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PubMed1997

Psychiatric expansionism and social control: the intersectioin of community care and state policy.

Informed by the theories of political economy and professional interests, this research argues that psychiatric commitments to community care and to scientific categorization have contributed to expanding control of the mentally ill, and that these ideological commitments run parallel to and are exacerbated by state responses to macro-economic conditions. Time series analysis of the period from 1932 to 1975 is used to assess the relative impact of deinstitutionalization, medical entrenchment, and state fiscal policy on psychiatric expansionism. The findings demonstrate that a professional interests explanation (indicated by a commitment to community and to science) provides a significant contribution to a materialist-based explanation of expanding psychiatric control.

Health Policy↗
PubMed1990

The relationship between enlargement of the temporal horns of the lateral ventricles and dementia in aging patients with Down syndrome.

Head CT studies of patients with Alzheimer's disease (AD) show global atrophic changes. Tissue loss is especially prominent in the temporal lobes, with widening of the temporal horns of the lateral ventricles and, usually, widening of the temporal sulci. Some recent studies have found a familial form of AD to be mapped to chromosome 21. Down syndrome (DS) results from the inheritance of three chromosomes 21, and it has been shown that after the age of 35 the brains of patients with DS commonly show neuropathological changes similar to those in patients with AD. CT studies of 25 patients with DS (ages 29-64 years) were examined for tissue loss in the temporal regions, and this was compared to the findings commonly seen in patients with AD. The widths of CSF spaces varied considerably in patients with DS, but after the age of 50 most of them showed significant widening of the temporal horns. In some patients the horns were large enough to suggest obstructive hydrocephalus. Because of a new trend toward deinstitutionalization of patients with DS, radiologists will be seeing more studies on these patients and should familiarize themselves with the unique ways in which they manifest the aging process.

Activities of Daily Living↗
PubMed1990

Housing environments and community adjustment of severely mentally ill persons.

This study examined relationships between the quality and appropriateness of housing environments and community adjustment of 729 deinstitutionalized severely mentally ill clients in a state-wide community support service program. Environmental measures included ratings of the physical condition of the client's residence, its adequacy for six key life activities, and the overall appropriateness of the residential setting for the client. Community adjustment measures included global level of functioning, degree of maladaptive behavior and client's perceived quality of life. Evidence is presented that quality and appropriateness of housing environments significantly affect aspects of client's community adjustment outcomes over a nine-month period.

Adult↗
PubMed1992

The mental health HMO: capitation funding for the chronically mentally ill. Why an HMO?

Excesses associated with deinstitutionalization during the 1970s provided a legacy of homelessness, revolving door rehospitalization, and gridlock in metropolitan hospital emergency rooms. To allow for the seriously and persistently mentally ill to move planfully into community life, caregivers must utilize new and improved care models. One option is the HMO capitation model being tested in the Monroe/Livingston County Mental Health Demonstration in New York State. Experience indicates positive results for patients and lower than anticipated costs. Integrated Mental Health (IMH) is the local authority for this locally designed demonstration in New York State. Community Mental Health Centers (CMHCs) act as "Lead Agencies" to manage care and rehabilitation for seriously mentally ill patients previously dependent totally on the State hospitals' services. Both improvements in patient functioning and in reduced cost of appropriate community care are being documented by this demonstration project.

Chronic Disease↗
PubMed1996

CCPP-Copenhagen Community Psychiatric Project. Implementation of community mental health centres in Copenhagen: effects of service utilization, social integration, quality of life and positive and negative symptoms.

Deinstitutionalization of psychiatry in Denmark has been extensive and the number of psychiatric beds per 1,000 inhabitants is among the lowest in Europe. The effect of supplementing hospital treatment with treatment in community mental health centres was evaluated in a quasi-experimental design. The patient group examined consisted of patients with long-term contact with psychiatric services. When development in intervention and control districts was compared, the only significant difference was that the total patient group in the intervention district had an increased number of day attendances per year. Comparison of patients from intervention districts who attended day-centres regularly with patients from control districts before and after implementation of community mental health centres indicated that patients from intervention districts had a reduction in the use of inpatient services, a significant increase in quality of life and a significant decrease in the presence of the negative symptom, alogia. We concluded that implementation of community mental health centres can increase the quality of life for the patients and decrease the frequency of the negative symptom, alogia.

Adult↗
PubMed1990

Family advocacy and the mental health system: the recent rise of the alliance for the mentally ill.

The family consumer movement arose as a response to deinstitutionalization and the removal of stigma from parents of mental health clients. In many states the families are a dynamic force in mental health policymaking. If mental health professionals are to collaborate in support and advocacy programs, they should be aware of the origins and goals of the movement. Through their national organization (AMI), families advocate a biological view of mental illness causation and increased power for the mental health system. If the system is unable to meet parent expectations, it is likely that families will place themselves in competition with existing agencies for available resources.

Adult↗
PubMed1975

The ecology of child treatment. A developmental/educational approach to the therapeutic milieu.

Many residential and day treatment programs for troubled children have experienced only limited success because of their inability to impact the child's total life sphere: family, peer group, school, and neighborhood. This has prompted the present move to deinstitutionalize children's mental health services--a movement which is sound in its underlying purpose, but which sometimes falls prey to the notion that merely altering the location of treatment from the ward or institution to the community setting will dramatically alter its results. It will not. This paper begins with the assumption that the focus of child treatment is as important as the locus and attempts to identify the critical elements in a therapeutic community-based program for the troubled child and his parents.

Affective Symptoms↗
PubMed1995

Case management for schizophrenic patients at risk for rehospitalization: a case control study.

In many countries deinstitutionalization of psychiatric patients is accompanied by fragmentation of care, giving responsibility to an array of different services and providers. One of the possible side effects of this is an increased rehospitalization rate and length of stay. The need to coordinate the services involved for the benefit of individuals has led to the conceptual development of case management. However, despite an apparent belief in the effectiveness of case management, there is only limited scientific evidence to support this assumption. In the case control study presented we compared a group of 97 schizophrenic patients in the aftercare of case management services with a group of patients who received no outpatient care by case management services after discharge from hospital. Each patient in the case-managed group was exactly matched with a control patient with regard to diagnosis and known risk factors for rehospitalization. Additionally, we considered influencing factors that result from general health system conditions such as regional differences and different types of hospital care. Our analyses demonstrate that, during an observation period of 2.5 years, case management had neither a significant effect on the risk of rehospitalization nor on the length of time in hospital in the event of rehospitalization.

Adult↗
PubMedDate not supplied

Variability in community functioning of mothers with serious mental illness.

In the post-deinstitutionalization era, everyday community functioning is an important aspect of assessment and treatment of individuals with serious mental illness. The current study focuses on correlates of community functioning among 332 low-income mothers with serious mental illness. Results revealed significant relationships between everyday functioning and a number of demographic, psychiatric, contextual, and mental health treatment variables. Current psychiatric symptoms accounted for the greatest amount of variance and completely mediated the effects of diagnosis and substance abuse history on community functioning; yet contextual variables such as financial worries and social support were also significant predictors, even after controlling for symptoms and other clinical characteristics. Additionally, use of mental health services was a significant moderator of the effect of social stress on community functioning. Implications of results for future research and practice are discussed.

Activities of Daily Living↗
PubMed1984

General hospital psychiatry in the 1980's.

There has been an increasing amount of attention being given to the role of community hospital based inpatient psychiatric services in the face of changing utilization patterns, state hospital deinstitutionalization and cutbacks in community support programs. These trends have converged over recent years to reshape the nature of psychiatric practice in the general hospital setting. It is likely that these trends will continue throughout the 80's and that general hospital based services will become increasingly pivotal in the care of mental illness at the community level. The challenge facing such programs will be adapt creatively to the changing demands of the market environment while maintaining the integrity of existing programs and coping with the pressures that these changes place on staff.

Community Mental Health Services↗
PubMed1998

Time trends in mental health care utilization in a Dutch area, 1976-1990.

This paper concerns time trends in mental health care utilization in a Dutch area from 1976 to 1990. In general, there was an increase in the use of psychiatric services during the study period, both in terms of the number of new patients (per 1000 population) and in terms of the amount of care utilized per patient. When only intramural services were taken into account the number of new psychiatric patients remained approximately constant, but the number of patients in care at a certain point in time (point prevalence) showed a rising trend. For most part, the increase in inpatient point prevalence rates could be ascribed to the increase in the elderly population (75 years or more). In addition to the proportional increase of the ageing population, a growing amount of psychosocial problems and broadening of the concept of illness were tentatively assumed to be related to the increase in mental health care utilization. Unlike some other countries, deinstitutionalization hardly occurred in the Netherlands.

Adolescent↗
PubMed1999

Patients' perspective on their relatives' involvement in treatment during a short-term psychiatric hospitalization.

With the growing interest in the patient's perspective regarding mental health services, several instruments have been developed for this area of research. However, despite the availability of multidimensional questionnaires, the dimensions evaluated have rarely addressed the issue of the involvement of relatives in treatment. The present study aimed at documenting the preferences and level of satisfaction of 92 patients hospitalized in short-term psychiatric units regarding the involvement of their relatives in treatment. Data was collected using an open-ended question and two standardized scales developed for the purposes of this study. The results demonstrated that the majority of patients preferred that their relatives be involved in many aspects of their treatment. In fact, a relatively high rate of dissatisfaction of 35.6% was observed among patients concerning the lack of notification of their relatives about changes in their treatment. In the context of deinstitutionalization, where relatives are invited to play an increasing role in the community reintegration of the patient, these findings highlight the pertinence of addressing the patient's perspective with regard to treatment planning with relatives.

Adult↗
PubMed2000

Change in Dutch mental health care: an evaluation.

BACKGROUND: In the Netherlands there has been no distinct period of deinstitutionalization or transinstitutionalization of mental health care. Rather, the Dutch government expects local mental health services to reform their joint service provision without forceful measures like cutting budgets of large mental hospitals. This study aimed at quantifying gradual changes in the use of community- and hospital-based care. METHODS: The Groningen psychiatric case register was used to determine the number of users and the amount of use of mental health services. Changes in population size and age distribution were accounted for by means of demographic data. RESULTS: The number of users of innovative psychiatric treatment modalities more than tripled between 1989 and 1997. In the same period, the volume of traditional inpatient care gradually decreased. This was caused primarily by a reduction in the length of stay in the hospital. CONCLUSIONS: These findings seem to support the effectiveness of Dutch substitution policy. However, there is also a cause for concern. Though people use new mental health care provisions, there is a rapidly growing number of them who do so.

Community Mental Health Services↗
PubMed2006

The quality of life of the mentally ill living in residential facilities: findings from a national survey in Italy.

Quality of Life (QOL) is an outcome measure particularly useful to assess the effects of deinstitutionalization policies. To date no large-scale study has been conducted in residential facilities (RFs). Participants included 1492 subjects living in 174 RFs (20% of the total) randomly sampled in 15 Italian regions. Assessment instruments included the WHOQOL-Bref, the GAF, and the Physical Health Index (PHI). WHOQOL scores of residents were compared with those of healthy subjects (N = 65) and outpatients with schizophrenia (N = 162). Multivariate analyses were used to examine the relationship between selected patients' characteristics and WHOQOL scores. Mean WHOQOL scores of residents were similar to those of outpatients with schizophrenia, and substantially lower than those of healthy controls. Lower scores on WHOQOL domains were associated with schizophrenia and non-affective psychoses, unipolar depression, anxiety or somatoform disorders, shorter duration of illness, positive, negative or mood symptoms, lower GAF scores, no participation in internal activities, and PHI score. Our findings are consistent with previous studies. The present study highlights a marked difference between patients in RFs and healthy controls in the social domain. This suggests the need of well-designed rehabilitation plans, tailored to patients' needs, to foster the development of their independence and, ultimately, improve their QOL.

Adolescent↗
PubMed2007

From principles to practice: a study of implementation of supported housing for psychiatric consumers.

In the post-deinstitutionalization era, supported housing has emerged as a housing and service approach considered most conducive to the goal of consumer empowerment and community integration. Although prior research found beneficial effects of supported housing, little empirical work has been done on identifying the gaps between the principles and practice of supported housing. Using multiple data sources on 27 supported independent living (SIL) programs for psychiatric consumers in a large metropolitan community, this paper examines the extent to which these programs are implemented in accordance with supported housing. Findings suggest consistency with as well as deviation from the supported housing approach in regard to consumer choice, typical and normalized housing, resource accessibility, consumer control and provision of individualized and flexible support. This study suggests methods for assessing housing programs for psychiatric consumers along these domains. Implications for the development of housing programs that promote consumer empowerment and community integration are discussed.

Community Mental Health Services↗
PubMedDate not supplied

Progress and issues in the implementation of the 1984 out-of-home care protection amendment.

The purpose of this paper is to assess the status of implementation of out-of-home protection programs since 1984 in the U.S. Data was obtained from a survey of state child protection services (CPS) liaisons in summer, 1989. A framework for viewing protection after placement is presented and the development of policy regarding maltreatment in out-of-home care is traced from its roots in the deinstitutionalization movement. Changes in state statutes and rules, results in out-of-home abuse and neglect reporting, how states operationalize "properly constituted authority" and "independent investigation," the role of licensing in preventing and remediating out-of-home maltreatment, training initiatives and the extent of the use of background checks are reported. A summary evaluation of the status of the implementation of the federal 1984 out-of-home care protection amendments by state agencies is offered.

Child↗
PubMed1996

Excess mortality of psychiatric inpatients in Taiwan.

The 6-year mortality rate of a nation-wide cohort of Taiwanese psychiatric inpatients admitted during the 1-year period from 1987 to 1988 was examined via record linkage. The psychiatric care system in Taiwan is mainly hospital-based. Of the 13,385 patients studied (9309 men and 4076 women), 2039 (1720 men and 319 women) had died by the end of 1993. The standardized mortality ratio (SMR) in this sample (3.10 for men and 4.83 for women) was as high as those reported in western industrialized countries during the pre-deinstitutionalization era. We also examined the relationship between the excess mortality of patients and age, sex, causes of death, diagnostic categories, and length of hospital stay. In general, the SMR was greatest for the youngest age group, women, unnatural deaths, substance use disorders, and in the first year after admission. Although the main cause for the excess mortality was unnatural deaths, there was also an excess mortality due to natural causes across all diagnostic categories. Several recommendations for the improvement of psychiatric care in Taiwan are made on the basis of these findings.

Adolescent↗
PubMed1986

Rings of madness: service areas of 19th century asylums in North America.

The mid-19th century saw the emergence of a major medical innovation, namely, the rise of the state lunatic asylum. Beginning in the northeast, the phenomenon spread rapidly westwards. By 1875 no fewer than 71 mental hospitals were opened in 32 existing states. Although premised upon belief in the efficacy of 'moral and humane' treatment, the asylums soon became custodial rather than therapeutic institutions. Average size continually increased; some accommodated well over 2000 patients. The provision of more asylums, and broadened definitions of insanity, generated increasing patient numbers which, in turn, caused public consternation and fear of increasing 'madness' in the population. Geographic analysis of admissions in 18 U.S. states and two Canadian provinces reveals the universality of distance decay around the asylums, and demonstrates that hospital service-area cones were predominantly local in effect. Thus the 'state' asylum was in reality a local institution. The deinstitutionalization movement of recent decades is apparently bringing to a closure a 100-year cycle of incarceration-decarceration of the mentally ill. Nevertheless, whether patients are geographically concentrated or dispersed, the influence of distance decay remains a relevant consideration.

History, 19th Century↗