Out-patient care in the structure of psychiatric institutions

The authors present models of functioning of hospital and out-patient psychiatric institutions, the problems faced in working together of the day treatment centre with other psychiatric institutions with special regard for the in-patient ward. The paper presents applied strategies of cooperation.     

Alternatives to seclusion in psychiatric care

The use of seclusion in psychiatry is declining. Its punitive nature has been acknowledged and alternative, more therapeutic approaches are needed to deal with disturbed patients. What alternatives are available? This article reports a study that sought to examine the response to incidents that formerly would have led to seclusion in one psychiatric intensive care unit. The sample consisted of 50 incidents. Information on the incident and subsequent action was recorded on standard incident forms and specially designed data collection sheets. The most frequent type of incident was damage to property, followed by direct or threatened physical assault on staff. The most common response was one-to-one nursing support, followed by the use of medication. In just over half the incidents, both responses were used together. This therapeutic strategy demonstrates that aggressive incidents can be dealt with safely without recourse to seclusion.     

The organizational structure of medical group practices in a managed care environment

This article analyzes the organizational structures of 155 medical group practices providing services in the highly competitive managed care environment in the upper midwest. The structure of the group practices and the methods of physicians' payment are analyzed in terms of the proportion of revenue obtained from financial risk-sharing managed care payment systems and the length of time involved with those systems.     

Using DSM-IV primary care version: a guide to psychiatric diagnosis in primary care

The prevalence of patients with psychiatric disorders in primary care settings indicates that family physicians have a need for a diagnostic manual suited to the realities of their practice. This article reviews the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., primary care version (DSM-IV-PC) and highlights the ways it accommodates the clinical needs of family physicians. DSM-IV-PC emphasizes the use of nine diagnostic algorithms for the most prevalent psychiatric disorders in primary care. The authors review the conceptual similarities between DSM-IV and DSM-IV-PC and the diagnostic features that are unique to DSM-IV-PC, and offer an illustrative case that incorporates a DSM-IV-PC approach to diagnosis. The authors also outline clinical and technical issues that remain unresolved in DSM-IV-PC.     

Approaches to recognition and management of childhood psychiatric disorders in pediatric primary care

Psychiatric disorders occur in 14% to 20% of American children and adolescents and are a leading cause of disability among them, yet fewer than one in five of these children are recognized. The most common psychiatric disorders presenting to pediatricians include ADHD, anxiety disorders, depression, substance-use disorders, and conduct disorder, Approaches to recognition include screening for psychosocial concerns using specific questions in the clinical interview, and using brief, written questionnaires. Case vignettes illustrate comprehensive treatment planning for children with psychiatric disorders in the primary care context. As psychopharmacologic treatments and the new subspecialty of pediatric psychopharmacology take on growing importance, the traditional oversight role of the pediatrician and effective communication among referring and consulting physicians remain critical to quality care.     

Managed care and the survival of neurology referral centers. A commitment to centers of excellence

Since the collapse of federal health system reform legislation in 1994, there has been a growing concern with the quality of care provided within managed care systems. Just as physicians practicing under a traditional fee-for-service payment base have financial incentives to do as much as possible for each patient (doing well by doing good), physicians working for managed care plans are sometimes given perverse incentives to do as little as possible. A major quality-related concern among patients and payers (often referred to jointly and ambiguously as consumers of care) is the much larger role assigned to primary care physicians in managed care plans than is usually the case with traditional indemnity insurance.     

Severity distribution of atopic dermatitis in the community and its relationship to secondary referral

A case of cutaneous leishmaniasis in a traveller from Belize, Central America is reported. Leishmaniasis presents rarely in Australia and delays in diagnosis and treatment often occur. A high index of suspicion in a patient who has returned from an endemic region is required. Subsequent confirmation of a diagnosis of cutaneous leishmaniasis is best achieved by demonstration of the organism on skin biopsy, aspiration or smear. The histology is variable and depends on geographic, parasite species and host factors. Speciation of New World disease as either Leishmania braziliensis or Leishmania mexicana is important to determine the risk of later development of mucosal disease, which normally only occurs with L. braziliensis infection, and for optimal treatment. Several different modes of treatment have been suggested, but antimonials, such as sodium stibogluconate, remain the treatment of choice in New World cutaneous leishmaniasis.     

Barriers to preventive care in general practice: the role of organizational and attitudinal factors

BACKGROUND: There are numerous barriers to preventive care. In this paper we focus on barriers related to the organization of preventive services and to the general practitioners' (GPs') attitudes and self-efficacy expectations. The prevention of cardiovascular disease was taken as a case study. AIM: To study the organization of cardiovascular services and the attitudes and self-efficacy expectations of GPs, the relationships that exist between these factors, and the influence of practice and provider characteristics. METHOD: A survey was conducted among 95 general practices with 195 GPs. RESULTS: Few practices were sufficiently well-organized to provide effective preventive services. Seventy per cent of the GPs had positive self-efficacy expectations. Thirty to fifty per cent had positive attitudes. Few relationships were found between the organization of services and positive attitudes or expectations. Moreover, few relationships were found between practice and provider characteristics and barriers studied. List size played some role in the presence of barriers. CONCLUSION: Barriers to prevention exist. Even a positive attitude or self-efficacy expectation does not automatically coincide with a practice organization equipped for prevention. Changing attitudes is probably not enough. Efforts have to be directed at the organization of services.     

Mode of referral to hospital of patients with heart attacks: relevance to home care and special ambulance services

Out of 1250 consecutive patients brought to hospital with heart attacks 956 (76%) were at home when their symptoms began. Of these, 587 (61%) called their general practitioner, and for the remainder an ambulance was summoned by a member of the public. Of the 294 patients who were away from home when the attack occurred 291 were brought to hospital by ambulance. Of these, only 70 (24%) were attended by a general practitioner. Patients for whom ambulances were called by a general practitioner had had their symptoms significantly longer and had significantly lower prehospital and hospital mortalities than those for whom ambulances were summoned by members of the public. Special "cardiac" ambulances appear to be inappropriate for patients who have been seen by a general practitioner, and for this group home care may well be as effective as hospital admission.     

Situations associated with admission to an acute care inpatient psychiatric unit.

This study examined whether stressful events occurred during the week preceding admission to an inpatient psychiatric unit in a sample of 97 adults with serious mental illness. The study also examined whether patients who had been readmitted within 30 days reported different stressful events than patients who had lived in the community for at least 6 months prior to admission. A structured interview was developed to obtain information about depressive and psychotic symptoms, stressful events, substance use, and aggressive and disruptive behaviors. Suicide risk was the most common reason for hospitalization (65%). Between 25% and 38% of patients reported interpersonal problems with family members or people outside their family, and about 50% reported financial problems immediately before hospitalization. Comparison of patients who had been readmitted within 30 days with patients who had been living in the community for at least 6 months since their last hospitalization found few differences between these groups. Results indicate that most patients were admitted to an inpatient psychiatric unit because of suicide risk, and interpersonal events seemed to precipitate hospital admission for these patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship of distress to mood disturbance in primary care and psychiatric populations.

Disagreement remains as how to interpret elevated scores on measures of self-reported distress. This study compared elevated scores on the Center for Epidemiologic Studies-Depression Scale (CES-D) in 2 samples to mood disturbance as assessed in an interview. In a primary medical care sample, most distressed patients did not have a mood disturbance, and distress without mood disturbance was associated with little impairment. Primary care patients with elevated scores on the CES-D were less distressed and less likely to have mood disturbance, major depression, or impairment than distressed psychiatric patients. Few patients with mood disturbance in either sample failed to meet criteria for major depression. Implications are discussed for research on depression using self-report measures, for generalizations across clinical and nonclinical populations, and for screening for preventive interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Residual psychopathology in released psychiatric patients and its relation to readmission.

The degree and type of mental pathology reflected in MMPI scores was surveyed in 147 hospitalized psychiatric patients upon admission and release. Both statistical and clinical assessments of the profiles were made with analyses related to changes during hospitalization and to comparison with normal groups. Results vary depending on method of assessment. A substantial group of profile-pairs are judged as showing improvement at release (75%), while the remainder (25%) show more illness. Statistical analysis shows significant group improvement but exit profiles do not resemble those of normals. Psychotic profile types do not change to resemble neurotic ones with hospital treatment. MMPI change scores seem to anticipate rehospitalization better than evaluation of the patients' exit profile alone. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of a case register to evaluate the costs of psychiatric care

Somatosensory evoked potentials (SEP) to ipsilateral and contralateral median nerve stimulations were recorded from subdural electrode grids over the perirolandic areas in 41 patients with medically refractory focal epilepsies who underwent evaluation for epilepsy surgery. All patients showed clearly defined, high-amplitude contralateral median SEPs. In addition, four patients showed ipsilateral SEPs. Compared with the contralateral SEPs, ipsilateral SEPs were very localized, had a different spatial distribution, were of considerably lower amplitude, had a longer latency (1.2-17.8 ms), did not show an initial negativity, and were markedly attenuated during sleep. Stimulation of the subdural electrodes overlying the sensory hand area was associated with contralateral hand paresthesias, but no ipsilateral hand paresthesias, occurred. It was concluded that subdurally recorded cortical SEPs to ipsilateral stimulation of the median nerve (M) reflect unconscious sensory input from the hand possibly serving fast bimanual hand control. The anatomical pathway of these ipsilateral short-latency MSEPs is not yet known. Transcallosal transmission seems unlikely because of the short delay between the ipsilateral and contralateral responses in selected cases. The infrequent occurrence of ipsilateral subdurally recorded SEPs and their low amplitude and limited distribution suggest that they contribute very little to the short-latency ipsilateral median SEPs recorded on the scalp.     

Patients' perceptions of care and safety within psychiatric settings.

There is growing concern over institutional measures of control (e.g., seclusion, restraint) and other potentially harmful or traumatic experiences within psychiatric hospitals. The purpose of the present study was to examine the relationship between demographic variables, potentially harmful and/or traumatic psychiatric experiences, and patients' perceptions of care and safety in psychiatric settings among 142 public-sector psychiatric patients. Data revealed 45.1% of patients reported they had been to a psychiatric facility they would never want to return to, and the majority of patients did not communicate with staff after a distressing event occurred. There were no significant differences in perceptions of care and safety by race, gender, or age. However, patients who reported potentially harmful or traumatic psychiatric events were significantly more likely to report that they had been to a psychiatric facility they would not want to return to. Encouragingly, most patients (84.5%) reported that psychiatric facilities have become safer in recent years. These data suggest the need to better understand how adverse psychiatric events influence how patients view their care and their subsequent engagement in that care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mission statement rationales and organizational alignment in the not-for-profit health care sector

This article presents the findings from a research study conducted on the use of mission statements in not-for-profit health care organizations. In particular, the study sought to determine if a relationship exists between the initial "rationales" that led to the creation of a mission statement and hospital performance. The findings suggest that some of the rationales for developing mission statements are indeed more important than others and that organizational alignment with the mission statement is of key importance to both the mission's and the hospital's success.     

Motivations to work and organizational performance.

Measures of 3 types of motivation to work were related to 2 criteria of job performance, both of which reflect the degree to which the organization has rewarded individual behaviors. In the white-collar sample (N = 1047), composed largely of technical personnel, low performers were motivated primarily by the social environment of the job and, to a lesser extent, by the opportunity of gaining recognition through advancement; few significant relationships were found between intrinsic self-actualizing motivations and job performance. In the blue-collar sample (N = 421), no significant relationships were found between any of the motivational measures and job performance. With advancing age and tenure, work became more meaningful for high performers but less meaningful for low performers, although the importance of the social environment increased for both high and low performers. (17 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family centered maternity care: its relationship to perinatal regionalization and neonatal intensive care

For several months prior to birth a major portion of a family's attention, conversation, thought, and often worry, is directed toward the idea of a new child. This prolonged attention and anticipation contribute to making childbirth an emotionally charged experience. In psychological terms, it is therefore a critical period of peak motivation for learning, and a time to peak susceptibility to reinforcement. Theory, reason, and scientific evidence indicate thng with childbirth and early postpartum experiences, can significantly affect subsequent parental behaviors, the child's central environment influence. Evidence strongly suggests that these parental attitudes and behaviors so crucial to the child's ultimate well-being are learned rather than derived instinctually, and therefore they are malleable and can be taught, directed, and corrected. Through education and reinforcement it is possible to encourage parental behaviors and child interactions which are products of feelings of control, competence, accomplishment, understanding, and caring. Similarly we can recognize and work toward replacing attitudes, feelings, and behaviors that express fear, worry, and insecurity about the child. Over the past 50 years major changes have occurred in the practice of obstetrics and newborn pediatrics. Other major changes will necessarily occur as we move toward perinatal regionalization. Changes instigated solely on physiologic data can have unrecognized collateral effects on the psychological component of the childbirth experience. All concerned health care personnel, especially obstetricians and pediatricians, can insist that the importance of desirable mother-father-child interactions be recognized and that practices fostering them be afforded a high priority. I would like to endorse a comment from a recent article by Richmond concerning the advent of behavioral pediatrics by adding that behavioral obstetrics is also "an idea whose time has arrived".