Showing papers in "Psychiatric Services in 1996"

Mortality and medical comorbidity among psychiatric patients: a review.

Abstract: OBJECTIVES To fuel advocacy for improved health care for mentally ill persons, the authors reviewed the literature that describes excess mortality and underrecognition and undertreatment of comorbid medical conditions in this population. Barriers to optimal primary medical care for psychiatric patients are discussed. METHODS A MEDLINE search focusing on mortality and medical problems in psychiatric patients yielded 66 papers in English published between 1934 and 1996. These studies and a German paper from 1912 are included in the review. RESULTS AND CONCLUSIONS Standardized mortality ratios for psychiatric patients, derived from comparisons with the general population and matched control groups, have repeatedly demonstrated excess mortality from both natural and unnatural causes among psychiatric patients. Several large studies that have attempted to clarify the issues underlying increased death rates are discussed. Although no single diagnostic group emerges as being at particularly high risk, substance abuse disorders alone or in combination with other psychiatric disorders have been repeatedly found to lead to increased mortality rates. Other studies have also repeatedly demonstrated that psychiatric patients suffer a high rate of comorbid medical illnesses, which are largely undiagnosed and untreated and which may cause or exacerbate psychiatric symptoms. Atypical presentations are common, and changes in vision are the symptoms most predictive of medical illness. Elderly patients and those with diagnoses of organic brain syndromes are at highest risk for comorbid medical illness. Parity in the medical and mental health treatment of psychiatric patients requires both political advocacy and development of primary care programs capable of efficiently meeting their needs.

Medication noncompliance and substance abuse among patients with schizophrenia.

Abstract: Objective: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. Met!wds: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects’ reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. Results: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. Conclusions: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group. (Psychiatric Services

Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders.

Abstract: OBJECTIVE: This study compared sexuality, reproduction, and childrearing characteristics of women with schizophrenia-spectrum disorders with those of women without serious mental illness. METHODS: A semistructured interview was given to 46 women meeting Research Diagnostic Criteria for schizophrenia or schizoaffective disorder and to 50 control subjects without major mental illness who were matched for age, race, education, employment status, and religion. RESULTS: Compared with the control subjects, the women with schizophrenic disorders had more lifetime sexual partners, were less likely to have a current partner, and were more likely to have been raped and to have engaged in prostitution. Despite being at high risk for HIV infection, as a group they were less likely to have been tested for HIV. They reported wanting sex less often than did control subjects and rated their physical and emotional satisfaction with sex lower. They had fewer planned pregnancies, more unwanted pregnancies, and more abortions and were more often victims of violence during pregnancy. They were more likely to have lost custody of children and to report that they were unable to meet their children's basic needs and less likely to have another caregiver helping them raise their children. Both groups reported high rates of substance abuse during pregnancy. CONCLUSIONS: Health care delivery systems could better meet the needs of women with severe mental illness by providing social skills training, family planning, and more consistent screening for pregnancy, HIV, and battering. In addition, barriers to care for pregnant women with severe mental illness and substance abuse should be reduced, and parenting training should be incorporated into psychosocial rehabilitation programs for mentally ill parents. Language: en

Physical aggression against psychiatric inpatients by family members and partners

Abstract: The rate of recent violence against newly admitted psychiatric inpatients by partners and family members was assessed. Sixty-nine patients who had a partner or contact with a family member participated. A high proportion of respondents reported physical victimization by either their partner (62.8 percent) or a family member (45.8 percent). Physical abuse was rarely documented in medical charts, and most respondents did not consider the violence they experienced to be abuse. Almost half of the respondents met criteria for posttraumatic stress disorder in response to their physical victimization. The findings underscore the importance of assessing recent partner and family violence in the routine evaluation of psychiatric patients.

The Working Alliance: Theory, Research, and Practice

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Predictors of receipt of aftercare and recidivism among persons with severe mental illness: a review.

Abstract: Objective This paper provides a comprehensive review of research predicting receipt of aftercare and recidivism (rehospitalization) among individuals with severe and persistent mental illness. Methods English-language studies were identified by searching PsycLIT from January 1974, the year of a previous comprehensive review of the literature on recidivism, to March 1994. A heuristic model was used to classify predictor variables into three categories: client vulnerability, community support, and system responsiveness. Results In general, variables related to system responsiveness were more consistent predictors of receipt of aftercare than variables related to either client vulnerability or community support. Community support variables were more consistent predictors of recidivism than variables in any of the other categories. Assertive community treatment and receipt of aftercare-both system responsiveness variables-were also associated with lower rates of rehospitalization. Conclusions Conclusions based on past research should be regarded as tentative, because of several methodological and theoretical weaknesses. Multivariate statistics have rarely been used, many of the studies are based on nonrepresentative samples, and interactions between client-level variables and system responsiveness variables have rarely been studied. Much of the research has relied on archival data, and choice of variables has thus often been guided more by the data available than by theory.

Anxiety Disorders in Children and Adolescents

Abstract: The first section covers historical and conceptual issues, including cognitive and developmental processes, clinical and theoretical models, phenomenology and classification, and evidence-based assessment. Subsequent sections cover the biology of child and adolescent anxiety, and environmental influences including traumatic events, parenting and the impact of the peer group. The final section addresses prevention and treatment of anxiety. All chapters incorporate new advances in the field, explicitly differentiate between children and adolescents, and incorporate a developmental perspective. Written and edited by an international team of leading experts in the field, this is a key text for researchers, practitioners, students and clinical trainees with interests in child and adolescent anxiety.

Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services.

Abstract: OBJECTIVE The study examined whether the prescription practices of clinicians in psychiatric emergency services differed for African-American patients. Prescription of antipsychotic medications and its relation to quality of care was a particular focus. METHODS Data from 442 independently observed evaluations of patients in psychiatric emergency services were examined using multivariate analyses. The observations were made during a five-year period at four urban general hospitals in California. RESULTS Clinicians in the four emergency services, most of whom were Caucasian, prescribed more psychiatric medications to African Americans than to other patients and devoted significantly less time to their evaluations. African Americans received more oral doses and more injections of antipsychotic medications, and the mean 24-hour dosage of antipsychotics (1,321 milligrams) was significantly higher than for other patients (825 milligrams). The tendency to overmedicate African-American patients was lower when clinicians' efforts to engage the patients in treatment were rated higher. CONCLUSIONS The results highlight the importance of efforts to engage African Americans in the treatment process and the need for clinical skills and training to help bridge cultural distances.

Effects of substance abuse on housing stability of homeless mentally ill persons in supported housing.

Abstract: Objective The study examined two-year housing outcomes of homeless mentally ill clients who took part in an experimental investigation of supported housing. The relationships between housing outcomes and client characteristics, such as gender, psychiatric diagnosis, and substance use, were of primary interest. Methods A two-factor, longitudinal design was used. Homeless clients in San Diego County who were diagnosed as having chronic and severe mental illness were randomly assigned to four experimental conditions. Half of the clients were given better access to independent housing through Section 8 rent subsidy certificates. All clients received flexible case management, but half were provided more comprehensive case management services. The housing of each individual over a two-year period was classified in one of three categories: stable independent housing, stable housing in another setting in the community, or unstable housing. Results Clients with access to Section 8 housing certificates were much more likely to achieve independent housing than clients without access to Section 8 certificates, but no differences emerged across the two different levels of case management. Housing stability was strongly mediated by several covariates, especially the presence of problems with drugs or alcohol. Conclusions Supported housing interventions can be very successful tools for stabilizing homeless mentally ill individuals in independent community settings. Advantages include the low level of restrictiveness of these settings and the preference of many clients for independent housing. However, the success of supported housing projects is likely to depend strongly on the specific characteristics of the population being served.

Reduced substance-abuse-related health care costs among voluntary participants in Alcoholics Anonymous.

Abstract: OBJECTIVE This study examined differences in outcomes, alcoholism treatment utilization, and costs between alcoholic individuals with no previous treatment history who chose to attend Alcoholics Anonymous (AA) or to seek help from a professional outpatient alcoholism treatment provider. METHODS Participants in this three-year prospective study were recruited at alcoholism information and referral services and at detoxification units in the San Francisco Bay Area. Chi square and t tests and repeated-measures analyses of variance were used to examine data gathered from interviews with 201 participants at baseline and at one and three years. RESULTS At baseline, participants who chose to attend AA meetings (N = 135) were not significantly different from those who chose professional outpatient treatment (N = 66) in sex, marital status, employment, race, and symptoms of alcohol dependence and depression. However, AA attendees had lower incomes and less education and experienced more adverse consequences of drinking at baseline than did those who sought outpatient care, suggesting somewhat worse prognoses for the AA group. Over the three-year study, per-person treatment costs for the AA group were 45 percent (or $1,826) lower than costs for the outpatient treatment group. Despite the lower costs, outcomes for the AA group at both one and three years were similar to those of the outpatient treatment group. CONCLUSIONS Voluntary AA participation may significantly reduce professional treatment costs. Clinicians, researchers, and policymakers should recognize the potential health care cost offsets offered by AA and other self-help organizations.

Job preferences of clients with severe psychiatric disorders participating in supported employment programs.

Abstract: OBJECTIVE The job preferences of adults with severe mental illness who were participating in supported employment programs were examined. METHODS Data were collected on job preferences, attainment of competitive employment, job satisfaction, and job tenure of 135 adults who participated in two supported employment programs in New Hampshire. Data obtained at baseline and at six-month follow-up were analyzed. RESULTS When the clients entered the supported employment programs, 81 percent expressed job preferences, and their preferences tended to be realistic and stable. People who obtained employment in preferred areas were more satisfied with their jobs and remained in their jobs twice as long as those who worked in nonpreferred areas. Clients were more likely to develop a new job preference or to change their preference if they participated in a program that emphasized rapid job search than if they participated in a prevocational skills training program. They were also more likely to develop a preference or change their preference if they obtained a competitive job. CONCLUSIONS Helping people with severe mental illness obtain competitive jobs that correspond with their explicit job preferences increases job satisfaction and tenure. Job preferences are more likely to develop or change through searching for a job or working at a job than through prevocational training.

Predictors of missed appointments for psychiatric consultations in a primary care clinic.

Abstract: OBJECTIVE The purpose of the study was to determine predictors of missed appointments for psychiatric consultations among patients in a general medical clinic. METHODS The charts of 180 patients consecutively referred for psychiatric consultations at a university-affiliated primary care clinic were reviewed. Ninety patients missed appointments for these consultations. Parametric and nonparametric tests were used to compare patients who missed and did not miss appointments on demographic and clinical variables, as well as measures related to patients' interactions with the clinic and the referring clinician. RESULTS Logistic regression analysis revealed three significant predictors of missed appointments. Patients with mild distress and those with significant resistance to seeing a psychiatrist were more likely to miss appointments, as were those who had to wait longer between the referral and the appointment date. CONCLUSIONS The results suggest that shortening the wait for a psychiatric consultation, reserving consultation for more severe cases, and working to reduce patients' resistance to consultation will reduce the number of missed appointments.

Subversive Dialogues: Theory in Feminist Therapy

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Evidence for limited validity of the revised global assessment of functioning scale.

Abstract: The study examined the concurrent validity of the revised Global Assessment of Functioning (GAF) scale, which is highly similar to the Social and Occupational Functioning Assessment Scale (SOFAS) in DSM-IV and which is designed to measure patients' functioning and not their clinical symptoms. Psychiatrists used the revised GAF to rate 337 psychiatric inpatients; the ratings were compared with nurses' ratings of the same sample using Lehman's Quality of Life Scale. Ratings on the revised GAF were most strongly correlated with ratings of clinical symptoms, not functioning. Reliance on the GAF as the only tool to assess patients' functioning may be problematic.

Moving from psychoeducation to family education for families of adults with serious mental illness.

Abstract: The number of psychosocial interventions for relatives of adults with serious and persistent mental illness has increased significantly in recent years. Psychoeducational interventions combine educational and therapeutic objectives, offering didactic material about the ill relative's disorder and therapeutic strategies to enhance the family's communication and coping skills with the goal of reducing the patient's rate of relapse. The more recent development of family education differs from psychoeducation in that its primary goals are didactic and supportive rather than therapeutic. Interventions are focused on improving family members' quality of life by reducing stress and burden and only secondarily on benefiting the ill relative. The author reviews the conceptual and empirical basis of both psychoeducation and family education, discusses the distinctions between these two approaches in program structure and effectiveness, and suggests future policy, program, and research directions for family interventions.

Day treatment versus supported employment for persons with severe mental illness: a replication study.

Abstract: Outcomes for 112 clients with severe mental disorders in a community mental health center that converted its rehabilitative day treatment program to a supported employment program were assessed during the year after the program conversion. The study replicated a previous study in showing that the rate of competitive employment improved, especially among clients who had formerly attended the day treatment program, without evidence of adverse effects.

Prevalence and characteristics of physical and sexual abuse among psychiatric outpatients.

Abstract: Eighty-six female and 34 male psychiatric outpatients completed a self-report questionnaire that retrospectively assessed their history of physical and sexual abuse and assault. Seventy percent reported an abusive experience in childhood or adulthood. Female subjects were more likely than male subjects to report childhood sexual abuse and adult physical and sexual assaults. For all subjects, childhood sexual abuse was associated with adult sexual and physical assault. The charts of several patients who reported abuse histories did not include any record of abuse. Language: en

Factors associated with homicide recidivism in a 13-year sample of homicide offenders in Finland

Abstract: OBJECTIVE: Data on persons known to have committed homicide during a 13-year period were studied to determine factors associated with increased risk of repeating homicide. METHODS: Between 1981 and 1993, a total of 1,649 homicides were committed in Finland. In 1,089 cases (66 percent), the offenders received an exhaustive forensic psychiatric examination. Data from reports of these examinations were analyzed to determine whether mental disorder and other factors were associated with homicide recidivism. RESULTS: Thirty-six homicide recidivists were identified. Twenty-four were alcoholics, 23 had a personality disorder, in most cases combined with alcoholism, four had schizophrenia, and two had major depression. Homicidal behavior was ten times more likely in men who had committed a previous homicide than in the general male population. Alcoholism increased the odds ratio of additional homicidal behavior in male homicide offenders about 13 times, and schizophrenia increased the odds ratio more than 25 times. During their first year after release from prison, male homicide offenders were about 250 times more likely to commit homicide than members of the general male population. CONCLUSIONS: The data suggest that mentally abnormal offenders are overrepresented among homicide recidivists in Finland. The risk of repeat homicide appears to be very high during the first year after release from prison. Language: en

A comparison of two levels of family-aided assertive community treatment.

Abstract: Objective: The study examined differences in outcomes for patients with schizophrenic disorders who were receiving assertive community treatment based on whether their families were involved in their treatment more intensively in psychoeducational multifamily groups or episodically in crisis family intervention. Methods: Sixty-eight individuals who met DSM-III-R criteria for schizophrenic disorders and who had at least one other major complicating factor were randomly assigned to the two treatment conditions, and dinical and functional outcomes over a 24-month follow-up period were compared. Results: Both groups had significant reductions in rehospitalization rates and symptom levels and increased participation in treatment. Patients in multifamily group treatment had higher employment rates during the study. Otherwise, few significant differences in the major outcome variables were found. In both treatment conditions family members reported significant improvements in their objective and subjective burden; in friction, dissatisfaction, and overinvolvement with the patient; and in the patient’s functioning. Conclusions: The results suggest that systematic family involvement enhances the rehabilitation and family-related outcomes of assertive community treatment. Patients in multifamily group treatment had better employment outcomes. (Psychiatric Services 47:744-750, 1996)

Suicide among immigrants from the Indian subcontinent: a review.

Abstract: OBJECTIVE: Studies of suicide among immigrants from the Indian subcontinent (India, Pakistan, Bangladesh, and Sri Lanka) were examined to increase awareness of suicide risk and to better understand social and psychological factors contributing to suicide in this group. METHODS: An online search was conducted of MEDLINE for the years 1966 to 1994 and Psychological Abstracts for the years 1974 to 1994, and all references on completed suicides in the target population were selected for review. RESULTS: Suicide rates of young women immigrants from the Indian subcontinent are consistently higher than those of their male counterparts and of young women in the indigenous populations of the countries to which they immigrate. Suicide rates among older men in this immigrant group have been reported to be low, although reports are less consistent. Use of violent methods such as hanging, burning, and poisoning is common among both men and women. A disproportionately higher number of immigrant Hindus commit suicide. Family conflict appears to be a precipitating factor in many suicides, whereas mental illness is rarely cited as a cause. Depression, anxiety, and domestic violence may contribute to the high rates. Affective disorders may be underdiagnosed in this population. CONCLUSIONS: More research is needed on the epidemiology of psychiatric illnesses and their contribution to suicide in this group. Language: en

Family burden of schizophrenia and bipolar disorder: perceptions of relatives and professionals.

Abstract: OBJECTIVE The study compared the burden that specific problem behaviors of patients with schizophrenia or bipolar disorder placed on relatives and evaluated the accuracy of mental health professionals' judgment of the burden. METHODS A questionnaire was developed to assess the burden of 20 common problem behaviors associated with manic, positive, and negative symptoms. The questionnaire was given to 48 relatives of patients with schizophrenia or bipolar disorder. In addition, 39 mental health professionals completed separate questionnaires indicating the amount of burden they believed relatives experienced due to these behaviors. RESULTS Relatives of patients with bipolar disorder rated manic symptoms as more burdensome than did relatives of patients with schizophrenia, but relatives of patients in the two groups did not differ in their ratings of burden associated with positive or negative symptoms. Professionals' perceptions of the burden associated with manic symptoms were relatively accurate, but they tended to underestimate the burden of positive and negative symptoms experienced by relative of patients with bipolar disorder. CONCLUSIONS Psychiatric diagnosis may be of limited value in understanding the burden relatives experience due to specific psychiatric symptoms. Professionals are encouraged to assess the burden that is associated with specific problem behaviors regardless of psychiatric diagnosis.

The effectiveness of outpatient civil commitment.

Abstract: The effects of outpatient civil commitment on community tenure and functioning were studied in a group of 20 patients with a history of recurrent hospitalizations, noncompliance with outpatient treatment, and good response to treatment. During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment. They significantly increased the number of appointments kept with their psychiatrist. It appears that when used judiciously, outpatient civil commitment is a helpful tool in maintaining hospital recidivists in the community.