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PubMed1983

From asylum to community. The threatened disintegration of public psychiatry.

Before 1950, publicly supported psychiatric services (i.e., those of so-called public psychiatry) were provided primarily at state hospitals. Over the past 30 years public psychiatry has shifted its emphasis away from long-term custodial care to outpatient and community-based services. Paradoxically, this broadening of focus has become associated with both an expanded use of psychiatric services and a threatened decline in clinical standards and treatment goals. Five areas of policy confusion and contradiction threaten the stability of public mental-health services: the shift in emphasis from public to private services, the issue of rehabilitation and reintegration into society versus custodial care, the differential treatment of the lower-class patient, the demedicalization of public services, and conflict between professionals and blurring of roles within the psychiatric profession. These problems reflect public psychiatry's overemphasis on social reform and political rather than clinical definitions of treatment, its lack of specific treatment and of defined treatment goals, and its inability to change psychiatry's (and society's) historical assignment of low status to the public patient.

Community Mental Health Centers↗
PubMed1984

Effectiveness of a geriatric evaluation unit. A randomized clinical trial.

We randomly assigned frail elderly inpatients with a high probability of nursing-home placement to an innovative geriatric evaluation unit intended to provide improved diagnostic assessment, therapy, rehabilitation, and placement. Patients randomly assigned to the experimental (n = 63) and control (n = 60) groups were equivalent at entry. At one year, patients who had been assigned to the geriatric unit had much lower mortality than controls (23.8 vs. 48.3 per cent, P less than 0.005) and were less likely to have initially been discharged to a nursing home (12.7 vs. 30.0 per cent, P less than 0.05) or to have spent any time in nursing home during the follow-up period (26.9 vs. 46.7 per cent, P less than 0.05). The control-group patients had substantially more acute-care hospital days, nursing-home days, and acute-care hospital readmissions. Patients in the geriatric unit were significantly more likely to have improvement in functional status and morale than controls (P less than 0.05). Direct costs for institutional care were lower for the experimental group, especially after adjustment for survival. We conclude that geriatric evaluation units can provide substantial benefits at minimal cost for appropriate groups of elderly patients, over and above the benefits of traditional hospital approaches.

Aged↗
PubMed1990

The increased needs of patients in nursing homes and patients receiving home health care.

To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.

Deinstitutionalization↗
PubMed1983

Gaining research access to retarded children in public schools.

The issue of gaining research access to mentally retarded children attending public schools is discussed. Preliminary steps completed prior to conducting a research investigation in the school settings were described within the framework of two independent studies. The important role of the special education teacher in conducting research in the natural environment is delineated.

Child↗
PubMed1989

Moral treatment in asylums and general hospitals in 19th-century America.

Moral treatment, a therapeutic approach that emphasized character and spiritual development, and called for kindness on the part of all who came in contact with the patient, flourished in American mental hospitals during the first half of the 19th century. Many of its essential features also existed then in the treatment of physical illness in American general hospitals. Changing social and welfare services and advances in scientific medicine contributed to a subsequent decline in moral treatment and to a divergence between the therapeutic approaches of the two kinds of hospitals. In recent years, there has been a gradual convergence in their treatment modes. Contemporary social and welfare services are contrasted with traditional moral treatment.

Deinstitutionalization↗
PubMed1984

The schizophrenic no-society revisited.

Twenty years ago in an article in this journal ( Sommer and Osmond 1962), we introduced the concept of the schizophrenic no-society, chracterizing the social organization of long-term mental hospital wards as a society in hich no voluntary social organization occurred among residents. In the intervening years, voluntary social organizations among schizophrenic persons which were lacking in mental hospitals in the 1960s or whether the concept of the schizophrenic no-society is still a valid one.

Chronic Disease↗
PubMed1990

Improving treatment for the severely mentally ill: implications of the decade-long Italian psychiatric reform.

Recent reviews of the results of the important Italian Psychiatric Reform have been unusual in that they have ranged from very enthusiastic to very negative. No recent report has focused on extrapolating from the Italian experience the pluses and minuses that might be applicable to the U.S. system of delivery of mental health services so as to improve the care of the seriously mentally ill. In this paper I will summarize my observations and clinical research during 6 months in Italy, emphasizing what has not been reported by others; I will analyze the impact of the Italian changes on Italian practice and try to identify in a balanced way any inferences that can be drawn from the Italian experience that add to ideas now current in the United States about treatment of the severely mentally ill.

Chronic Disease↗
PubMed2006

Using electronic patient records in mental health care to capture housing and homelessness information of psychiatric consumers.

Homelessness among people with psychiatric illness is at an all time high. Many explanations for this phenomenon exist, including the incidence of discharge from inpatient hospital directly into the streets or shelter system. With little known about this unseen social issue afflicting many mental health consumers, this manuscript provides recommendations for using electronic patient records (EPR) as a conduit to capture housing and homelessness related information. With the increased use of EPRs in the Canadian health care system, the research and clinical benefits of this technology have only recently begun to be realized in mental health care.

Canada↗