Comparison of usual and experimental patients in a psychiatric day center.

In a previously reported study by the authors (see record 1976-28530-001) of inpatient and day hospitalization, 59 seriously ill female psychiatric patients were randomly assigned to an inpatient or a day hospital setting. The present study compared the 29 seriously ill patients randomly assigned to the day hospital with a control group of 34 "usual" day patients. Ss were assessed on 14 outcome measures, some of which were derived from the Psychiatric Status Schedules and the Psychiatric Evaluation Form. The experimental group showed significantly more improvement from baseline to subsequent time periods in 3 distinct areas: global mental status, subjective distress, and family adjustment. The controls, on the other hand, spent fewer nights in the hospital, used the hospital facilities significantly less during the 1st 3 mo, and incurred a significantly lower cost for the same period. Two measures—number of social work contacts and amount of time spent in the treatment milieu—indicated that experimentals initially required more staff effort than controls, but at later time periods the reverse was true. (29 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled comparison of psychiatric day treatment and inpatient hospitalization.

59 seriously ill, female, 16-72 yr old psychiatric patients were randomly assigned, after 2-6 wks of inpatient evaluation, to an inpatient or day service where they were evaluated, along with a control group of 34 "usual" day hospital patients, for up to 24 mo. Data from the Psychiatric Status Schedule, Psychiatric Evaluation Form, Dynamic Assessment Scale, and other similar measures indicate that for the range of patients studied, day treatment is, on the whole, superior to inpatient treatment in 5 distinct areas: subjective distress, community functioning, family burden, total hospital cost, and days of attachment to the hospital program. The findings of other controlled studies are confirmed and extended to include previously unreported outcome dimensions and a broader socioeconomic population. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of seclusion in psychiatry: a literature review

This article reports on a literature review of the practice of seclusion in psychiatric inpatient facilities. Attention is paid to the moral debate on seclusion. Most publications consider seclusion as a necessary intervention to manage problem behavior. The first part of the article deals with definitional aspects leading toward concept clarification. The review shows differences in definitional aspects, motives for seclusion, hospital characteristics, and patient characteristics. Data on frequency, incidence, and duration appear to be widely divergent. The experiences of patients who have been secluded are mostly negative, but positive reactions are also reported. In the publications of the last decade, there is emphasis on the contribution of hospital characteristics to trends in use of seclusion. Finally, it is concluded that seclusion is an effective way to manage (potentially) dangerous behavior and that seclusion is an intervention that may create therapeutic possibilities for care.     

Therapeutic jurisprudence, preventive law, and creative problem solving: An essay on harnessing emotion and human connection.

Combining the principles of therapeutic jurisprudence, preventive law, and creative problem solving reveals an overuse by legal professionals of a "judging" problem-solving style that emphasizes the problem-solving tools of order, power, and normative expectation. It neglects—sometimes even suppresses—human emotion and interpersonal relationship, which are also important tools for solving problems. In contrast, psychologists often use an "accommodation" style of problem solving that emphasizes emotion and human connection. Legal professionals could be more effective and contribute importantly to community discourse were they to incorporate the accommodation style more frequently in legal problem solving. Doing so poses some threat to formal equality and due process, but therapeutic jurisprudence and preventive law scholarship offer promising examples for reconciling the accommodation style with traditional liberal values. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Efficacy of psychiatric rehabilitation.

Surveys the comparative effectiveness of various psychiatric rehabilitation procedures on posthospital adjustment using the outcome criteria of hospital recidivism and posthospital employment. The percentage of psychiatric patients who receive the traditional hospital regimen of drug treatment, and perhaps some form of individual or group therapy, and who are able to remain out of the hospital or find employment was established as a base line against which the unique effects of rehabilitation procedures could be evaluated. It was found that most all types of inpatient treatment innovations improved the patients' in-hospital behavior but did not singularly effect posthospital adjustment. Expatients who attended aftercare clinics had a lower rate of recidivism than nonattenders. Transitional facilities reduced recidivism but demonstrated little effect on enabling patients to function independently in the community. It is concluded that there is a definite need for the continued use of specific outcome criteria so that the comparative effectiveness of various psychiatric rehabilitation procedures can be meaningfully evaluated. (57 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Problem-solving appraisal in an alcoholic population.

The major purpose of this study was to generalize research on problem-solving appraisal beyond normal populations to a clinical population, namely, inpatient recovering male alcoholics from a Veterans Administration hospital. Seventy-eight veterans were administered the Problem-Solving Inventory, the Mooney Problem Checklist, and the Psychiatric Diagnostic Interview. The results indicated that inpatient male alcoholics reported their problem-solving appraisal as more similar to late adolescents than to adults to whom they were closer in age. The severity of alcohol abuse did not positively correlate with problem-solving appraisal, but it did correlate with acknowledged personal problems. No differences were found between three major subgroups of alcoholics as to how they appraised their problem-solving ability. The results suggest that problem-solving appraisal of recovering alcoholics do not correspond with their ability to manage everyday life and their alcohol abuse. The results are further discussed in terms of psychological adjustment, the congruence between appraisal and ability, and "over-approaching" problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The patient-staff community meeting: old tools, new rules

1. Psychiatric inpatient units with rapid turnover and acutely ill clients are vulnerable to the development of antitherapeutic trends, including destructiveness, disorganization, dysphoria, deviance, and dependency. 2. Inpatient therapists can apply the principles and techniques of milieu therapy, with certain modifications, to establish a therapeutic environment. 3. The patient-staff community plays a central role in this transformation, if it is structured to promote experiences of safety, order, support, involvement, and validation. 4. To accomplish these goals, the leaders of the meeting should establish clear rules and healthy norms, energize and guide participation, and focus discussion on topics relevant to unit events and to the processes of treatment and recovery.     

Intensive, integrated, in-home psychiatric services. The catalyst to enhancing outpatient intervention

The authors introduce the Yale Intensive In-Home Child and Adolescent Psychiatric Service, a model of home-based care for children with severe psychiatric disturbances. This model synthesizes the principles and method of the wrap-around paradigm and in-patient child psychiatric practice within the reality of the managed care system. A clinical team, under the direct supervision of a child psychiatrist, works directly within the family to understand and address the multilevel transactions that have affected the child's ability to function in various domains and resulted in recommendations for intensive intervention, including psychiatric hospitalization. This article suggests that if the psychiatrist is to provide the highest level of care, cognizance of and involvement in the child's ecology are as essential for the child and adolescent psychiatrist as other aspects of the child's world and life. In the days of ever shortening patient lengths of stay, this model of care offers promise for both clinical and fiscal effectiveness.     

Changing patterns of psychiatric inpatient care in the United States, 1988-1994

Using data from the National Hospital Discharge Survey and the Inventory of Mental Health Organizations, this article examines national trends in psychiatric inpatient care from 1988 to 1994 in general hospitals and mental hospitals. We find that discharges with a primary diagnosis of mental illness in general hospitals increased from 1.4 to 1.9 million during this period. The total increase of 1.2 million days of care in general hospitals was small relative to the reduction of 12.5 million inpatient days in mental hospitals. General hospital discharges increased most in private nonprofit hospitals and declined substantially in public hospitals. Length of stay has fallen most substantially in private nonprofit hospitals. Public programs have increasingly replaced private insurance as the major source of payment. These observations suggest that psychiatric inpatient care in general hospitals can be characterized as a process in which patients who would have been clients of public mental hospitals in a prior period replace privately insured patients who, under managed care, are largely treated in community settings. Private nonprofit general hospitals increasingly treat publicly financed patients with more severe illnesses.     

Chronic mental patient: Current status future directions.

The "hard core" group of chronically hospitalized mental patients still fill most hospital beds, and are not participants in the current upsurge in discharge rates. Target areas for rehabilitation of this population are suggested on the basis of a review of institutional studies within an interactional framework. A review of institutional treatment research suggests that "milieu" and "social learning" approaches, combined with special community aftercare procedures, offer the greatest promise for the future. Both approaches appear sufficiently promising to call for controlled comparative investigations. A program combining features of both milieu and social learning approaches is suggested for the interim. (4 p. ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ecological constraints on mental health services.

Proposes 4 principles for community mental health programing that are consistent with an ecological thesis: (1) Assessment methods are focused on the total population rather than on those persons who presently receive a mental health service. (2) Mental health services are designed to reduce a high risk for community service. (3) Professional and research services are created as local community resources. "By initiating the informal coordination of current services, the community mental health program helps to create specific new community services as needed." (4) The program plans for change; this involves mobilizing anticipatory problem-solving resources not only for clients but for professionals as well. A "conception of community mental health work based upon the ecological thesis that adaptive programs change" is presented. (39 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcomes of the treatment climate in psychiatric and substance abuse programs

This study examines how key aspects of the treatment climate are related to program differences in the aggregate behaviors of patients residing in 89 psychiatric or substance abuse facilities. More active support, personal expression, and practical orientation were related to better patient functioning, more patient activity in the facility and in the community, and more use by patients of the program's health-treatment services and social-recreational activities. These results held for both patients' and staff members' consensual perceptions of the treatment climate. On the whole, these aspects of the treatment milieu were especially beneficial for groups of patients with greater psychiatric impairment.     

Comparative effectiveness of day hospital and inpatient psychiatric treatment.

Employed a pre–posttreatment control group design to compare the treatment effects of partial hospitalization to those of full-time hospitalization. Ratings of home and community adjustment were obtained from community informants (relatives or close friends) for 2 groups of Ss: (a) 24 day-hospital clients (partial hospitalization condition) matched on age (average age 32 yrs), education, and intelligence with (b) 24 inpatient clients (full-time hospitalization condition), and from an unmatched sample of 79 consecutive inpatient admissions. Treatment outcome was measured by clients' pre- and postscores on the Personal Adjustment and Role Skills scale. Results show that all groups evidenced improvement 2 mo after treatment started, particularly on measures of symptom reduction. Although patterns of improvement were comparable for both settings in univariate data analyses, multiple discriminant function analysis indicated that the day hospital sample evidenced greater gains in attentiveness and in employment. Gains favoring the day hospital sample were more striking for the unmatched 3-group comparison than for the matched 2-group comparison. Findings indicate that partial hospitalization is an attractive alternative to inpatient psychiatric hospitalization. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Follow-up studies of psychotic patients receiving inpatient treatment or alternative forms of psychiatric care

An analysis of populations treated in the III Department of Psychiatry indicates that 12 years since the transformation of the organizational model of care for patients from sub-regionalized catchment area, inpatient treatment continues to be of major importance, as it was provided to over half of all referrals. Intermediate forms of care, replacing a half of the former number of psychiatric beds, were offered mainly to schizophrenic patients, with the exclusion of those with a marked agitation, psychomotor retardation, or aggressive, presenting imminent danger to self or others. At one-year follow-up J.E. Overall's scale was used to examine 39 schizophrenic patients treated at the inpatient ward, day hospital, or by a community treatment team. Patients treated at the day hospital providing an intense therapeutic program manifested a significantly more marked improvement in respect of 6 symptoms: autism, affective bluntness, guilt feelings, tension, suspiciousness, and bizarre thoughts. No significant differences were found between the compared forms of care as regards the degree of other symptoms amelioration. Thus, the day hospital turned out to be a more effective form of care in case of schizophrenic patients manifesting the cluster of symptoms listed above.     

The cultural context model in clinical supervision.

This article introduces principles from the Cultural Context Model (CCM) on the training of master's and doctoral level mental health professionals to the field of psychology, highlighting its consistencies using critical psychology principles. The main tenets of the CCM are described and illustrated with examples pertaining to clinical supervision. Clinical practice within the model is described to illustrate the learning tasks involved in the supervisory process. This system of clinical theory and practice offers an expanded family paradigm based on an analysis of societal patterns that contribute to social inequality organizing family and community life. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Three principles of salience in the organization of the patient-analyst interaction.

Explores the proposal that infant research is applicable to adult treatment through organizational principles of interactive regulation. Three organizing principles derived from infant research are used to create metaphors and analogies for adult treatment. These 3 principles (ongoing regulation, disruption and repair, and heightened affective moments) constitute hypotheses about how analyst–patient interactions become patterned and salient. They can further specify modes of therapeutic action in adult treatment. The case of a 36-yr-old professional woman with a depressive outlook on life and a strong belief that therapy would not help is used to illustrate the therapeutic action of the 3 principles. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suicide after discharge from psychiatric inpatient care

People with a history of psychiatric disorder are at higher risk of suicide than people without such a history. The policy of reducing inpatient care in psychiatry has probably meant that some of the risk of suicide has shifted from the hospital to the community setting. We have quantified the risk of suicide within a year of psychiatric discharge in a population-based study in the Oxford health region, UK. We calculated suicide rates per 1000 person-years at risk (time from discharge to death, subsequent readmission, or the end of the study) and the standardised mortality ratio (SMR) for suicide, taking the value among the general population as 1. Among male patients the SMR for suicide (defined by coroner's verdict of suicide) in the first 28 days after discharge from inpatient care was 213 (95% CI 137-317); the equivalent SMR for female patients was 134 (67-240). The result was similar when we defined suicide more broadly as a suicide, open, or misadventure verdict. The suicide rate in the first 28 days after discharge was 7.1 (4.1-12) times higher for male patients and 3.0 (1.5-6.0) times higher for female patients than the rate during the remaining 48 weeks of the first year after discharge. Most of the patients studied (both those who committed suicide and those who did not) had been psychiatric inpatients for only a short time. The findings confirm that there is significant clustering of suicide soon after discharge from psychiatric care. Skilled support after discharge for high-risk patients in the community is essential. Audit of suicides that occur soon after discharge may help identify the patients at highest risk and thereby reduce the number of avoidable deaths.     

Psychiatric hospitalization of adolescents for conduct disorder

OBJECTIVE: The authors' goal was to review current published literature on the psychiatric hospitalization of adolescents with a diagnosis of conduct disorder. METHODS: The English-language literature from 1980 to 1991 cited in the MEDLINE database was searched using the key words conduct disorder, adolescent psychiatric hospitalization, psychiatric hospitalization criteria, adolescent psychiatric inpatient hospitalization, and adolescent psychiatric admissions. RESULTS: A diagnosis of conduct disorder or presenting symptoms and behaviors consistent with that diagnosis are commonly reported for adolescent psychiatric admissions. Estimates of the percentage of admissions to psychiatric inpatient treatment facilities of adolescents with conduct disorder or symptoms consistent with that disorder range from 30 to 70 percent. There are no research-based criteria for hospitalization of adolescents for conduct disorder, and systematic studies of the outcome of psychiatric hospitalization for this group have not been published. Comorbid psychiatric diagnoses and similar behavioral symptoms in conduct disorder and comorbid disorders complicate inpatient treatment of adolescents with conduct disorder. CONCLUSIONS: Studies of the outcome of psychiatric hospitalization of adolescents for conduct disorder are needed to determine the appropriate use of this modality.     

The future of psychiatric hospitals

We are of the opinion that it is less important whether a large mental hospital is regionalized or not, but whether it is possible to realize the principle of universal psychiatric protection as a "unity of responsibilities of all subjects who take part in the protection of mental health and the society in the whole" by improvement and advancement of the existing system. We accept the opinion that the internal organization of mental hospitals has to be changed by organizing hospitals wards with 30-50 beds. We consider that in a perspective organization of psychiatric protection of all institutions (large hospitals, clinic, psychiatric wards of general hospitals, dispensaries and health centers) have their role and that the achieved level of the protection greatly depends on socio-economic level and possibilities.