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Biomedical subjects

M S Swartz

Publications and source records attributed to M S Swartz.

At least 37 records · Page 2Linked to original sources
PubMed1995

New directions in research on involuntary outpatient commitment.

OBJECTIVE: Involuntary outpatient commitment has been used as a method of improving tenure in community programs for individuals with severe and persistent mental illness. This paper reviews literature on research about involuntary outpatient commitment and suggests questions and methods for future research. METHODS: Literature describing research studies of involuntary outpatient commitment, located by searching MEDLINE and following up references cited in relevant articles, was reviewed with attention to patient characteristics and diagnostic, treatment, and outcomes measures. RESULTS: Involuntary outpatient commitment appears to provide limited but improved outcomes in rates of rehospitalization and lengths of hospital stay. Variability in community treatment makes interpretation of other types of outcome difficult. Few studies specifically identify results among patients with severe and persistent mental illness. CONCLUSIONS: No studies have examined the extent to which outpatient commitment affects compliance and treatment when essential community services such as case management are consistently and aggressively provided, nor have studies controlled for potentially confounding factors such as treatment and nontreatment effects, including informal coercion. A randomized trial of involuntary outpatient commitment should be useful in evaluating the effectiveness of this type of intervention.

Ambulatory Care↗
PubMed1994

The relationship between insurance coverage and psychiatric disorder in predicting use of mental health services.

OBJECTIVE: This study investigated how insurance coverage for mental health services affects outpatient mental health service utilization among those with and among those without a DSM-III psychiatric diagnosis. The authors used a representative community sample to compare the regression effects of insurance coverage on utilization of mental health services among these subjects. METHOD: Data are from the second wave of the Piedmont, North Carolina, site of the Epidemiologic Catchment Area project. These data contain DSM-III diagnostic measures derived from the National Institute of Mental Health Diagnostic Interview Schedule as well as measures of insurance coverage and utilization. Responses from 2,889 community residents were analyzed using both ordinary least squares and logistic regression. RESULTS: In both models, insurance coverage was strongly associated with care among those with as well as among those without a psychiatric disorder. The association between coverage and the probability of care was strongest among those with a disorder. CONCLUSIONS: The findings are not consistent with the claim that failing to provide insurance coverage will reduce discretionary but not necessary mental health care utilization. They provide evidence that failing to provide insurance coverage will reduce utilization as much or more among those with a psychiatric disorder as among those without. This result has important implications for health care reform.

Adult↗
PubMed1994

The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey.

OBJECTIVE: Major depression is a frequent and disabling psychiatric disorder in the United States. This report examines the prevalence and risk factor profile of both pure and comorbid major depression according to data from the National Comorbidity Survey. METHOD: To estimate the prevalence of psychiatric comorbidity in the United States, a national sample of 8,098 persons 15-54 years of age from the 48 conterminous states was surveyed with a modified version of the Composite International Diagnostic Interview. RESULTS: From the survey data the prevalence of current (30-day) major depression was estimated to be 4.9%, with a relatively higher prevalence in females, young adults, and persons with less than a college education. The prevalence estimate for lifetime major depression was 17.1%, with a similar demographic distribution. Both 30-day and lifetime prevalence estimates were higher than estimates from the earlier Epidemiologic Catchment Area study. When pure major depression was compared with major depression co-occurring with other psychiatric disorders, the risk factor profiles exhibited clear differences. CONCLUSIONS: These findings suggest a greater burden of major depression in community-dwelling persons than has been estimated from previous community samples. The risk factor profile showed significant differences between persons with pure and combined major depression.

Adolescent↗
PubMed1993

Deciding to terminate treatment: a practical guide for physicians.

Providing house officers and practicing physicians with annotated, concise, practical guidelines for decisions to terminate treatment is the objective of this report. The study selection and data extraction focused on statutes, regulations, court decisions, medicolegal analyses, clinical studies, and position papers addressing termination-of-treatment issues. To foster a systematic approach, we developed a laminated, pocket-sized card containing a series of questions to be asked by any physician confronted with termination-of-treatment decisions. Systematic identification and deliberate assessment of (1) brain death; (2) the nature, extent, cause, prognosis, and reversibility of impairment; (3) the type of treatment to be withheld or withdrawn; (4) the futility of any proposed intervention; (5) the capacity of the patient for health care decision-making; (6) the evidence of patient's wishes; (7) the proper roles of family members, surrogate decision makers, and other health professionals (eg, ethics committees); and (8) applicable policies, ethics, laws, and potential conflicts of interest will enhance efficiency and add value to the decision-making process at the end of life.

Brain Death↗
PubMed1993

Long-term psychosocial effects of childhood exposure to parental problem drinking.

OBJECTIVE: The effects of childhood exposure to parental problem drinking remain unclear because of inconsistent findings and methodologic difficulties in previous studies. The authors used a large community sample to examine whether exposure to parental problem drinking in childhood was related to a greater number of psychiatric symptoms and impaired social and occupational functioning in adulthood. METHOD: The study used self-report data from the Piedmont Health Survey, a project of the Epidemiologic Catchment Area program, which were collected from a stratified random sample of 2,936 adults residing in a five-county catchment area in North Carolina. The National Institute of Mental Health Diagnostic Interview Schedule was used to measure the subjects' lifetime psychiatric symptoms. Social and occupational functioning were assessed with two scales measuring social support, a scale measuring occupational prestige, and an occupational problem index. Regression analyses were used to determine whether exposure to parental problem drinking in childhood was associated with adverse psychosocial outcomes in adulthood. RESULTS: Adults who had been exposed to parental problem drinking in childhood were more likely to manifest psychiatric symptoms and marital instability, but they showed no difference from the rest of the sample in occupational functioning. CONCLUSIONS: Exposure to parental problem drinking in childhood is positively associated with specific adverse effects in adulthood even after controlling for other confounding childhood risk factors.

Adaptation, Psychological↗
PubMed1990

Social outcomes related to age of onset among psychiatric disorders.

Analyses are presented that examine the impact of a diagnosis of affective disorder, anxiety disorder, and substance abuse before and after age 20 on multiple measures of education, socioeconomic and employment status, childbearing, marital status, and instability in a random sample (N = 3,000) of community respondents from the Piedmont Health Survey. Results indicate that all categories are associated with social outcomes regardless of age of onset, particularly for marital and family outcomes. For socioeconomic outcomes, the correlates of anxiety disorder are more pervasive, and the effects of a substance abuse diagnosis are stronger for early onset.

Adolescent↗
PubMed1989

Antisocial and related disorders in a southern community. An application of grade of membership analysis.

Symptoms of antisocial personality disorder (ASPD) and of psychiatric conditions reported to be related to ASPD were subjected to grade of membership analysis, a relatively new procedure for medical classification, to identify the pure types that would empirically emerge in the absence of prior assumptions about the clustering of those symptoms. The sample consists of 914 respondents who participated in the NIMH Epidemiologic Catchment Area Program at the North Carolina site. Symptom and diagnostic data were obtained using the Diagnostic Interview Schedule. Seven pure types emerged from the grade of membership analysis. Two pure types closely resemble the DSM-III portrait of ASPD. Two other pure types consisted of alcohol abuse/dependence symptoms and indicators of illicit drug use for recreational purposes. Only two of the symptomatic pure types were common among women. The first of these was characterized by marital instability, other domestic problems, and employment difficulties; as such this type resembles the DSM-III description of borderline and/or histrionic personality disorder. The other female pure type was characterized by multiple symptoms of depression and selected symptoms of other axis I disorders. The final pure type was characterized by an absence of psychiatric symptoms and served as a comparison group against which the symptomatic pure types were compared.

Adolescent↗
PubMed1989

Identification of borderline personality disorder with the NIMH Diagnostic Interview Schedule.

No lay-administered interviews are currently available to identify persons with borderline personality disorder. The authors studied 79 subjects with the NIMH Diagnostic Interview Schedule (DIS), a lay-administered interview, and the Diagnostic Interview for Borderline Patients (DIB) and used the results to construct a DIS-based diagnostic index to identify borderline personality disorder. Using the clinician-administered DIB as the diagnostic standard, the authors found that the DIS borderline index had a sensitivity of 85.7%, a specificity of 86.2%, and a kappa of 0.67. The DIS borderline index is a promising extension of the DIS that will facilitate studies of borderline personality disorder in clinical and community settings.

Adolescent↗
PubMed1989

Oscillations of attachment in borderline personality disorder.

The authors propose that oscillations of attachment in borderline personality disorder stem from a central problem with regulation of interpersonal distance. This problem derives from borderline patients' conflicts between fears of abandonment and domination. When they move closer to others, they fear that they will be dominated; when they move away, they fear that they will be abandoned. Whichever direction they move, they experience negative feedback. This gives rise to recurrent oscillations between attachment to and detachment from others. Because the oscillations are reinforced by the ambivalent reactions of significant others and the involvement of third parties, family therapy is often indicated.

Borderline Personality Disorder↗
PubMed1988

AIDS testing and informed consent.

This article examines whether hospitals should obtain specific informed consent for HIV testing in addition to the general consent for routine procedures that is obtained upon admission. The article argues that specific consent should be obtained in all instances in which the HIV test is ordered. When the test is ordered to protect health care workers rather than to benefit the patient, the patient must be informed of the true purpose of the test: special care must be taken to avoid claims of fraud or duress that might invalidate the patient's consent. Furthermore, testing patients for the sole purpose of protecting health care workers should be discouraged, since the protection of health care workers can already be accomplished through universal blood and bodily fluid precautions. In balancing the inconvenience caused by universal blood and bodily fluid precautions against the privacy rights of patients, the patients' rights should prevail.

AIDS Serodiagnosis↗
PubMed1987

What constitutes a psychiatric emergency: clinical and legal dimensions.

In true medical emergencies, informed consent is presumed or implied without application of the usual standard. In the litigation over the right to refuse treatment in psychiatry, a limited right for involuntarily committed patients to refuse treatment has been upheld, absent a finding of a psychiatric emergency. Increasingly, clinicians may find that their sole extrajudicial option in instituting treatment over the patient's objection is in invoking a psychiatric emergency. The purpose of this communication is to discuss the clinical and legal issues in defining and invoking a psychiatric emergency in treatment refusal. The substantive and procedural issues in the use of the emergency exception in treatment refusal are discussed with recommendations for their use in clinical practice.

Adult↗
PubMed1987

A study of somatization disorder in a community population utilizing grade of membership analysis.

A new multivariate analytical technique for the analysis of medical classification, Grade of Membership analysis, is utilized to examine somatization disorder in a community population. The authors examine whether somatic symptoms will cluster into a clinical syndrome resembling somatization disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), if no prior assumptions are made about the inter-relationship of somatic symptoms or their clustering into clinical syndromes. Using respondents in the US National Institute of Mental Health Epidemiologic Catchment Area project of the Piedmont Region of North Carolina, Grade of Membership analysis was applied to all respondents reporting 3 or more somatic symptoms from the somatization disorder section of the Diagnostic Interview Schedule. Seven 'pure' types, roughly analogous to clusters in cluster analysis emerged from the analysis. One 'pure' type in the analysis is nearly identical to DSM-III somatization disorder and is associated with demographic characteristics found among patients with DSM-III somatization disorder. The results indicate that symptoms associated with somatization disorder cluster in a highly predictable fashion and represent a strong validation of the natural occurrence of an entity resembling somatization disorder.

Adult↗
PubMed1986

Emergency room management of conversion disorders.

The authors present guidelines for diagnosing and managing conversion disorders in an emergency room setting. Assessment of the patient must be based on a careful physical and psychiatric evaluation that will identify any underlying physical illness or concurrent psychopathology. An accurate assessment is also vital to the clinician's decision about whether to use simple supportive interventions, to refer or hospitalize the patient, or to try to uncover the conflicts generating the conversion symptoms. If there are no contraindications to uncovering the conflicts, such as chronic symptomatology or a pathological family network, the clinician may use such techniques as hypnosis or a sodium amytal interview.

Adult↗
PubMed1982

A case of intermittent delirious mania.

The authors present a case of intermittent delirious mania in a hypomanic man. Studies revealed no other cause for the delirium, and it remitted with lithium carbonate therapy.

Affective Disorders, Psychotic↗