Showing papers in "Psychiatric Services in 2005"
1,224 citations
TL;DR: Evidence for the psychological benefits for clinical populations comes from two meta-analyses of outcomes of depressed patients that showed that effects of exercise were similar to those of psychotherapeutic interventions.
Abstract: This article reviews evidence supporting the need for interventions to promote physical activity among persons with serious mental illness. Principles of designing effective physical activity interventions are discussed along with ways to adapt such interventions for this population. Individuals with serious mental illness are at high risk of chronic diseases associated with sedentary behavior, including diabetes and cardiovascular disease. The effects of lifestyle modification on chronic disease outcomes are large and consistent across multiple studies. Evidence for the psychological benefits for clinical populations comes from two meta-analyses of outcomes of depressed patients that showed that effects of exercise were similar to those of psychotherapeutic interventions. Exercise can also alleviate secondary symptoms such as low self-esteem and social withdrawal. Although structured group programs can be effective for persons with serious mental illness, especially walking programs, lifestyle changes th...
440 citations
TL;DR: Having medications used as a threat or punishment, unwanted sexual advances in a psychiatric setting, inadequate privacy, and sexual assault by a staff member were associated with a history of exposure to sexual assault as an adult.
Abstract: OBJECTIVE: This study examined the frequency and associated distress of potentially traumatic or harmful experiences occurring within psychiatric settings among persons with severe mental illness who were served by a public-sector mental health system. METHODS: Participants were 142 randomly selected adult psychiatric patients who were recruited through a day hospital program. Participants completed a battery of self-report measures to assess traumatic and harmful events that occurred during the course of their mental health care, lifetime trauma exposure, and symptoms of posttraumatic stress disorder. RESULTS: Data revealed high rates of reported lifetime trauma that occurred within psychiatric settings, including physical assault (31 percent), sexual assault (8 percent), and witnessing traumatic events (63 percent). The reported rates of potentially harmful experiences, such as being around frightening or violent patients (54 percent), were also high. Finally, reported rates of institutional measures of...
438 citations
330 citations
TL;DR: Data on how mental illness is represented in newspapers yield a useful perspective on structural stigma and the policies and standards that are applied by the news media, which has implications for influencing the press.
Abstract: OBJECTIVES: Structural stigma and discrimination occur when an institution like a newspaper, rather than an individual, promulgates stigmatizing messages about mental illness. This study examined current trends in the news media on reporting topics of mental illness. METHODS: All relevant stories (N=3,353) in large U.S. newspapers were identified and coded during six weeklong periods in 2002. Stories were coded by themes that fit into four categories: dangerousness, blame, treatment and recovery, and advocacy action (that is, calls for public policy and action that increase the quality of care or opportunities for those with mental illness). RESULTS: Thirty-nine percent of all stories focused on dangerousness and violence; these stories most often ended up in the front section. Few stories promulgated the idea that either the person or the family was responsible for mental illness (2 percent). Instead, stories about genetic or biological or environmental causation (for example, stress and trauma) were mor...
308 citations
TL;DR: Adolescents tended to discriminate among conditions, viewing substance abuse more harshly than the other disorders, and contact with persons with mental illness led to more discrimination.
Abstract: OBJECTIVES: Research among adults has yielded three sets of conclusions about the stigma of mental illness. First, people with mental illness are stigmatized more severely than those with physical health conditions; those who abuse alcohol are viewed more harshly than those with mental illness. Second, stereotypes of mental illness related to responsibility and dangerousness lead to negative emotional reactions and discriminatory behaviors. Third, familiarity with people with mental illness tends to diminish stigma. This study attempted to validate these findings with a large and diverse sample of adolescents. METHODS: A total of 303 adolescents completed a revised version of the Attribution Questionnaire (rAQ) that presented four vignettes, each describing a different type of peer: a peer with mental illness, with mental illness caused by a brain tumor, with alcohol abuse problems, and with leukemia. The rAQ comprises seven Likert scale items of agreement that research participants rated for each vignett...
297 citations
TL;DR: Mental health-related visits constitute a significant and increasing burden of care in U.S. emergency departments and increased significantly among non-Hispanic whites, patients older than 70 years, and patients with insurance across the decade.
Abstract: OBJECTIVE: The objective of this study was to ascertain trends in mental health-related visits to U.S. emergency departments. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey by using mental health-related ICD-9-CM, E, and V codes as well as mental health-related reasons for visit. RESULTS: From 1992 to 2001, there were 53 million mental health-related visits, representing an increase from 4.9 percent to 6.3 percent of all emergency department visits and an increase from 17.1 to 23.6 visits per 1,000 U.S. population across the decade. The most prevalent diagnoses were substance-related disorders (22 percent of visits), mood disorders (17 percent), and anxiety disorders (16 percent). Mental health-related visits increased significantly among non-Hispanic whites, patients older than 70 years, and patients with insurance. Medications were administered during 61 percent of all mental health-related visits, most commonly psychotropic medication, the prescription rate of whi...
285 citations
TL;DR: The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.
Abstract: OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-relate...
273 citations
TL;DR: The multiple ICT model may be helpful to clinicians who are faced with making decisions about discharge planning for acutely hospitalized civil patients and may reflect the "shrinkage" expected in moving from construction to validation samples.
Abstract: OBJECTIVES: An actuarial model was developed in the MacArthur Violence Risk Assessment Study to predict violence in the community among patients who have recently been discharged from psychiatric facilities. This model, called the multiple iterative classification tree (ICT) model, showed considerable accuracy in predicting violence in the construction sample. The purpose of the study reported here was to determine the validity of the multiple ICT model in distinguishing between patients with high and low risk of violence in the community when applied to a new sample of individuals. METHODS: Software incorporating the multiple ICT model was administered with independent samples of acutely hospitalized civil patients. Patients who were classified as having a high or a low risk of violence were followed in the community for 20 weeks after discharge. Violence included any battery with physical injury, use of a weapon, threats made with a weapon in hand, and sexual assault. RESULTS: Expected rates of violence...
231 citations
TL;DR: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment with analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement.
Abstract: OBJECTIVE: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. METHODS: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. RESULTS: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the u...
226 citations
TL;DR: The rate and duration of seclusion and mechanical restraint decreased dramatically during this period and many factors contributed to the success of this effort, including advocacy efforts, state policy change, improved patient-staff ratios, response teams, and second-generation antipsychotics.
Abstract: OBJECTIVES: This study examined the use of seclusion and mechanical restraint from 1990 to 2000 and the rate of staff injuries from patient assaults from 1998 to 2000 in a state hospital system. METHODS: Records of patients older than 18 years who were civilly committed to one of the nine state hospitals in Pennsylvania were included in the analyses. Two databases were used in each of the nine hospitals: one identified date, time, duration, and justification for each episode of seclusion or restraint and the other identified when a patient was hospitalized and the demographic characteristics and the diagnosis of the patient. Rate and duration of seclusion and restraint were calculated. Reports from compensation claims were used to determine staff injuries from patient assaults. RESULTS: The rate and duration of seclusion and mechanical restraint decreased dramatically during this period. From 1990 to 2000, the rate of seclusion decreased from 4.2 to .3 episodes per 1,000 patient-days. The average duration...
TL;DR: Current treatment options do not address the needs of difficult-to-treat patients with chronic insomnia, such as the elderly, and those with comorbid medical and psychiatric conditions.
Abstract: OBJECTIVE: Insomnia has high prevalence rates and is associated with significant personal and socioeconomic burden, yet it remains largely underrecognized and inadequately treated. METHODS: A PubMed search for English-language articles covering randomized controlled trials published between 1970 and 2004 was conducted. Search terms used were "insomnia," "behavioral therapy," and the generic names of agents commonly used to treat insomnia (the Food and Drug Administration-approved benzodiazepines and nonbenzodiazepines, trazodone, and over-the-counter agents). RESULTS: Evidence from epidemiologic studies, physician surveys, and clinical studies suggests that numerous patient and physician factors contribute to the fact that the needs of patients with insomnia remain unmet, including low reporting of insomnia by patients, limited physician training, and office-based time constraints, as well as misconceptions about the seriousness of insomnia, the advantages of treatment, and the risks associated with hypno...
TL;DR: Delinquents with substance use disorders, either with or without comorbid major mental disorders, are at particular risk of HIV-AIDS, and the juvenile justice and public health systems must provide HIV- AIDS interventions as well as mental health and substance abuse treatment.
Abstract: OBJECTIVES: This study determined the prevalence of 20 HIV-AIDS risk behaviors of four groups of juvenile detainees: those with major mental disorders alone, those with substance use disorders alone, those with comorbid mental and substance use disorders, and those without any major mental or substance use disorder. METHODS: Interviewers administered the AIDS Risk Behavior Assessment to 800 randomly selected juvenile detainees aged ten to 18 years who were initially arrested between 1997 and 1998. Diagnoses were determined with the Diagnostic Interview Schedule for Children, Version 2.3. RESULTS: The sample included 340 females and 460 males. As with the other groups of detainees, youths with major mental disorders had a high prevalence of most HIV-AIDS risk behaviors, much higher than the rates found among youths in the general population. Comorbid substance use disorders substantially increased risk; 96 percent of youths in this group had been sexually active, 62 percent had had multiple partners within...
TL;DR: A majority of primary care patients with depression were adequately treated for depression, with no detectable disparity related to race or age, and mild to moderate depressive symptoms and specific medications were associated with a lower rate of adequacy.
Abstract: OBJECTIVES: Depression is most commonly treated in the primary care setting. However, most studies have shown that depression care in this setting is often inadequate. This study examined the adequacy of antidepressant treatment and overall depression management by primary care physicians and identified patient characteristics related to inadequate care. METHODS: Adequacy of depression care among patients with depression who presented to a primary care office was evaluated by using physicians' self-reports and medication prescription data. Adequacy of depression care was measured in two ways: adequacy of the current medication trial was measured by using the Antidepressant Treatment and History Form (ATHF), and adequacy of overall management by the physician was measured by using an algorithm developed for this study. The association was examined between patient characteristics and adequacy of the medication trial or depression management. RESULTS: Data were gathered for 389 patients with depression. Over...
TL;DR: Positive relationships between continuity of care and health outcomes among persons with severe mental illness suggest that efforts at improving continuity in and among mental health services are worthwhile.
Abstract: OBJECTIVES: Continuity of care is considered to be essential to the effective treatment of persons with severe mental illness, yet evidence to support the association between continuity and outcomes is sparse because of a lack of longitudinal studies and of comprehensive continuity measures. The purpose of this study was to examine the relationship between continuity of care and outcomes. METHODS: A new multilevel measure of service continuity, the Alberta Continuity of Services Scale for Mental Health (ACSS-MH), was used in a 17-month follow-up study of 486 adults with severe mental illness in three health regions of Alberta, Canada. RESULTS: Endpoint information was obtained for 411 participants (85 percent). The mean continuity score reported by patients was 131±20 out of a possible 185. The mean continuity score as rated by observers was 39±10 out of a possible 59. Higher levels of observer-rated continuity were associated with older age, lower annual household income, a diagnosis of psychotic disorde...
TL;DR: GAF ratings made by an individual rater can be used to measure changes and outcomes at the group level, however, the measurement error is too large for assessment of change for an individual patient, in which case it might be necessary to use several raters.
Abstract: OBJECTIVE: In the Swedish psychiatric care system, systematic follow-up of clinical work with patients is becoming a part of regular service, and a number of care providers are using the Global Assessment of Functioning (GAF) to measure outcomes. This study investigated the reliability of the GAF and analyzed certain factors that affect measurement errors when the scale is used by regular psychiatric staff. METHODS: Eighty-one raters from various psychiatric outpatient clinics rated eight case vignettes. Interrater reliability was assessed by using intraclass correlation coefficients (ICCs), and factors associated with reliability were analyzed by using raters' unique residual values. RESULTS: The results showed that staff who are responsible for assessing first-time patients at outpatient psychiatric clinics and making diagnoses are using the GAF with satisfactory reliability (ICC1,1=.81). The factors associated with reliability were raters' subjective attitude toward the GAF and motivation to use the sc...
TL;DR: A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use.
Abstract: OBJECTIVES: A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage—money (representative payee or money handler), housing, criminal justice, and outpatient commitment—was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage. METHODS: Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States. RESULTS: The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, a...
TL;DR: The Clark County MHC successfully reduced rearrest rates for new criminal offenses and probation violations and provided the mental health support services to stabilize mental health consumers in the community.
Abstract: OBJECTIVE: This study examined rearrest and linkage to mental health services among 368 misdemeanants with severe and persistent mental illness who were served by the Clark County Mental Health Court (MHC). This court, established in April 2000, is based on the concepts of therapeutic jurisprudence. This study addressed the following questions about the effectiveness of the Clark County MHC: Did MHC clients receive more comprehensive mental health services? Did the MHC successfully reduce recidivism? Were there any client or program characteristics associated with recidivism? METHODS: A secondary analysis of use of mental health services and jail data for the MHC clients enrolled from April 2000 through April 2003 was conducted. The authors used a 12-month pre-post comparison design to determine whether MHC participants experienced reduced rearrest rates for new offenses, reduced probation violations, and increased mental health services 12 months postenrollment in the MHC compared with 12 months preenrol...
TL;DR: PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.
Abstract: This study examined 184 African-American outpatients in a mental health clinic in the inner city to define the rate of occurrence of traumatic experience and posttraumatic stress disorder (PTSD). This population experienced a high rate of severe trauma. Forty-three percent were found to have PTSD, as measured by the PTSD Symptom Scale. Finally, a chart review of 72 participants found that only 11 percent of participants who met DSM-IV criteria for PTSD also had a chart diagnosis of PTSD. PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.
TL;DR: It was found that delay in scheduling appointments had a significant impact on rate of kept appointments, and the impact was significant during the first week of delay and appeared to stabilize after day seven.
Abstract: Failure to keep initial appointments at a community mental health center results in a burden on the staff and the center's financial resources. The authors studied referrals to an outpatient program and found that delay in scheduling appointments had a significant impact on rate of kept appointments. The impact was significant during the first week of delay and appeared to stabilize after day seven. Age influenced the rate but differed in influence between the adult and child programs. Changes aimed at reducing wait time for initial appointments may favorably affect rate of kept appointments and ultimately preserve staff and financial resources.
TL;DR: The findings suggest that the psychological distress of nurses who worked during the SARS outbreak was moderate, and the distress was more prominent among the two groups of Nurses who were working with patients with SARS.
Abstract: OBJECTIVES: This study explored whether nurses who were working during the severe acute respiratory syndrome (SARS) crisis showed symptoms of distress. This study also examined whether nurses experienced stress from being conscripted to work in higher-risk units. METHODS: This study was conducted in Taiwan during the peak of the SARS outbreak in 2003. Participants were recruited from nursing staff in a community hospital. Participants were divided into three groups: those who originally worked in units with a high risk of SARS exposure (N=65), those who had been involuntarily conscripted into such units because of manpower demands (N=21), and those who worked in units with a low risk of SARS exposure (N=45). Participants were evaluated with two questionnaires: the Impact of Event Scale and the 90-item Symptom Checklist-Revised. RESULTS: The results showed that 11 percent of the nurses surveyed had stress reaction syndrome. The symptoms of psychological stress reactions included anxiety, depression, hostil...
TL;DR: Although imams have little formal training in counseling, they are asked to help congregants who come to them with mental health and social service issues and need more support from mental health professionals to fulfill a potentially vital role in improving access to services.
Abstract: OBJECTIVE: Muslims are one of the most rapidly growing minority groups in the United States and have experienced increased stress since September 11, 2001. The purpose of this study was to elucidate the roles of imams, Islamic clergy, in meeting the counseling needs of their communities. METHODS: An anonymous self-report questionnaire was mailed to 730 mosques across the United States. RESULTS: Sixty-two responses were received from a diverse group of imams, few of whom had received formal counseling training. Imams reported that their congregants came to them most often for religious or spiritual guidance and relationship or marital concerns. Imams reported that since September 11, 2001, there has been an increased need to counsel persons for discrimination. An increased need to counsel persons who were discriminated against was reported by all imams with congregations in which a majority are Arab American, 60 percent of imams with congregations in which a majority are South Asian American, and 50 percen...
TL;DR: Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.
Abstract: OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use di...
TL;DR: It may be helpful to use two definitions of high utilizer to identify patients at different phases of their illness and to guide clinical interventions and mental health policies.
Abstract: OBJECTIVE: The purpose of this study was to examine the sociodemographic and clinical characteristics of high utilizers of psychiatric emergency services. METHODS: Data were collected over four years for 761 patients who were identified as high utilizers according to three definitions (two standard deviations above the mean number of visits to an urban psychiatric emergency service, six visits in a year, and four visits in a quarter) and for 1,585 nonfrequent utilizers (control group). Univariate analysis of variance and logistic regression models were used to determine group differences. RESULTS: Two distinct groups of high utilizers emerged: high utilizers by quarter and high utilizers by standard deviation. Compared with the control group, the high utilizers were more likely to be homeless, to have developmental delays, to be enrolled in a mental health plan, to have a history of voluntary and involuntary hospitalizations, to be uncooperative, to have personality disorders, to have unreliable social su...
TL;DR: This study found high levels of service use for outpatient services but very low levels for primary and preventive services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998.
Abstract: OBJECTIVE: The aim of this study was to examine patterns of use of general medical services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. METHODS: A total of 669 persons with a severe and persistent mental illness were identified by using statewide clinical criteria. A three-year database of Medicaid claims was developed to examine service use. The main outcome measures were use of outpatient services for a general medical problem, use of dental and vision services, and use of screening tests for women. Service use was examined by primary psychiatric diagnosis (schizophrenic, affective, paranoid, and anxiety disorders), and analyses controlled for the presence of a chronic medical condition, age, race, and sex. RESULTS: This study found high levels of service use for outpatient services but very low levels for primary and preventive services. Although 78 percent of persons with a schizophrenic disorder had an office-based visit during the three-year peri...
TL;DR: Disparities in depression care for Latinos were not attributable to sociodemographic and clinical characteristics, and they weren't attributable to receiving care in clinics that served ethnically similar or dissimilar clientele, suggesting that other patient or provider factors may be responsible.
Abstract: OBJECTIVE: This study examined the impact of patient characteristics and source of care on differences between whites and Latinos in use and quality of depression treatment in managed primary care settings. METHODS: Data were examined for 1,175 patients (398 Latinos and 777 whites) in 46 managed primary care practices who screened positive for probable depressive disorder. Patient baseline assessments were used to compile sociodemographic and clinical characteristics and to derive variables for receipt of any depression care and depression care that met minimum guidelines (antidepressant use or specialty counseling) in the past six months. Clinics were classified by the percentage of their patient population that consisted of Latinos to determine whether patients in highly Latino clinics reported lower rates of care. Predictors of use and quality of depression care were examined by using logistic regression. RESULTS: Rates of receipt of any depression care and guideline-level depression care were low, and...
TL;DR: Examples of structural stigma uncovered by surveys such as this one can inform advocates for persons with mental illness as to where an individual state stands in relation to the number of bills that affect persons withmental illness and whether these bills expand or contract the liberties of this stigmatized group.
Abstract: OBJECTIVE: This article discusses examples of structural stigma that results from state governments' enactment of laws that diminish the opportunities of people with mental illness. METHODS: To examine current trends in structural stigma, the authors identified and coded all relevant bills introduced in 2002 in the 50 states. Bills were categorized in terms of their effect on liberties, protection from discrimination, and privacy. The terms used to describe the targets of bills were examined: persons with "mental illness" or persons who are "incompetent" or "disabled" because of mental illness. RESULTS: About one-quarter of the state bills reviewed for this survey related to protection from discrimination. Within that category, half the bills reduced protections for the targeted individuals, such as restriction of firearms for people with current or past mental illness and reduced parental rights among persons with a history of mental illness. Half the bills seemed to expand protections, such as those tha...
TL;DR: The findings suggest that many mental health consumers have had a lifetime sanctuary experience that they perceived as harmful, and suggestions for how the mental health service delivery system might reduce the potential for sanctuary harm experiences are offered.
Abstract: OBJECTIVE: Recent studies show a high prevalence of trauma symptoms among people with serious mental illness who are treated in public-sector mental health systems. Unfortunately, growing evidence suggests that many consumers have had traumatic or harmful experiences while being treated in various psychiatric settings. This study explores consumers' perceptions of such harmful inpatient experiences, events that the authors place under the rubric of "sanctuary harm." METHODS: The authors conducted semistructured qualitative interviews with 27 randomly selected mental health consumers to hear their descriptions of adverse events that they experienced while receiving psychiatric care. Our analysis of interview transcriptions focused on understanding consumers' narratives of harmful experiences—events that would not meet DSM-IV criteria for trauma but that nevertheless resulted in significant distress. RESULTS: Eighteen of 27 interviewees described harmful incidents that they had witnessed or experienced dire...