five states and the District of Columbia have laws permitting outpatient commitment. Georgia, Hawaii, and North Carolina use different criteria for outpatient commitment than for inpatient commitment. In only 12 states and the District of Columbia was use of outpatient commitment rated as very common or common. Reasons for not using it include concerns about civil liberties, liability, and fiscal burden as well as lack of information and interest, the failure of some states to set enforceable consequences for noncompliance, and criteria that are too restrictive. Some states use alternative formal or informal mechanisms to encourage treatment compliance; conditional release is widely used in New Hampshire and conservatorship-guardianship in California. Within many states the availability of outpatient commitment varies considerably by locale. CONCLUSIONS To clarify the role of outpatient commitment in psychiatric services, more research is needed to identify optimal candidates for its use. Research is also needed on its overall effectiveness compared with conditional release and conservatorship-guardianship and on the consequences of not using such mechanisms to improve treatment compliance.

A multisite study of client outcomes in assertive community treatment.

Abstract: OBJECTIVE This study examined outcomes of clients admitted to assertive community treatment programs simultaneously implemented at six sites in northeastern Indiana. METHODS A total of 212 clients at risk for psychiatric rehospitalization were assessed at baseline and at six-month intervals for 18 months after admission to assertive community treatment programs. Data on rehospitalization, quality of life, and level of functioning were compared using t tests. Progressive improvement was also examined by linear trend analysis. RESULTS Frequency of psychiatric hospitalization was reduced by one-third and the number of inpatient days by 50 percent after admission to the program. Improvements were progressive, with continued reductions over the 18-month period. Progressive improvements also occurred in quality of life as measured by both client and staff ratings. Case managers rated clients as having improved family and social support, increased self-reliance and independence, and improved daily living skills. Clients reported significantly more legal problems, which may have been an artifact of increased monitoring during treatment. A key element of the programs' success was the position of clinical coordinator, important functions of which are described. CONCLUSIONS Results of this study provide support for wide-scale dissemination of assertive community treatment as an effective form of community care for persons with serious mental illness.

A review of studies of heavy users of psychiatric services.

Abstract: Objectives: This paper reviews studies of patients who are heavy users of psychiatric services and identifies areas in which further research and evaluation are indicated. Methods: Extensive searches were conducted of the English language psychiatric and psychological literature before 1994. Important references from initially identified studies were followed up. More than 200 articles were reviewed, 72 of which are described in this review. The 72 papers were selected because they dealt with three questions: What is heavy service use? What patient characteristics contribute to it? What service delivery characteristics contribute to it? Results and conclusions: Criteria for identifying and defining heavy users of psychiatric services vary among studies. Few studies of heavy service users have attempted to examine use of all psychiatric services, beth inpatient and community based. In most studies, 10 to 30 percent of patients are identified as heavy users, those who utilize between 50 and 80 percent of service resources. This group consists of a constantly changing cohort of patients who generally have psychotic illnesses as well as comorbid personality disorders and high levels of drug and alcohol misuse. Few studies have examined social issues such as isolation, homelessness, and social support, although these factors appear to contribute significantly to heavy service use. Few attempts have been made to define heavy-user groups in fiscal terms. More research on heavy users of psychiatric services is clearly needed to improve providers' ability to plan appropriately targeted mental health services for this disabled group of patients who use expensive resources.

Dissemination of assertive community treatment programs.

Abstract: OBJECTIVE: The study sought to estimate the number of programs in the U.S. for severely mentally ill adults that used the assertive community treatment model and to describe variations in characteristics of the intervention across programs. METHODS: Assertive community treatment programs identified by state mental health authorities completed a 12-item survey. The survey included questions on caseload, composition of the treatment team, nature of services, and structure of service provision. RESULTS: A total of 303 of 340 programs (89 percent) identified by states responded to the survey. More than 75 percent provided most of their services in the field, delivered medications, included medical staff on the assertive community treatment team, and had caseload ratios of less than 20 consumers for each provider. CONCLUSIONS: Assertive community treatment programs have disseminated quite unevenly across 33 states, with the highest concentrations of programs in midwestern and eastern states.

Service utilization and costs of care for severely mentally ill clients in an intensive case management program.

Abstract: Objective The study evaluated the effects of an intensive case management model on clients' use of inpatient and outpatient psychiatric care and on the costs of care. Methods Ninety clients of a county mental health system who were frequent users of inpatient services were randomly assigned to either an intensive case management group, a traditional case management group, or a control group who received no particular services. Outcome variables measured over a two-year period were number of units used by clients and costs of inpatient care in county and private facilities and various types of outpatient care, including day treatment and use of an emergency psychiatric unit. Results Clients who received intensive case management had fewer inpatient days and reduced overall costs for mental health services. Conclusions Assertive outreach and intensive case management can reduce hospitalizations of clients who are frequent users of inpatient care and can reduce overall mental health care costs. Mental health consumers employed as case management aides can play an important role in the delivery of mental health services, particularly with frequent users of inpatient care.

Implementing assertive community treatment teams.

Abstract: The Connecticut Department of Mental Health began creating assertive community treatment teams in 1987. The authors describe the approach taken by the department in defining the assertive community treatment model, in creating new assertive community treatment teams, and in monitoring the creation and functioning of these teams to ensure that fidelity to the assertive community treatment model is maintained. Assertive community treatment teams can be created even in the absence of funding for new staff by reconfiguring current community-based staff and by moving staff from state hospitals to the community. Preliminary data from a randomized trial in Connecticut comparing assertive community treatment with high-quality case management in areas with an array of community services indicated that the intended models were replicated, with variations in practice style across programs. Clients in assertive community treatment were in the hospital about half as often as clients in standard services and were also less likely to be without a permanent residence. Training and ongoing monitoring of assertive community treatment teams are necessary to detect practices that diverge from the intervention model so that corrective action can be taken.

Effects of homelessness on the quality of life of persons with severe mental illness.

Abstract: Objective: This study assessed the relationship between homelessness and specific quality-of-life prob- kms for persons with severe and persistent mental illness. Methods: The objective and subjective qual- ity of life of 106 homeless persons with severe mental illness who lived on the streets or in shelters in Baltimore was compared with that of 146 domiciled persons with se- vere mental illness who lived in the community. Results: Objective and subjective quality of life of the homeless subjects was clearly worse than that oftbe domiciledgroup in the areas of living situation, fam- ily and social relations, employ- ment, daily activities, and legal andsafetyproblems. Homeless sub- jects were also less likely to have federal disability entitlements. Conclusions: Poorer quality of l:fe is associated with bomelessness among persons with severe mental illness. Their quality oflife may be improved by efforts to increase their access to disability entitle- ments and treatment services and to help them develop supportive so- cial networks. (Psychiatric Services

Modifying the PACT Model to Serve Homeless Persons With Severe Mental Illness

Abstract: The success of the Program for Assertive Community Treatment (PACT) has led to its replication with different client populations, especially those who are underserved by the traditional treatment system. This paper describes a program in Baltimore that has adapted the PACT model to serve homeless persons with severe mental illness. Although the essential ingredients and philosophy of the original model were maintained, the original team approach has been modified by the use of "miniteams." All staff share knowledge of all program clients through formal mechanisms such as daily meetings; however, each client is assigned to a miniteam composed of a clinical case manager, a psychiatrist, and a consumer advocate. Another deviation from the PACT model is that services can be time limited. The authors describe four phases of treatment and problems, including interventions characteristic of each phase.

A Comparative Analysis of Family Caregivers Perceived Relationships With Mental Health Professionals

Abstract: OBJECTIVE Family caregivers' relationships with mental health professionals who provided care for their mentally ill relative were examined to identify changes in types of contacts and levels of satisfaction over time and differences among caregiver groups. METHODS White upper-middle-class members of a family support group surveyed by mail in 1991 to obtain information about their contacts with mental health professionals and their opinions about needed supports and services. Data from the 1991 survey were compared with data from a similar group of caregivers surveyed in 1983 and from a 1990-1991 study of white and black caregivers in lower socioeconomic groups. RESULTS The analysis showed that a significant minority of caregivers continue to be dissatisfied with their contacts with mental health professionals. The 1991 survey found that professionals did not actively involve caregivers in the treatment of their mentally ill family member, and caregivers ranked more communication with professionals as their greatest need. Few differences were found between caregiver groups in types of professional contact or levels of satisfaction. However, caregivers in the lower socioeconomic groups in the 1990-1991 study received more advice from professionals than did support group members in the 1991 survey, and black caregivers were significantly more satisfied with their professional contacts than support group members in the 1991 survey. CONCLUSIONS Partnerships between family caregivers and mental health professionals must be developed and nurtured to address caregivers' unmet needs.

Postdischarge medication compliance of inpatients converted from an oral to a depot neuroleptic regimen.

Abstract: OBJECTIVE This preliminary study assessed the effects on outpatient medication compliance of converting inpatients with schizophrenia from oral to depot neuroleptic medication. METHODS Subjects consisted of 93 neuroleptic-responsive inpatients with schizophrenia from three New York City hospitals who were part of a one-year prospective longitudinal study of medication compliance. Forty patients were converted to depot neuroleptic medication while hospitalized; the other 53 remained on oral medication. Symptoms, side effects, and medication compliance of the two groups were compared at one, six, and 12 months postdischarge. RESULTS Inpatients converted to depot medication had significantly better compliance at one month postdischarge. Differences in demographic characteristics, symptoms, hospital site, and baseline attitudes toward medication did not account for this finding. The initial positive effect on compliance waned, and no significant between-group differences in compliance were found at six and 12 months postdischarge. CONCLUSIONS Conversion to depot medication before hospital discharge may facilitate medication compliance during transition to outpatient treatment, but other interventions are needed to maintain compliance over time.

Identifying anxiety disorders in adolescents hospitalized for alcohol abuse or dependence.

Abstract: In structured clinical interviews of 43 adolescents hospitalized for alcohol abuse or dependence, 17 subjects met criteria for an anxiety disorder, with social phobia (N = 9) and posttraumatic stress disorder (N = 7) most common. Of these 17 subjects, only four were identified in hospital records as having an anxiety disorder. In a comparison of 30 hospitalized adolescents with a matched control group of 30 adolescents from the community, the hospitalized adolescents had a higher rate of anxiety disorders, psychoactive substance use disorders, disruptive behavior disorders, and mood disorders.

Base-rate estimates of criminal behavior by homeless mentally ill persons in New York City.

Abstract: OBJECTIVES: The study aimed to estimate the prevalence of homelessness among mentally disordered offenders entering the criminal justice and forensic mental health systems, to compare base rates of arrest for violent and nonviolent criminal charges among homeless and domiciled persons with mental illness, and to examine patterns in the categories of victims chosen by these two groups. METHODS: The authors analyzed data from structured psychiatric interviews and criminal and psychiatric records of 77 homeless defendants and 107 domiciled defendants referred for psychiatric examination by the criminal and supreme courts in Manhattan over a six-month period. RESULTS: Mentally disordered defendants had 40 times the rate of homelessness found in the general population, and 21 times the rate in the population of mentally ill persons in the city. The overall rate of criminal offenses was 35 times higher in the homeless mentally ill population than in the domiciled mentally ill population. The rate of violent crimes was 40 times higher and the rate of nonviolent crimes 27 times higher in the homeless population. Homeless defendants were significantly more likely to have been charged with victimizing strangers. CONCLUSIONS: Homeless mentally ill persons appear to be grossly overrepresented among mentally disordered defendants entering the criminal justice and forensic mental health systems and to have a higher base rate of arrest for both violent and nonviolent crimes than domiciled mentally ill persons. Language: en

Symptom Severity and Number of Previous Psychiatric Admissions as Predictors of Readmission

Abstract: OBJECTIVE The study examined factors predicting early readmission (within 30 days of discharge) to a state hospital METHODS A total of 189 patients with acute symptoms who were admitted to a state hospital were evaluated at discharge using the Brief Psychiatric Rating Scale (BPRS) and the Nurses Observation Scale for Inpatient Evaluation (NOSIE) Patients who were readmitted within 30 days were compared with those who were not on BPRS and NOSIE ratings and on other variables, including length of stay, number of previous admissions, demographic characteristics, and diagnosis RESULTS Scores on the thought disorder factor and self-neglect question on the BPRS and the number of previous admissions were significantly higher among patients who where readmitted within 30 days of discharge The variables correctly predicted readmission for 86 percent of cases in the study CONCLUSIONS The characteristics of high scores at discharge on the BPRS thought disorder factor and the BPRS item on self-neglect, along with a high number of previous admission, may be helpful in identifying patients at risk for readmission to inpatient psychiatric settings

Effect of demographic and behavioral variables on burden of caregivers of chronic mentally ill persons.

Abstract: OBJECTIVE Persons who provide care for individuals with chronic mental illness experience both objective burden (observable, tangible cost) and subjective (perceived) burden. This study sought to determine the relative power of behaviors of chronic mentally ill clients, behaviors required of caregivers, and demographic characteristics of both groups in predicting burden. METHODS A total of 189 caregiver-client dyads were studied using a cross-sectional, correlational design. Caregivers were interviewed by phone about clients' needs for help in nine areas and about seven potentially troublesome client behaviors. Correlation and regression analyses were used to determine relationships among variables. RESULTS Caregivers reported much less subjective than objective burden, although the relationship between the two types of burden was not consistent across the various areas in which clients needed help. Overall, more of the reported burden was related to caregivers' behaviors (their day-to-day tasks) than to clients' behaviors. Burden was greatly increased for caregivers who lived with the client. Caregivers most at risk for burden were those who lived with male clients who threatened suicide. CONCLUSIONS Caregivers become accustomed to the stabilized behavioral profile of the client. Mental health professionals should be sensitive to profiles and situations that may produce increased objective and subjective caregiver burden.

New directions in research on involuntary outpatient commitment.

Abstract: OBJECTIVE Involuntary outpatient commitment has been used as a method of improving tenure in community programs for individuals with severe and persistent mental illness. This paper reviews literature on research about involuntary outpatient commitment and suggests questions and methods for future research. METHODS Literature describing research studies of involuntary outpatient commitment, located by searching MEDLINE and following up references cited in relevant articles, was reviewed with attention to patient characteristics and diagnostic, treatment, and outcomes measures. RESULTS Involuntary outpatient commitment appears to provide limited but improved outcomes in rates of rehospitalization and lengths of hospital stay. Variability in community treatment makes interpretation of other types of outcome difficult. Few studies specifically identify results among patients with severe and persistent mental illness. CONCLUSIONS No studies have examined the extent to which outpatient commitment affects compliance and treatment when essential community services such as case management are consistently and aggressively provided, nor have studies controlled for potentially confounding factors such as treatment and nontreatment effects, including informal coercion. A randomized trial of involuntary outpatient commitment should be useful in evaluating the effectiveness of this type of intervention.