Hospital & community psychiatry最新文献

Objective: The study's aim was to document the economic assistance in the form of money, in-kind contributions, and time spent in care-giving by families of adults with both severe mental illness and substance use disorders.

Methods: A total of 119 families of adults with dual disorders were compared with a similar group of 127 families whose adult children had no chronic illnesses. In telephone interviews, parents reported the amount of money, goods, and direct care family members gave to a designated adult child. Two methods were used to estimate the value of family time: opportunity costs, based on the average wage for production workers in the study area, and the cost of paid substitutes for the task being performed.

Results: Parents of adults with dual disorders reported that family members gave significantly more money and time to the adult child than did parents of adults with no chronic illnesses. The estimated value of family assistance in the dual disorder group was $9,703 using the opportunity-cost method and $13,891 using the substitution method, compared with costs of $2,421 and $3,547 for the group with no chronic illnesses.

Conclusions: Dual disorders impose a significant economic burden on families. Direct support that families provide to adult children with dual disorders should be considered carefully in treatment planning and policy decisions.

Objective: The treatment of suicidal patients contributes to escalating mental health expenditures. Fiscal realities necessitate that cost-containment measures be implemented wherever possible. The authors reviewed the literature to delineate factors that impede cost containment for the treatment of suicidal patients and to outline strategies for controlling costs while improving the quality of care.

Methods: Psychological Abstracts and MEDLINE databases were reviewed. Retrieval and analysis focused on literature published between 1982 and 1992.

Results and conclusions: Five factors unique to the treatment of suicidal patients that impede cost containment were identified: the lack of a specific and cost-effective screening method to determine true risk of suicide, the high number of parasuicidal and malingering patients, revolving-door admissions of involuntary patients who become noncompliant with treatment after discharge, the adverse clinical consequences of further increases in existing discriminatory mental health benefits, and the medicolegal liability incurred in treating suicidal patients. The low frequency of completed suicides in relation to attempts and reported ideation indicates that most inpatients labeled suicidal are hospitalized unnecessarily. Thus inpatient treatment should be reserved for patients who make attempts of high lethality and patients with suicidal ideation who are at high risk because of other factors. Ideally, suicidal patients should be committed not to an inpatient facility but to a treatment network in which they can move appropriately between inpatient, day hospital, and outpatient care.

Objective: This study compared homelessness in New York City and London to examine the relative roles of individual pathology and structural forces in causing homelessness, the effect of sociopolitical and cultural differences on policy decisions toward solving homelessness, and the effect of broader structural forces on service programs for the homeless.

Methods: A review of the scholarly literature and news reports was combined with interviews of staff members and homeless persons associated with various community agencies in London and New York City. Homelessness in the two cities was compared in relation to definition, demography, nonpsychiatric and psychiatric etiological factors, public policy, governmental responses, financial support, service strategies, and the practicalities of securing services and entitlements.

Results and conclusions: The results indicate that characterizations of homelessness as a trait rather than a state reflect the tensions between social justice, public concepts, and a nation's economic resources. The absolute numbers of homeless persons, including those who are mentally ill, primarily reflect structural factors such as the availability of low-cost housing and public benefits. The commonalities that mentally ill homeless persons share with other vulnerable groups generally outweight their differences. The statutory rights to entitlements may be vitiated in times of shortage, especially for the least capable citizens. In both countries, efforts have been made to use the voluntary sector to serve the homeless, although it has been used much more extensively in Britain.

Objective: This study examined the characteristics of families who dropped out and families who maintained contact with a children's psychiatric outpatient clinic through various phases of intake and treatment.

Methods: One year after intake, the authors examined the status of all patients (N = 555) who had sought treatment at an urban, university-affiliated children's psychiatric outpatient clinic over a two-year period and had completed the intake process. Factors associated with dropout were identified at four points in the clinic process: during intake, during evaluation, at completion of evaluation, and during treatment.

Results: Urban residence, minority status, single-parent status, and Medicaid status were related to dropout at intake and during evaluation but not at subsequent clinic phases. Nonminority, two-parent, suburban families of higher socioeconomic status were more likely to drop out at the completion of the evaluation.

Conclusions: These results indicate that factors associated with attrition vary with the clinic phase. Further investigations of the clinical course of minority children and families involved with children's mental health services are necessary to understand the needs of this population and to design interventions such as increasing minority staff and providing training in multi-cultural competence.

Although many clinicians agree in principle that work is central to personal identity and mental health, issues related to patients' experiences in the workplace have not been a central focus in clinical practice in psychiatry. However, the link between work and mental health continues to be confirmed by research, and interest in occupational and organizational psychiatry, which focuses on the psychopathology that the individual brings to the workplace and that results from the individual's experiences in the workplace, has increased in the past decade. The three main areas of practice in the field--direct clinical services, consultation, and applied research--include evaluating work-related psychiatric disability, providing case management for employees who receive psychiatric treatment, evaluating a candidate for an executive position, and conducting epidemiological research about stress-related disorders. A patient's occupational or work history can provide valuable information for routine psychiatric diagnosis and treatment planning.