The Effects of Alcohol Abuse Among the New Chronically Mentally Ill

In recent years, there has been a growing recongition of the high incidence of alcohol abuse among the new generation of chronically mentally ill. This article reports on a study that tracked a subgroup of the chronically mentally ill, those discharged from state psychiatric hospitals, through an entire community mental health aftercare system and its major auxiliary human service agencies. Those who were assessed by hospital discharge social workers as having a need for alcoholism services were found to be less likely to be referred for aftercare and to make contact with aftercare agencies post discharge; and for those with an alcoholism problem who do make contact, they generally received less service than those who did not have a need for alcoholism services. The professionals in both the mental health and alcholism fields need to work together to better meet the needs of the chronically mentally ill with an alcohol problem.     

Assessing the service needs of the discharged psychiatric patient

In recent years the chronically mentally ill have come to be regarded as a heterogeneous population with a diversity and multiplicity of needs. Social workers assessed a cohort of psychiatric patients being discharged from two state hospitals in terms of their postdischarge service needs. The findings confirmed that these patients needed not only basic mental health services of chemotherapy and counseling but also social rehabilitative services and specialized services such as substance abuse counseling. The data have been utilized by agencies and state and county governmental entities to document the need for new programs and to reorder service priorities. To start a planning process, recommendations on the study findings are being distributed to mental health and human service agencies and family coalitions on a communitywide basis.     

Mental health services system research: the National Institute of Mental Health program.

There is a critical need for research to examine the changing mental health services system, to evaluate major innovations in the provision of mental health treatment, and to remove existing barriers to comprehensive and cost-effective care. To achieve these aims, collaboration is needed among government agencies, mental health services programs, academic institutions, and the private sector. The National Institute of Mental Health supports research and research training on the mental health services system primarily through the Division of Biometry and Applied Sciences. This article focuses on the division's three priority research areas of the mental health services system: the provision of mental health care in the primary care sector, the organization and delivery of care for the chronically mentally ill, and financing and reimbursement of care. The various mechanisms of research support are also highlighted.     

Deinstitutionalization: A microcosmic perspective

Changes have taken place in caring for chronic patients due to deinstitutionalization, and these changes have affected the services rendered by the community mental health centers. Statistical data on dehospitalized patients treated in a community mental health center located in the South Central Bronx are examined to determine trends in service utilization by these patients. Demographic characteristics of this population are also examined. Issues surounding treatment and rehabilitation of chronic mentally ill patients are critically explored and recommendations for changes in the care of the chronically mentally ill patient are offered.     

Are mental health problems associated with use of Accident and Emergency and health-related harm?

BACKGROUND: Previous findings indicate that mental health problems are common in Emergency departments; however, there are few studies of the extent of health-related problems and emergency service use in mental health populations as a whole. METHODS: Record linkage methods were used to map the association between mental health, age, gender, and health-related harm across total health and mental health care populations in one geographical area, over three years. By examining patterns of health-related harm, an accurate profile of mentally ill Emergency patients was generated enabling identification of factors that increased vulnerability to harm. RESULTS: Of the total population of 625 964 individuals, 10.7% contacted Accident and Emergency (A&E) over three years, this proportion rose to 28.6% among the total secondary care mental health population. Young men and older women were more likely to contact A&E, both overall and within mental health populations and were also more likely to be frequent attendees at A&E. Four distinct groups (typologies) of mental health patients attending A&E emerged: young, male frequent attendees with self-inflicted and other traumatic injuries; young females also presenting with self-harm; older patients with multiple medical conditions; and very old patients with cardiac conditions and fractures. CONCLUSION: The study indicates increased A+E service use and unmet health-related need within a total mental health population. It identifies specific 'care populations' particularly vulnerable to accidents and self-harm and highlights the need for targeted services for mentally ill groups who may not access traditional health and social care services effectively.     

Health and social services integration: a review of concepts and models

Health and social services integration is particularly relevant for populations whose needs span physical health, mental health, housing, and disability services, along with others. Veterans, homeless, chronically ill, and aging are among those populations. This review examines recent peer-reviewed literature about different approaches to services integration, rationales behind those approaches, and successes of those approaches, including factors that make them succeed or fail. The focus here is on services that cross disciplinary boundaries; that is, those that integrate health services with social services, health services with mental health services, or one social service with a categorically different social service.     

A community project to encourage compliance with mental health treatment aftercare.

Rehospitalization of mentally ill persons has been associated mainly with two major factors, noncompliance with the prescribed course of medication and noncompliance with planned aftercare. The authors developed and pilot tested a community health project designed to assist chronically ill mental health patients who, when discharged from hospital care, are considered at high risk for rehospitalization. The project was designed to support clients'' efforts to comply with their prescribed course of aftercare therapy, support, and medication. The project was developed at the University of Maryland at Baltimore, School of Nursing, in cooperation with the U.S. Department of Veterans Affairs. The project consisted of interventions during the critical time after hospital discharge but before the client becomes fully established in outpatient treatment. The interventions were based on the principle of catching the high-risk client before a crisis situation occurred. The four interventions were (a) discharge planning for the individual client that stressed education about the client''s psychiatric illness; (b) education about medications prescribed for the client; (c) an education program for family members and others to assist them in helping the individual client; and (d) communicating with the client to reinforce the support network concept, using a 48-hour followup telephone call, an information contact by post-card, and a noncrisis telephone line. The project was implemented on a pilot basis during the fall of 1992 by the nursing students and staff members at a major urban Department of Veterans Affairs Medical Center (VAMC). The pilot project involved 31 staff and community health professionals and 68 client interactions during 1992.(ABSTRACT TRUNCATED AT 250 WORDS)     

The last resort? Bed and breakfast accommodation for mentally ill people in a seaside town

There have been few studies about the seaside hotel accommodation provided for mentally ill people in the United Kingdom, despite its extensive use. This paper reports the findings of a survey in Southend, which compared living conditions and residents in bed and breakfast accommodation with those in sheltered accommodation for mentally ill adults. The results show that the mentally ill residents of bed and breakfast accommodation were living in less attractive and less well maintained surroundings. They were not only more likely to have been recently discharged from a psychiatric unit, but also had less contact with the range of community mental health services. Residents in bed and breakfast accommodation were, however, closer to local amenities, such as day centres and parks, than the control group. Staff practices were less restrictive in bed and breakfast accommodation than in the majority of sheltered homes; homes employing psychiatric nurses allowed residents the most freedom. These findings support the need for more accommodation of an acceptable standard for those people discharged from psychiatric units. Local liaison schemes between health workers responsible for the continuing care of mentally ill people and the landlords of bed and breakfast accommodation could improve the quality of life for these residents.     

Priority setting in mental health services

This paper sets out an approach to priority setting in mental health services, built around programme budgeting and marginal analysis (PBMA). The paper also discusses the question of building in equity, especially the concept of vertical equity which, given the relative neglect of mental health services when resources have been allocated in the past, might serve as a mechanism for redressing the imbalance in resource allocation to the mentally ill. Beyond that the importance of eliciting community values to aid priority setting in mental health services is highlighted, particularly with respect to the principles underlying the mental health services or what one might call 'the nature of the good' that society wants from its mental health services. While it can be argued that trying to ascertain these principles or the nature of the good applies in all health services--and that is not disputed here--in mental health there is yet more need for clarification than in many other, indeed most other, health services. The need to exercise value judgments is emphasised. There is also a word of caution on the dangers of over-reliance on waiting for perfect evidence. Finally the paper considers how best to operationalise priority setting in mental health services, and perhaps make it less of a nightmare for mental health service planners than it currently seems to be.     

Living with the mentally ill: Effects on the health and functioning of other household members

Based on data from the National Health Interview Survey Mental Health Supplement, 1989 (NCHS, 1991), this article compares health outcomes for respondents living with someone who is mentally ill (N = 776) with a randomly selected subsample of respondents not living with someone identified as mentally ill (N = 716). When other predictors of health are controlled, sharing a household with a mentally ill person is associated with poorer self-reported physical health, increased risk of reporting some activity limitation, and increased service utilization—both greater risk of hospitalization or visiting a physician, and a greater number of days hospitalized and number of physician visits among those utilizing these services. The severity and duration of mental illness have little effect across health outcome measures. Impaired health and increased utilization of medical care among persons living with someone who is mentally ill suggest hidden costs to individuals, to families of the mentally ill, and to the service system.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Access and use of health services by chronically mentally ill Medicaid beneficiaries

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.     

Community care for people who are homeless and mentally ill

This qualitative longitudinal study documents the experiences of 60 people who are homeless and mentally ill from their state mental hospital discharge through their first two years in community housing. The study explores the personal, cultural, and environmental contexts of life for adults who are homeless and mentally ill and examines the interaction between an individual's needs and community resources. The research identifies forces that perpetuate homelessness and traces the struggles that people who are homeless and mentally ill encounter during the transition from the streets to stable housing. The findings describe a culturally based pattern of mutual avoidance between homeless mentally ill clients and caregivers, which limits delivery of services to the population. Recommendations include development of alternative systems of care delivery, expansion of educational experiences with underserved populations, and increased funding for service or research with people who are homeless and mentally ill.     

Utilization of outpatient mental health services after inpatient alcoholism treatment

It is generally agreed that use of aftercare services following discharge from alcoholism treatment is optimum for patients to achieve long-term recovery. However, the quantity and duration of utilization of such services in non-experimental settings are generally unknown. Using secondary data sources, we studied 5,635 alcoholics completing formal extended inpatient treatment and 1,860 alcoholics discharged from brief inpatient hospitalizations in Department of Veterans Affairs medical centers. Weekly use of outpatient mental health services (OPMH) prior to hospital admission was equally low for both patient groups (approximately 2–3% of patients) until four weeks prior to admission, at which time OPMH use increased, particularly for the extended treatment group. In the four weeks after discharge, use of OPMH services was substantially higher for patients with extended treatment compared to those with brief hospitalizations (40% vs. 18%), with 22% of patients completing treatment utilizing such services in the first week after discharge. Utilization steadily decreased until only 8% and 4% of both groups, respectively, were using OPMH services at the end of six months after discharge. Study results suggest the need to examine barriers to outpatient mental health utilization after discharge as well as interventions to increase compliance with long-term aftercare. This study was supported by grants R01-AA08732 (all authors) and P50-AA07378 (Dr. Blow) from the National Institute on Alcohol Abuse and Alcoholism.     

The health of clients referred to social workers in an intake team

Though numerous reports have strongly argued that there is a need for a closer collaboration between the health and social services, studies investigating the health of clients in contact with the personal social services have been few and limited. This study collected information regarding the physical and mental health of clients referred to social workers in the local authority intake team by means of questionnaires completed by the clients, and a selected sub-sample was also given an interview. Details were also taken regarding the social worker's assessment of health, reasons for referral and their intervention. The results indicated that the proportion of patients with physical or mental illness, or both, were very high and that social workers tended to under-report or under-estimate these illnesses. While there is some suggestion that the social workers were more likely to carry out more interviews with those clients who were ill, either physically or mentally, the contacts between social workers and medical personnel were very limited indeed.     

Families of chronically mentally ill people: siblings speak to social workers

Twenty siblings of chronically mentally ill people discussed their emotional responses to the mental illness of their brother or sister. The findings were drawn from a study that was part of the author's practice experience as a social worker in a community mental health setting. The findings also paralleled the author's life experiences as a sibling of a chronically mentally ill person. Sibling emotional responses were categorized into grief and loss phases of denial, anger, bargaining, depression, relief/respite, and acceptance. Siblings believed that their expressions of grief and loss were impaired by characteristics of mental illness and by mixed messages from the mental health system. The siblings recommended inclusion of siblings in client treatment; support and education for siblings; clear communication between social worker and family; a social worker focus on family strengths; and, most of all, effective client intervention. The sibling perspective points out the salient need for social workers to use their ecological, person-in-environment training to facilitate healthier family support networks for chronically mentally ill people.     

Accomplishments and challenges in Medicaid mental health

Although Medicaid was not designed as a mental health program, it is now a major source of financing for mental health services and care, especially for the chronically mentally ill. This paper examines the role Medicaid plays today for the low-income population with mental health needs and then reviews some of the current pressures and challenges in the program that could reshape this role.     

CONSULTATION WITH COMMUNITY CARE FACILITIES

An innovative application of consultation to community care facilities, also known as board and care homes, is presented in order to improve services to chronically ill mental persons. An extended Caplanian model for establishing an effective consultant-consultee relationship with administrators is described with reference to the following tasks: (a) understanding the setting; (b) recognizing an unmet need; (c) resolving problems of entry; and (d) negotiating a contract for case consultation and for program consultation. Interventions that reduce theme interference and work efficiency are described by examining realistic conflict resolutions utilizing problem clarificaiton, expressing understanding, sharing feelings, and exploring solutions. The results include development of a climate of responsibility among the chronically mentally ill residents and more effective use of community resources.     

Coping and resilience of children of a mentally ill parent

This paper examines the needs and stress reactions of children of mentally ill parents, as well as coping and resilience. The study is based on the interviews of six 9-11 years old children and narratives of seventeen female grown up children of mentally ill parents. The younger and older children of the mentally ill parents had not been informed about their parent's illness. The illness of the parent aroused a variety of emotions in them. The children used both practical problem solving and emotional coping mechanisms. Informal social support was available to them but seldom from the public services. It is recommended that professionals in mental health and child welfare services clarify their roles when working with mentally ill parents. The best interest of the child and the parenting they need should be carefully assessed. Open care measures should be offered to families early enough to prevent serious child welfare and mental problems.     

Integrated mental health: A creative model for community mental health in the 1980s

Integrated Mental Health is a membership corporation designed as a non-profit management, funding, planning and evaluation vehicle for a two-county community mental health service system. It emphasizes incentives, coordination and research capability with special attention to the chronically mentally ill.