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PubMed2001

Reduction of chronic aggressive behaviour 10 years after brain injury.

This study demonstrates the successful management of aggressive behaviour with a client 10 years post-injury in a small, residential neurorehabilitation unit. The case presented is unusual for two main reasons. First, it proved possible to significantly modify previously chronic challenging behaviour many years after brain injury had been sustained. Secondly, the rehabilitation environment in which treatment was conducted did not comprise a highly specialized neurobehavioural service, Instead, staff were specifically trained regarding the administration of the treatment programme, which was based on principles derived from behaviour modification and applied neuropsychology. Specific interventions used included those of differential reinforcement and graduated increase of expectations. Recordings made over the course of 85 weeks demonstrate a significant decrease in the frequency and severity of aggression. Successful inhibition of challenging behaviour attained a level which facilitated transfer of the client to a non-institutionalized community home. Reasons underlying the success of the intervention, and the limitations inherent in attempting to manage aggression within neurorehabilitation environments will be discussed.

Adult↗
PubMed1998

Seizures in the de-institutionalized patients with early brain injuries.

The number of individuals with early brain injury and multiple disabilities discharged from institutions had increased steadily over the past 10 years. The most frequently encountered problems by patients with early brain injury and epilepsy placed in the community were reviewed. Unavailability of specialized services, inadequate reimbursement, high turnover and lack of knowledge by caregivers, lack of understanding/acceptance of the concepts of seizure intractability and pseudoseizures, unrealistic expectations by overseeing agencies and/or family, and side effects of antiepileptic medications were the most common seizure-related problems afflicting these patients. Everything else being equal, good exchange of information between the various caregivers and continued education of caregivers, both time consuming endeavors, are the crucial factors for the successful management of seizures in this population.

Brain Injuries↗
PubMed2002

Long-term consequences of the reformation of psychiatric care: a 15-year follow-up study.

Although there are a great many epidemiological studies of psychiatric diseases and the outcomes of controlled rehabilitation programmes, there is a shortage of studies of routine psychiatric care. This study is a retrospective cohort study of the total number (n=138) of patients receiving inpatient care at a psychiatric rehabilitation clinic in Jönköping during 1984. The follow-up period is 15 years, 1984-98. The group had a considerable amount of inpatient care, but this decreased dramatically during the time of investigation. Positive indications were that there were no suicides during the last 5 years of the period and that the number of registered crimes showed a marked decrease from 1992. Negative indications were low levels of work and occupation and few social contacts.

Adult↗
PubMed2006

Predictors of post-release primary care utilization among HIV-positive prison inmates: a pilot study.

The primary aims of this exploratory pilot study were (1) to determine the proportion of a sample of HIV-positive inmates utilizing primary care after recent release, and (2) to identify variables associated with utilization of primary care at the time of a post-release interview. Sixty HIV-positive, male and female state prison inmates were interviewed approximately three months prior to release, and 30 were interviewed again between seven and 21 days after release. Variables associated with having utilized primary care at the time of a post-release interview (chi(2) p-values < 0.20) included: taking anti-HIV medications at the time of release, no alcohol use since release, living in the same place as before incarceration and rating of housing situation as 'comfortable' or 'very comfortable'. For exploratory purposes, these variables were entered into a logistic regression model. The model correctly classified 80% of cases overall. Future studies are required to ascertain whether these results would obtain with a statistically adequate sample size.

Adult↗
PubMed1995

Unmet needs for help among persons with AIDS.

Current trends in AIDS care in the United States, including dehospitalization and improved outpatient treatment, may place many persons with AIDS (PWAs) at increased risk for having unmet need for help with daily living demands. Using interviews with 224 PWAs, we examined the prevalence and correlates of unmet need for assistance across six functional domains: personal care, instrumental activities of daily living (e.g. home chores, using transportation), social functioning, role performance, taking care of one's health and negotiating systems. Overall, 74.1% of respondents reported having either a partially or completely unmet need for help in one or more areas of functioning. Unmet need for help was highest for instrumental activities of daily living (46.4%). Unmet need was associated with illness severity (i.e. more symptoms and hospitalizations), minority status and support network characteristics (proximity, size and type of supporters). Implications of unmet needs data for improving the clinical care of PWAs are discussed.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Social context and health consequences of the antipsychotics introduction.

BACKGROUND: From the vantage point of fifty years after the introduction of antipsychotics to clinical practice, this article examines the social context and health consequences of their introduction. METHODS: Historical review of literature sources with commentary. CONCLUSIONS: The availability of antipsychotics over nearly half a century has powerfully influenced concepts of mental illness, dominant models of care versus control, health outcomes and side effect burdens. The large demand and economic success of antipsychotic medications is an important driver for research and development as well as sophistication in marketing. Regulatory agencies, funders and clinicians are faced with a moving target as indications for use of antipsychotics move well beyond the traditional core of schizophrenia and acute mania into depression, anxiety, behavioral disturbance with dementia and some forms of personality disturbance. The history of antipsychotics and mental illness is arguably being written as forcefully now, in an environment of rapid scientific change, as was the case in the 1960s era of rapid social change when chlorpromazine prompted a shift of emphasis from asylum to community. Psychosis is a challenge to how we interpret and approach our inner experiences and societal structures. Accordingly, it is not surprising that the history of antipsychotic drugs resonates with a lively interplay of social, health and economic issues and an ongoing quest to comprehend mental phenomena and their variants.

Antipsychotic Agents↗
PubMed2006

Family attitudes to deinstitutionalisation: changes during and after reform years in a Scandinavian country.

BACKGROUND: Research shows that many families initially oppose relocation from institutions to community care, but also that a majority change their mind after resettlement. The paper addresses the question of whether this post-resettlement preference for community services is only short-term or likely to last. METHOD; Data were gathered at three points in time on people resettling from institutions in Norway: before resettlement (1989/90), shortly after resettlement (1994/95), and about ten years after resettlement (2001). Participants in 1989/90 and 1994/95 were identical (N = 222, aged 18-67 in 1989). The 2001 sample was different (N = 176, aged 20-67). Data gathering consisted of interviews with staff and a postal questionnaire to families. RESULTS: In 1989/90, only 17% of families preferred community care, while in 1994/95 and 2001 respectively, 73% and 76% of families preferred community care. CONCLUSIONS: The preference for community care appears not to be short-term. The question of empowerment/choice associated with the pattern of change from before to after resettlement is briefly discussed.

Adult↗
PubMed2006

Deinstitutionalisation and community living: progress, problems and priorities.

BACKGROUND: Deinstitutionalisation of services for people with intellectual disabilities has become a focus of disability policy in many countries. Research for the most part supports this strategy. However, outcomes are not uniformly better for everyone who moves to community living. This paper explores reasons for variability in service quality and highlights important lessons for countries starting to modernise services. METHOD: The effects of deinstitutionalisation are summarised and emerging problems identified. The changing context of different welfare-state models and paradigms in disability and public administration are outlined. RESULTS: The main changes which have impacted on the implementation of deinstitutionalisation include: the rise of market-based approaches to service provision, arrangements for rationing services, the "de-differentiation" of intellectual disability services, and the rise of a rights-based model in disability policy. CONCLUSIONS: The paper sets out priorities for the future development of community services. Success is likely to require a renewed focus on demonstrating improvement in the quality of life of people with intellectual disabilities and a change in the role of staff to provide more facilitative, enabling support of individuals, especially those with the most severe or complex disabilities.

Australia↗
PubMed2000

Deinstitutionalisation for long-term mental illness: cost differences in hospital and community care.

OBJECTIVE: This project studied the cost analysis of psychiatric hospital and then community care for long-stay patients with chronic mental illness discharged during the closure of a psychiatric hospital in Sydney. METHOD: Expenditure and income data in both settings were collected. Costs were analysed on an occupied bed-day basis. RESULTS: The hospital setting cost more per patient per day compared with the various community costs which were one-third to one-half of the comparable hospital costs. CONCLUSIONS: The analysis demonstrated overall that hospital care was nearly twice as expensive as care in the community setting. The factors which may have influenced, although not necessarily altered, the substance of the findings largely related to 'organisational efficiency'. The mental hospital as an older, more rigid system was likely to be less efficient than the newer community service provision which was under intensive scrutiny both clinically and financially by all interested parties.

Australia↗
PubMed2000

Deinstitutionalisation for long-term mental illness: an ethnographic study.

OBJECTIVE: Deinstitutionalisation of seriously mentally ill people in the developed world, including Australia, has occurred since the middle of this century. Evaluation of the effects of this change on the lives of individuals is of paramount importance to ensure that policies are acceptable and effective. Increasingly, multifaceted studies are considered essential for comprehensive health research. The qualitative aspect of this study complements the clinical and economic components. METHOD: An ethnographic approach enabled contextual, qualitative data to be gathered from within the social world of 47 hospital residents as they moved to the community. A social anthropologist acting explicitly as a participant observer undertook fieldwork over two and a half years both pre- and post-discharge. Qualitative data were collected, stored and analysed separately from quantitative and economic data. RESULTS: Ethnographic findings generally supported and, in many cases, mirrored clinical results. Of the total cohort of 47 patients transferred to the community, the 40 who continue to live outside of hospital all reported a preference for community living. The importance of freedom and simple liberties cannot be underestimated as factors that enabled this resilient group of people to work creatively through difficult periods. CONCLUSION: Properly planned and resourced deinstitutionalisation not only maintains people with a prolonged mental illness outside of hospital, it also enhances their quality of life. Subjective descriptive material focusing on personal experiences adds meaning to quantitative research data allowing health professionals to more fully understand the implications of health policy on the lives of individuals.

Anthropology↗
PubMed2000

Deinstitutionalisation for long-term mental illness: a 2-year clinical evaluation.

OBJECTIVE: The closure of a long-stay psychiatric hospital in Sydney caused the transfer of an initial 40 very long-term patients to four community residences, each with 10 beds, for a continuing process of deinstitutionalisation. Community psychiatric service support and 24-h supervision were provided. This paper describes the residents' clinical progress which was assessed over a 2-year period. METHOD: This study employed a quasi-experimental longitudinal design. Evaluation commenced prior to discharge and continued for 2 years following community relocation using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Readmission, demographic, case history and medication data were also collected. RESULTS: Of the 40 patients initially transferred to the community, seven required long-term readmission to hospital (either prior to or after amalgamation) and one patient died of medical causes. Additional patients transferred from the hospital to the community following the readmissions. Three of these additional patients had achieved a 2-year community tenure during the study period and were included in the clinical evaluation. The 35 residents in total who remained in the community for 2 years, demonstrated a significant improvement in psychotic symptoms, without significant change in the level of neuroleptic medication. Importantly, the 2 years of community living resulted in a significant increase in the residents' life satisfaction. There were no statistically significant changes in residents' living skills, depressive symptoms or social behaviour problems over the 2 years, indicative of the need for supervision and community service support following deinstitutionalisation. Over the 2-year period, some 37% of the residents required temporary readmission. CONCLUSION: This study demonstrates the clinical effectiveness of deinstitutionalisation, when planned within a mental health system with adequate community resources.

Adolescent↗
PubMedDate not supplied

Outcomes for elderly patients with mental illness following relocation from a stand-alone psychiatric hospital to community-based extended care units.

OBJECTIVE: To assess the outcomes for a group of elderly patients with mental illness following their discharge from a stand-alone psychiatric facility to seven extended care units (ECUs). METHOD: All patients (n=60) who were relocated to the ECUs were assessed using a number of standardized clinical and general functioning instruments at 6 months and 6 weeks pre-move, and again at 6 weeks, 6 months and 18 months post-move. RESULTS: By 18 months post-discharge, 13 of the 60 patients (21.7%) had died and seven others had been transferred to nursing homes. Those who died were older and had significantly higher levels of physical ill health when compared to those who did not die. Changes on measures of clinical and behavioural functioning in those who remained in the study did not reach statistical significance by 18 months post-move. However, participants did demonstrate improvements in quality of life with significantly higher scores on measures of social contact and community access. CONCLUSIONS: The mortality observed in the follow-up period is likely to be related to physical ill health and old age rather than the trauma associated with relocation. While overall functioning did not improve following relocation, patients had more independence and greater access to community-based activities.

Aftercare↗