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This chapter looks at the research on environmental factors at community level and speculates on innovations that could reduce the occurrence of schizophrenia, improve its course, and enhance the quality of life.
There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.
Professionals who operate from a clinical rather than a political ethic must be prepared to reclaim and accept leadership roles and responsibilities, which have shifted to the political arena.
Over the past ten years, FSH has seen the initial implementation of the SLP grow from a single ward in the maximum-security forensic unit to include three additional wards within that unit, two wards on the medium-security forensic unit, and two wards within the general adult psychiatric service. There are now four FSH group homes, which admit clients from the hospital's forensic as well as nonforensic populations. Six to eight clients live in each home and function in a relatively self-sufficient manner, and many more (including forensic clients) have been discharged from the group homes and now live independently in the community. They work in supported employment or competitive job settings and manage their own households. Several of our discharged clients even return to visit us from time to time. The FSH administration remains solidly committed to being a rehabilitation-ready facility. We have had a number of positive outcomes over the years (Baldwin and others, 1992; Beck and others, 1991; Beck and others, 1997; Finnell, Card, and Menditto, 1997; Menditto, Baldwin, O'Neal, and Beck, 1991; Menditto, Valdes, and Beck, 1994; Menditto and others, 1996; Menditto, Beck, and Stuve, in press; Pestle, Card, and Menditto, 1998), and we regularly host visitors from other state hospitals seeking consultation on how to make their own facilities rehabilitation-ready. Recently, we were featured on a segment of the nationally broadcast medical education program psychLINK (Glazer, 1998), where it was suggested that rehabilitation programming models such as ours represent the future of state hospitals. The "Not Ready for Rehab Players" think so too.
Ultimately, the outcome and cost-effectiveness research should convince a compassionate public that rehabilitation is worthwhile, wherever it takes place.
If the law provided for accessible and efficient means to facilitate mental health treatment, the law itself could be a component of the comprehensive care system.
Assertive Community Treatment and related approaches will have a defining impact on state hospitals, now and in the future.
There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.
The implementation of a community mental health service in Mannheim (FRG), a city with 315,000 inhabitants, is being evaluated by means of the data of the Cumulative Psychiatric Case Register at the Central Institute of Mental Health. Within a four-year period of extending services for crisis intervention and emergency care, aftercare (sheltered apartments, homes, workshops) and of providing psychiatric beds in the city, the total number of treatment episodes has increased by more than 100% from about 1.1 to about 2.2 per 1000 inhabitants aged over 14, mainly at the out-patient level of care. Admissions to hospital showed an increase of about 40% whereas bed occupancy remained stable at a rate of about 1.7/1000-respectively 1.3/1000 if beds provided by a psychogeriatric nursing home are deducted. This development can be attributed to various factors: (1) A true increase of morbidity may occur mainly in diagnostic groups I.C.D. No.300, 301, 305-308, especially an increase in attempted suicides and in alcohol- and drug-related diseases. (2) The increased provision of help, mainly on the sector of crisis intervention and emergency care and - in diagnostic categories - mainly in minor neurotic disorders, crises, and affective psychoses, has resulted in a large rise in utilization. (3) The continuous decrease of long-term hospital stays, above all in schizophrenic patients, has led to increased utilization of out- and in-patient services in the community when crises and relapses occurred. A comparison of two cohorts of "old" and "new" patients, the latter having accumulated under the conditions of a community mental health service, has shown that these patients are admitted for a long-term hospital stay considerably later and less frequently than formerly, mostly only after several attempts for rehabilitation. In the group of schizophrenic patients, only about 5% of all first admissions stayed in a psychiatric hospital for more than one year in 1979/80. About the year 1900, this group had still amounted to between 60% and 70%. A comparison with evaluations of comprehensive community care systems in other countries shows that there are largely identical trends, although the initial rate for psychiatric beds was comparably lower in Mannheim.
The reliability of Italian suicide data derived from returns made by the Police and Carabinieri was examined by comparing regional suicide data from that source with those based on medically certified cause of death for the years 1973-1980. Rates of medically certified suicide were found to be higher than those derived from the Police/Carabinieri returns, a difference which increased steadily over the years of study. The between-region within-year correlations (between the suicide rates derived from the two sources) were very high, but tended to decrease with time. The between-year within-region correlations were +0.700 or above for 12 of the 19 Italian regions and between +0.500 and +0.700 for a further 3. The correlation between the rates of suicide derived from the two sources was poor for the remaining 4 regions. A previous analysis of the influence on suicide of the Italian psychiatric reform used Police/Carabinieri data (Williams et al. 1986): this was repeated excluding data from these 4 regions, and the previous results were confirmed. Indeed, the negative correlation between suicide and the provision of general hospital psychiatric beds was stronger than that previously reported.
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In 1978 a major psychiatric reform drastically changed the Italian psychiatric system by the closing of admissions to mental hospitals and the development of psychiatric units in general hospitals and of alternative services in the community. The paper presents the results of a study in which two treatment environments set up according to the reform, i.e. a psychiatric unit in a general hospital and a community mental health center run by the same staff, were examined using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environment Scale (COPES). In addition, validity studies of the Italian versions of the WAS and COPES are presented. Both instruments were found to be feasible and useful, easily understood, easy to administer and relatively well accepted by the psychiatric staff. The quality of the two scales has been confirmed by psychometric analysis, with the exception of the independence of scales. No major differences between the two environments emerged, both showing characteristics consistent with the new treatment philosophy.
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This paper reports the results of a study of community acceptance of housing for the mentally ill in Maryland. The findings indicate that community opposition is less likely to occur (1) when establishing apartmental living arrangements rather than group homes, (2) in less organized neighborhoods, (3) where other housing for specialized populations has not been previously developed, and (4) by using a "low profile" strategy which avoids informing community members in advance of start-up.
Legislation of a case management service provided an opportunity to conduct a natural experiment exploring questions about implementation and effectiveness of case management services. A sample of 21 case managed and 21 comparison clients was interviewed using a protocol adapted from the Quality of Life Questionnaire (Fixed Response Alternative version). Results indicate that case managed clients received more services and had fewer unmet service needs. Quality of life was greater for case managed clients, hospital utilization was reduced, and a possible relationship among services, quality of life, and hospital utilization was identified.
This paper describes the demographic, clinical, and psychosocial characteristics of a sample of chronically mentally ill clients at a large comprehensive community mental health center. Utilizing cluster analytic procedures, five basic types of chronically mentally ill clients are empirically identified. The differential pattern of psychosocial characteristics associated with each type is explored and the distinctive profile of each type is delineated. Finally, the implications of this typology for the design of community support treatment programs and allocation of increasingly scarce resources are presented.
There is a growing body of evidence which suggests that normalization is significantly related to improved adaptive functioning among disabled persons. If this is so, then the concept of normalization should be taken into account in program planning. The present study suggests that characteristics of clients such as age and adaptive functioning level contribute to the achievement of high levels of environmental normalization in residential settings, but that characteristics of the residence, particularly its size, and the number of types of disability groups residing in the home, as well as the nature of the community in which the residence is located are even more important than individual characteristics. Some tentative conclusions for planning residential facilities are advanced.