Behavioral comparison of a token economy and a standard psychiatric treatment ward

Observations were made using specific patient behaviors on a token economy and a standard psychiatric ward. Differential performance was emitted for grooming, attendance at activities, time in bed, smiling, and distress comments. Generally, patients on the token economy ward were better groomed, attended more activities, spent less time in bed, and made fewer distress comments. Patients on the standard treatment ward smiled more. The results are discussed in terms of expectations for the different psychiatric treatments.     

Training and treatment costs in a community mental health center

Defining and allocating training costs among CMHC programs is troublesome but necessary. A method for doing this is offered, demonstrating that services by some students approximate the costs of their training. A CMHC may require subsidies to train others.     

Antecedents and interventions for aggressive behavior of patients at a geropsychiatric state hospital

Aggressive geropsychiatric patients pose major problems for long-term care facilities. Two exploratory surveys at a geropsychiatric state hospital, separated by brief programs of inservice training on managing aggressive patients, examined several aspects of aggressive behavior and staff interventions. Major findings included a stable overall prevalence of aggressive behavior in both survey periods; a persistently higher prevalence of aggression and a higher rate of physical aggression among dementia patients than among other patients; and staff-patient exchanges as a major triggering event for aggression. In the survey period after the inservice training, staff interventions remained similar for nondementia patients; however, for dementia patients, interpersonal interventions were used less frequently, and p.r.n. medications, alone or in combination with seclusion or restraint, were used more often.     

The clinical research ward as a therapeutic community: incompatibilities.

The authors discuss the numerous incompatibilities between the clinical research ward, with its emphasis on the collection of baseline and treatment data, and the therapeutic milieu environment, with its emphasis on an open door, team orientation, and nonauthoritarianism. They posit that the two orientations may be mutually destructive and that the therapeutic milieu may not be the best treatment setting for patients with schizophrenic or certain affective disorders. Two case histories illustrating these ideas are included.     

Health care costs of therapy-refractory schizophrenic patients treated with clozapine: a study in a community psychiatric service in Italy

This study evaluates the utilization of clozapine in the treatment of therapy-refractory schizophrenia in terms both of patterns of care and of health care costs in a community psychiatric service in Italy. Data covering the year prior to commencing clozapine and the year following the initiation of the therapy were collected. Clinical outcome was assessed by means of the Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) scales. Cost analysis followed a two-step procedure: (i) to record all health care services provided to patients and (ii) to assign a monetary value to each service. Three of the 15 patients enrolled in the study dropped out before the end of the 12-month period of therapy. Considering the 12 patients on clozapine treatment for at least 1 year, clinical improvements are associated with a substantial modification of the pattern of care. While patients in the pre-clozapine period were mainly managed in hospital settings, patients on clozapine were prevalently placed in the community and participated in intensive rehabilitative programmes. The higher costs of drug therapy and community services in the post-clozapine period were more than offset by the lower costs of acute hospital care.     

The community impact of consolidating long-term inpatient care at a single state hospital

OBJECTIVE: A community impact model was used to estimate how consolidation of all long-term inpatient care at one state mental hospital affected the town in which the hospital was located. METHODS: Qualitative and quantitative methods were used to measure objective and subjective impacts of the hospital's expanded role. Objective impacts included employment, retail sales, and use of local services such as police, welfare, and education. Subjective impacts included residents' perceptions of safety. Data were obtained from hospital records, service providers, merchants, residents, and persons living on the streets or in shelters. RESULTS: Overall, the policy had a positive net impact on the community, estimated at roughly $4 million during the 18 months after implementation. Nearly $1 million was a direct payment from the state in lieu of taxes for the property occupied by the hospital. The hospital's payments to businesses in the town increased 10 percent. The number of hospital employees increased by 61 percent, to 1,336. The number of local residents working in the hospital grew from 200 to 320, and the proportion of the hospital's annual payroll paid to local residents increased from 14 to 24 percent. Local service use did not increase, and no change was noted in the crime rate. More patients were discharged to other towns than were admitted from the host town. Eighty percent of the residents surveyed said the town had either improved or had not changed. CONCLUSIONS: The benefits brought by the consolidation are likely to be sustained in the long run if the state continues the current rate of payments to the community and the hospital continues its policy of discharging patients to the town where they resided before hospitalization.     

The therapeutic community as a research ward: myths and facts.

The clinical research ward run as a therapeutic community has been criticized as inefficient and scientifically unsound. This article discusses the therapeutic community as a research ward and identifies certain misconceptions which underlie many criticisms. The following myths are discussed and refuted: (1) There is an insurmountable community-research chasm. (2) The therapeutic community induces stress that interferes with research. (3) Patient passivity is engendered by research and this is destructive to the therapeutic community. (4) Symptoms are exacerbated by a research ward that is disruptive to the community. (5) Normal research subjects cannot live in a therapeutic community without pathologic psychic changes. These inaccurate myths are seen as a reflection of attempts to oversimplify very complex clinical and research issues. The use of mythology to simplify experiments, to artificially "clarify" complex issues, or to "protect" patients is seen as a disservice. The therapeutic community and research are syntonic when both receive appropriate support.     

Infant day care as a treatment intervention: A follow-up comparison study

Three-year-old children who had been in an infant day care treatment program were compared with matched normal children who were entering regular day care for the first time at age 3, to evaluate the effects of early day care intervention. All children were assessed on general pathology, play, socialization, and separation variables in arrival, play, and mealtime situations and were naturalistically observed in the day centers. No significant differences between groups were found on any of the variables within situations or across situations, supporting the hypothesis that the treatment intervention supported major positive emotional developments and that the early separations were not detrimental in effect. Significant differences between the two groups on clusters of variables suggest patterns in coping and disturbance style specific to the control group and significantly different from the day care group.This study was supported by a grant from the Van Ameringen Foundation, New York City. We wish also to acknowledge the assistance of Inge King and Blanca Masor, MA.     

Measuring the treatment environment of a psychiatric ward and a community mental health center after the Italian reform

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 Environemt 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.This study was supported by the Consiglio Nazionale delle Ricerche (CNR, Roma) through a grant to Professor M. Tansella (No 122.04, Prot. 51359, 1981).     

Evaluation of a special nursing home unit for dementia sufferers: a randomised controlled comparison with community care

Applicants for a newly opened special unit for dementia sufferers were randomly allocated to full-time care in the unit or placed on a waiting list and offered periodic respite care in the meantime. All applicants were living in the community at the time of random assignment. Both groups were followed up for three months to assess the effects on the dementia sufferers and on their family care-givers. Care-givers initially had a high level of psychological symptoms, which was greatly reduced after admission of the dementia sufferer to full-time care. By contrast, the care-givers of the community care group of sufferers continued to have a high level of symptoms. Dementia sufferers continued to deteriorate with both forms of care, with little difference between the two groups. Admission of dementia sufferers to full-time care in a special unit appears to be of great benefit to the psychological health of their care-givers and has no adverse effects on the dementia sufferers themselves.     

The closure of a mental hospital in Sweden: Characteristics of patients in long-term care facing relocation into the community

Summary A political decision to decentralize psychiatric care in a county of Sweden was made in October 1984, leading to the closure of the only large mental hospital in the area (290,000 inhabitants). The hospital is of the traditional type, with 490 beds and 1,294 staff members. It has units for long-term care, short-term care and rehabilitation and a unit for research and education. The long-term care is to cease completely and be replaced by community based alternative types of care. In this study, the long-term population (n=199) was characterized and their levels of functioning were measured. The results showed that 91% of the patients were 65 years old or more and that more than half of them were organically demented. Only 20% were chronic schizophrenics. All patients were cognitively impaired and 80% were also impaired in ADL functioning. A correlation between length of stay in hospital and ADL functioning was found in the organically demented group, but not in the group of chronic psychiatrically ill patients. Thirty-nine per cent of the population were severely impaired in ADL functioning and needed nursing care around the clock; 34% were moderately impaired and needed help and support that could be given in alternative types of care; 27% were not impaired at all to midly impaired and could be relocated to some type of service apartment. Thus, all patients needed sheltered living arrangements and care provided by staff with adequate training.