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PubMed1988

Monitoring and predicting community mental health centre utilization in Auckland, New Zealand.

Deinstitutionalization of mental health care has been in progress in many countries for over a quarter of a century. A comprehensive and detailed literature has evolved focussing on this process and its implications for alternative forms of combatting the incidence of mental illness. Most notably, literature has concentrated on the need for community-based mental health services both to prevent hospitalization in the first place and to ease the return of the hospital patient into the outside environment. In this paper the evolution of such a community-based system in metropolitan Auckland, New Zealand is discussed. More specifically, the focus is on the utilization of four community-based centres, with a view to plan better growth or reduction of service provision. Two dimensions of centre use, spatial and sociodemographic, are analysed and incorporated into four predictive models that, with appropriate refinement, can be used to determine the likely level of centre use in unserviced parts of the metropolitan area. Distance of individuals from centre locations is shown to be a significant factor in affecting use for three suburban primary prevention and intervention centres, whilst distance is non-significant for an inner-city aftercare facility. Also, various combinations of socio-demographic variables, reflecting service-specific needs for specific groups in the population, are shown to contribute significantly to predicting centre use. The paper presents the results against a policy backdrop in New Zealand where community mental health services are very much experimental in nature. The results reaffirm the importance of community mental health care in fulfilling an important need in society that health care administrators should take seriously in future policy developments.

Adolescent↗
PubMedDate not supplied

Schizophrenia: Emil Kraepelin, Adolph Meyer, and beyond.

Prior to 1800, insane persons often lived on the streets or were incarcerated in asylums, jails, or prisons. The 19th century witnessed progression in the understanding of psychosis, and the hospital management of psychotic patients began. While Kraepelin in Europe described the symptoms of what would later be called schizophrenia, Meyer developed humanistic treatment for the illness in the United States. The early 20th century treatments for schizophrenia included insulin coma, metrazol shock, electro-convulsive therapy, and frontal leukotomy. Neuroleptic medications were first used in the early 1950s. Deinstitutionalization, beginning in the 1960s, resulted in medicated, stable schizophrenics being released from state hospitals. However, lack of stable living arrangements, misuse of funds, poor medical follow-up, and drug use resulted in deterioration of a large segment of this outpatient schizophrenic population. The 1990s have seen the development of newer, more effective antipsychotic agents and managed care. Both have impacted the state of health of schizophrenics in our society.

Europe↗
PubMed1999

Medication discontinuation and symptom provocation in research: a consumer and family perspective.

Research involving symptom provocation and medication discontinuation, although common throughout medicine, raises some significant issues for consumers and family members facing severe mental illnesses. Reasons for our attention to these research approaches include the apparent prevalence of this research; the prospect of significant distress, illness, or disability, especially in the event of medication discontinuation; questions about the scientific strength of at least some challenge studies; the changing nature and pressures on research, including its "deinstitutionalization," and the increasing role of private funders; early evidence of consumer concerns about medication discontinuation; the possibility of long-term damage as a result of delayed treatment; concerns about subject recruitment methods and the adequacy of informed consent for these studies; and the lack of data concerning consumer experience and outcome from this research. Because research involving symptom provocation and medication discontinuation can present significant risks to the consumer participating in the study, we must take steps to make sure of the following: that the use of this research methodology be minimized as much as possible; that it meets the very highest standards of scientific merit and necessity; that it includes the strongest possible protections for human subjects, including optimal informed consent about the nature and risks of the study and communication with care-giving family members and others; that in discontinuation studies research protocols precisely spell out in advance the clinical situations that will trigger intervention and what the intervention will be, and furthermore, that discontinuation studies should assure adequate clinical monitoring for early identification and treatment of signs of clinical distress or deterioration; and that researchers should begin systematically collecting and publishing information on the outcomes for and experiences of consumers in these types of studies. Enhanced oversight of these research protocols, by funders and IRBs is essential. Finally, our consideration of these issues has raised concerns for us about recruitment methods, which warrant examination; and we would like to see attention to placebo control use, insofar as it is necessary to show new medications are effective.

Consumer Advocacy↗
PubMed2003

Maximizing the synergy between pharmacotherapy and psychosocial therapies for schizophrenia.

Although the traditional antipsychotic medications were a major advancement in schizophrenia therapeutics and made possible the era of deinstitutionalization, just maintaining a patient out of the hospital no longer can be viewed as the final goal of treatment. Most patients are able to maintain outpatient status despite persistent psychotic symptoms, pervasive negative symptoms and poor social competence. It is hoped that the availability of the atypical antipsychotic drugs will improve significantly compliance, treatment of symptoms, and possibly relapse rates and overall outcome. It should be the norm and not the exception for patients to be treated with these new medications as early as possible in their illness. The clinician should not be complacent and quick to accept persistent psychosis, and patients with various forms of treatment resistance should be tried early in the course of illness with clozapine (or other medications as they become available if they show superiority for treatment-resistant patients). Pharmacologic interventions aimed at deficit symptoms may become available in the future. Psychosocial interventions have a place in the modern therapeutic armamentarium. Relatively simple sustained family interventions and more comprehensive ACT programs are effective for relapse prevention and reduction of the "revolving door syndrome," whereas patients with psychosis nonresponsive to medication may benefit from new modalities of CBT. For patients with persistent negative symptoms and limited social competence, SST is indicated where available, and even in places where staff may be limited and social skills and other programs difficult to implement, family psychoeducational interventions can be carried out to good effect.

Antipsychotic Agents↗
PubMed2005

Mortality among patients with schizophrenia and reduced psychiatric hospital care.

BACKGROUND: There are suggestions that mortality, especially that due to suicide, increases among schizophrenia patients during a period of declining psychiatric beds. We investigated the mortality of schizophrenia patients in the general population of Finland during the reduction of psychiatric beds during 1980-1996. METHOD: Patients hospitalized for schizophrenia before 31 December 1996, and alive on 1 January 1980 (n = 58761) were identified via the National Hospital Discharge Register. General population data came from the National Population Register, and mortality data from the National Causes of Death Register. We calculated relative risks (RR) for total mortality, mortality due to natural causes (cancer, ischaemic heart disease, respiratory disease), unnatural causes (accident, homicide, suicide), and suicide. RESULTS: Patients with schizophrenia had an increased mortality both from natural causes (RR 2.59, 95% CI 2.55-2.63) and from suicide (RR 9.9, 95% CI 9.43-10.30). The RR for both natural and unnatural deaths was highest among patients with < 5 years since onset of schizophrenia. Among them all-cause mortality rose in the 1990s, but decreased among patients with > 10 years from onset. Otherwise no major changes or linear trends were found in mortality during deinstitutionalization. CONCLUSIONS: Reduction of psychiatric beds did not generally increase the mortality of patients with schizophrenia. However, patients in their early years of illness experienced increased mortality after the steepest bed reduction. Improved recognition and treatment of somatic illness would benefit patients with schizophrenia.

Adolescent↗
PubMed2001

Quality of life in boarding houses and hostels: a residents' perspective.

In the last forty years deinstitutionalization has transferred the care of people with a serious mental illness from the psychiatric hospitals to community based facilities. More recently it has been questioned whether these new facilities offer the anticipated benefits of quality of life. This study examines the Quality of Life (QOL) of people diagnosed with schizophrenia living in two different accommodation facilities, hostels and boarding houses. QOL is examined from the resident's perspective. Lehman's (1988b) QOL Interview was used to measure objective, subjective, and global QOL of 60 participants in three hostels and two boarding house clusters. Hostel and boarding house data were compared and results showed that residents preferred boarding house accommodation. Overall, residents of both accommodation facilities reported satisfaction with QOL, and indicated that they regard them as asylum or sanctuary from the outside world.

Adult↗
PubMed2001

Mental health service provision in England.

OBJECTIVE: To describe mental health service provision for adults of working age in England. METHOD: Services in an inner London area are described so as to illustrate current patterns of service organization in England. National trends are then discussed. RESULTS: Despite relatively low public expenditure, substantial progress has been made in deinstitutionalization and development of comprehensive community-based services. Persisting difficulties include high staff turnover, a minority of patients. who do not engage with community services, user and carer dissatisfaction with emergency services, and social exclusion because of stigma. Recent government policy advocates resolving some of these problems using new service models such as assertive outreach and crisis teams. CONCLUSION: Closure of the large asylums has largely been accomplished. England is now entering a new phase in community service development, with a range of innovative developments aimed at resolving problems still encountered after the initial phases of integrated community service development.

Adult↗
PubMed1989

Public and private responsibility for mental health services.

Relative to public services, private sector corporate mental health care has significantly increased since the late 1960s. The many tensions encountered in assigning public and private responsibility for mental health service give rise to significant value-laden questions for psychologists. These questions go to the heart of community mental health, deinstitutionalization, mental health policy development and evaluation, and many other areas in which psychologists are playing major roles. The public-private issue should be understood historically, from the twin vantage points of developments in general medicine and in mental health. Among the many public interest and public policy matters psychologists and others concerned with mental health should address are the emergence of corporate chains; the nature, cost, and quality of private sector services; the compatibility of profit motivation and the motivation to provide care; and patient selection issues (e.g., cream-skimming). Public and private cooperation and planning are certainly in order if the public interest is to be served in addressing the nation's mental health problems.

Community Mental Health Services↗
PubMed2000

Parenting among mothers with a serious mental illness.

In the past few decades, deinstitutionalization and community-based rehabilitation and support programs have increased the likelihood that women with serious mental disorders will be parents and will raise their children. This review describes what is known about the parenting of these women, focusing on diagnosis, child characteristics, and other contextual effects.

Child↗
PubMed2001

"Simply to be let in": inclusion as a basis for recovery.

This article takes its inspiration from a poem by Borges, in which the author makes a plea to simply be "let in" without being wondered at or required to succeed. Based on the view that these issues have applied historically to people with mental illnesses--first during the period of the asylum, and now more recently as a result of deinstitutionalization--this article argues for the adoption of a broad conceptual framework of inclusion that, based on a disability paradigm, neither alienates or requires people to succeed. First, the ways in which such a framework augments existing approaches to treatment, rehabilitation, and recovery are outlined. Next, the authors describe the three elements of friendship, reciprocity, and hopefulness as aspects of inclusion that may provide a foundation for efforts toward recovery, and illustrate each of these elements through the stories of participants in a supported socialization program. Implications for future research and policy are suggested based on these data.

Convalescence↗
PubMed2001

Meeting the needs of consumers in the community: a working partnership in mental health in New Zealand.

AIM: The aim was to evaluate whether the services community mental health nurses provide are meeting the needs of consumers in the community. RATIONALE: The role of the mental health nurse in the community is changing as a result of deinstitutionalization, the consumer movement and the market model of health care delivery. In this context it is important for mental health nurses to evaluate whether the service they are currently providing is meeting the needs of consumers. DESIGN: This was a joint project between nurses and consumers. It was a service-specific descriptive research project utilizing qualitative methods of data collection and analysis that provides a model for working in partnership. FINDINGS: The results of this research identify collaboration in planning care and sharing information as two areas of concern but generally the consumers were very satisfied with the care provided by community mental health nurses. The analysis of the data suggests that consumers value nursing care because nurses provide support in their own home; they help consumers develop strategies for coping with their illness and their life; they provide practical assistance when it is required; they are vigilant about any deterioration or improvement; and they are available and accessible. CONCLUSION: The results of this study have demonstrated that nurses will remain critical to the success of community-based care because of their ability and willingness to be flexible to the demands of their own organization and the users of services.

Adult↗
PubMed2004

Quality of life of clients with schizophrenia.

BACKGROUND: Because of the deinstitutionalization of mental health care in Hong Kong that has taken place since the 1980s, many people with mental health problems are being cared for in the community. The majority of clients have a diagnosis of schizophrenia, and many have a long duration of illness and multiple readmissions. There is concern about their quality of life. AIM: To investigate quality of life and related factors in clients with a diagnosis of schizophrenia in Hong Kong. DESIGN: A convenience sample was recruited from a psychiatric outpatient department. Structured face-to-face interviews were conducted using the Brief Psychiatric Rating Scale and the Hong Kong Chinese World Health Organization Quality of Life Scale-Brief Version. RESULTS: A total of 172 people participated in the study. Most of them were single and unemployed. They were least satisfied with their psychological health, financial situation, life enjoyment and sexual activity. Women (n = 91) reported less satisfaction with quality of life than men (n = 86). Unemployed people (n = 100) were less satisfied with their quality of life than the employed (n = 76). Higher levels of mental health problems and higher numbers of previous hospitalizations were associated with negative perceptions of quality of life. DISCUSSION: People with mental health problems had significantly less satisfaction with their quality of life than a sample from the general population in Hong Kong surveyed in a previous study. As well as experiencing distressing mental symptoms, they had many difficulties, such as financial problems, unemployment and lack of opportunities to participate in social activities, that resulted from stigma and discrimination. These had a great impact on their quality of life. STUDY LIMITATIONS: Because of the small sample size and its convenience nature, the findings may not be generalizable to all clients in Hong Kong. A generic instrument was used to measure quality of life, and this may not have been sensitive to certain aspects of mental health clients' lives. CONCLUSION: The findings suggest that there is a need to strengthen social and vocational rehabilitation for people with mental health problems in Hong Kong. A more holistic and intensive model of care is required to meet their complex needs. A larger and more diverse sample should be used in future research, and a quality of life measure specifically designed for people with mental health problems should be used.

Adolescent↗
PubMed2002

Research and literature on sex offenders with intellectual and developmental disabilities.

The present paper sets out to review the literature on several aspects of sex offenders with intellectual and developmental disabilities, including the relationship between sex offending and developmental disabilities, the prevalence and characteristics of sex offenders in this client group, assessment, treatment, and outcome of intervention. Several important variables were identified as influencing the disparate results found in different prevalence studies. These include variations in inclusion criteria, differences in the source of the sample, differences in determination of IQ, the impact of deinstitutionalization, and the effect of changing social and penal policies in the area where studies have been conducted. Although some studies have suggested an increasing incidence, there is no clear evidence for the over- or under-representation of people with developmental disabilities amongst sex offenders. One of the main methodological flaws in several reports listing the characteristics of sex offenders is that considerations are based on clinical samples. Therefore, there is no control group to show that these characteristics do not exist in other samples of individuals with intellectual disability (ID). It does appear that sex offenders with ID are more likely to commit offences across categories and to be less discriminating in their victims. There may also be an association with sexual abuse in childhood. The primary issue considered has been assessment of competency, in that people with ID are considered to be disadvantaged by the criminal justice process. While several authors have delineated the important areas for assessment, there are few assessment measures with robust psychometric properties. Pharmacological, behavioural, educational and cognitive treatments are reviewed. Several comprehensive treatments which include all of the aforementioned methods are also considered. Although most studies do not report particularly positive outcomes, several authors have found better outcomes with treatment lasting at least 2 years.

Cross-Sectional Studies↗
PubMed2001

Protection and advocacy: an ethics practice in mental health.

This paper reports the findings of investigations into allegations of patient abuse and the implications for policy and practice. These investigations were carried out by a nurse with a background in ethics for the office of Protection and Advocacy for Individuals with Mental Illness (PAIMI), a state agency operating under a United States federal law entitling it to investigate complaints by psychiatric patients. PAIMI uses investigations both to help individuals and to provide an avenue for broader change. There are four steps in the investigation process: (1) definition of the problem; (2) gathering information; (3) synthesis; and (4) addressing the problem. Cases are presented to illustrate the investigation process and identify ethical issues arising in mental health treatment. Among the issues raised are autonomy and forced treatment, deinstitutionalization, bias against the mentally ill, privacy, and surrogate treatment decisions. Resolutions range from providing individual advice to clients or clinicians, to changes in institutional policy and the publication of guidelines for specific situations. The following lessons were learnt from the investigations: (1) tell patients what to expect; (2) pay attention to the process of giving care; (3) allow patients to feel ambivalent about treatment; and (4) work to develop good relationships; underlying every investigation has been a poor relationship.

Adult↗
PubMed2001

A plea for respect: involuntarily hospitalized psychiatric patients' narratives about being subjected to coercion.

Eighteen involuntarily hospitalized psychiatric patients narrated their experiences of being subjected to coercion and their thoughts on how to prevent the coercion. A qualitative content analysis identified recurring themes, which were incorporated in two core themes describing the participants' experience. The core theme Not being respected as a human being included most of their narrated experiences, described in the themes Not being involved in one's own care, Receiving care perceived as meaningless and not good, and Being an inferior kind of human being. The core theme Being respected as a human being included a minor part of the narrated experiences and how the participants wanted things to be, described in the themes Being involved in one's own care, Receiving good care, and Being a human being like other people. The participants' plea for respect is discussed in relation to the ongoing deinstitutionalization of psychiatric care and the need for attitude changes in care and community, leading to the treating of mentally disordered people with more respect.

Adult↗
PubMed2000

Permanent and stable housing for individuals living with a mental illness in the community: a paradigm shift in attitude for mental health nurses.

The provision of appropriate housing for individuals with a mental illness has been recognized by a number of researchers as a means to enhance effectiveness of treatment and rehabilitation services, to maintain treatment gains, and to decrease community opposition to deinstitutionalization. Whether community-based services, which are now meant to be the focus of treatment, are successful or not is crucially related to the nature and availability of accommodation. This paper argues a case for change in the current philosophical basis of, and services provided by, mental health professionals and agencies that are charged with the responsibility of meeting the housing needs of consumers of mental health services. This change, it is contended, needs to be to an approach that is more flexible, more supportive of the consumer, and in which the consumers are empowered to make decisions and choices about their housing needs.

Attitude of Health Personnel↗
PubMed2004

[Changes in the provision of psychiatric services at a psychiatric district hospital].

Changes in the provision of psychiatric services within the last decennials are probably best understood if the impact of national socialism on clinical psychiatry is regarded. Many psychiatrists took part in the "Aktion T4" the organised killing of their patients, at least they did not resist campaigns directed to killing or sterilisation patients. After WW II, a period of silence and acceptance of inhuman circumstances in the large mental state hospitals appeared, when in the sixties a new generation of psychiatrists was no longer willing to continue the traditional system of mental health care delivery. The Expert Commission on Mental Health Care reported a comprehensive agenda on reformation of service delivery in 1975, which was influential in the development of alternative structures of psychiatric services. Most mental state hospitals reduced their capacities and parallel to this process smaller units, devoted to principles of community psychiatry, associated to general hospitals were created. Overall, the number of hospital driven beds decreased at about 33 %, but in the large hospitals at two thirds within the last 25 years in Baden-Wurttemberg. This process of deinstitutionalization was accompanied by the development of structures for community care, internal reorganization and modernization, and important steps in budget development, which lead to better treatment opportunities for all kinds of psychiatric institutions. The concrete and historical reality of these circumstances and changes, and possible future directions are exemplified for the psychiatric hospital in Weinsberg.

Delivery of Health Care↗
PubMed2005

[Social exclusion of the mentally ill -- a critical review and outlook of community psychiatry at the beginning of the 21st century].

The social implications and disabilities of long-term mental disorders have been well described and are known for a long time. The classical paradigm of social psychiatry postulating that dehospitalization automatically generates social integration has proven to be wrong. Along that line the view that living in the community supported by different services aiming at integration has also failed to be successful. Without explicitly labelling it: community-based psychiatry has yielded a psychiatry-based community. It never served the majority of the non-chronically mentally ill with disordered social skills who also need specific support or are as well bound for unemployment and social disadvantages. Without doubt, the progress made by community psychiatry in the past was eminently linked to the ideology and implementation of deinstitutionalization. Defining and dealing with social exclusion means a turning point for social and community psychiatry - a new paradigm that could generate a different view upon therapeutical outcomes and the way that therapy and rehabilitation have to be organised and implemented. Especially the example of vocational rehabilitation could mark a stepping stone by initiating further investigations and progress for new approaches in community support. Supported employment programmes have shown the superiority of "place and train" instead of first train in institutions or services and then place on the spot. Thus a so-called inclusion therapy could arise that takes place "in vivo et actu" and near to the individual's real world of tasks and demands. Progress in any part of multidimensional therapy is legitimized only by empirical validation of functional outcome and social inclusion measures. Such an evaluation of complex programmes taking social inclusion into account is sophisticated but seems to be necessary in the field of general psychiatric therapies as well as for the legitimation of financial resources needed. Foreseeing the perspective of social psychiatry a next substantial step could be the identification of social and functional outcome variables.

Bias↗