Integrating clinical and research psychiatry.

Residents involved in clinical research are frequently unprepared for the problems which may arise in relation to the dual roles of clinician-investigator and patient-subject. Common problems for the clinician-investigator will be outlined including: 1. enlisting patients; 2. using treatment one does not necessarily consider first choice; 3. being blind to treatment prescribed; 4. adhering to a fixed treatment protocol; and 5. deciding when to terminate a trial. Possible solutions will also be offered. In addition, the altered role of the patient as subject will also be considered as it affects patient care within trials.     

Solving problems with randomized clinical trials is not enough to improve psychotherapy outcome: comments on Krause

The problems noted by Krause (see record 2011-19228-002) with regards to interpreting evidence from randomized clinical trials are discussed. It is suggested that some of these problems have already been addressed and improvements made by some researchers, mainly examining the changes made by every patient in the treatment groups through the use of clinically significant change. It is suggested that regardless of the evidence-behind treatments, maximal patient outcome can best be obtained through formally monitoring patient treatment response in real time, session-by-session.     

Treatment of sleep apnea syndrome in a Down syndrome patient with behavioral problems by noninvasive positive pressure ventilation: a successful case report

The use of noninvasive positive pressure ventilation (NPPV) is increasingly accepted as a treatment of respiratory problems in patients with neuromuscular disease. However, its use in mentally retarded and un-cooperative patients has not been reported. We report here the evaluation and treatment of sleep apnea in a Down syndrome patient. After recovering from a life threatening respiratory failure the patient had persistent sleep apnea syndrome. Limited examinations disclosed that he had two types of apnea; obstructive and central type apnea. Our treatment was a diet with intake restricted up to 1,000 kcal per day for the obstructive apnea, and NPPV with low dosage of oxygen for the obstructive and central apnea. With these treatments in one year's hospitalization, his quality of life was significantly improved. He has continued the treatment in the outpatient department and enjoys a better quality of life both at home and in the community. The successful treatment of this case may become an example of the more extensive use of NPPV for such respiratory problems in handicapped children and adults with behavioral problems.     

Psychiatric treatment in severe brain injury: A case report

A patient with severe, penetrating brain injury is presented. The patient was in psychiatric treatment for four years, starting two months after the injury; psychological tests were administered four times. By most criteria, the patient recovered completely. The case confirmed earlier observations that intelligence measured by verbal subtests, recovers faster than that measured by performance subtests. The latter continued to improve during the two to four year period after injury. The case clearly indicates the emotional and psychological problems that arise in the presence of severe brain damage. These reactions may hamper rehabilitation, although the gross psychological disabilities caused by the brain injury have improved. It is suggested, therefore, that brain damaged patients should receive psychiatric treatment. Some of the problems of such psychotherapeutic treatment are briefly discussed.     

Drop-In Access to Specialist Services for Eating Disorders: A Qualitative Study of Patient Experiences

Lack of patient motivation and dropout are common problems in the treatment of eating disorders. The present study explored patient experiences with open access to specialist eating disorder services through a drop-in program aiming to enable early identification of eating disorders, address motivational problems, and strengthen the therapeutic alliance. Semi-structured qualitative interviews were used to explore the experiences of 11 individuals attending the program. Results suggest that drop-in access may strengthen the therapeutic alliance, motivate engagement in treatment, and reduce dropout. Strengths and weaknesses of the program are discussed and the need for more systematic research is elaborated.     

Developmental coordination disorder in a child with ADHD; is DCD a DSM-IV diagnosis that is not recognised by child psychiatry?

A five-year-old boy received treatment for attention deficit hyperactivity disorder (ADHD). In connection with his motor problems he was referred to a rehabilitation centre specialising in the study and treatment of developmental coordination disorder (DCD). When treating a patient with ADHD, doctors should ask regularly about the patient's motor functioning and, if necessary, arrange a referral. In the first instance a young patient should be referred to a paediatric physiotherapist or, if the problems are complex, referral should be to a paediatric rehabilitation doctor. A combination of ADHD and DCD has a poorer prognosis than ADHD alone.     

Problems to anticipate in treating difficult patients in a long-term psychiatric hospital

In a previous report, the authors identified four dimensions of patient pathology associated with treatment difficulty: withdrawn psychoticism, character pathology, violence-agitation and suicidal-depressed behavior. In a subsequent study, they linked these dimensions to patterns of countertransference. The present research extends the two prior reports by examining the relations of the patient pathology dimensions to staff members' dissatisfaction with four areas of treatment: interpersonal approaches, structure and control, quality of teamwork, and medication. The major findings are: withdrawn psychoticism primarily relates to dissatisfaction with interpersonal treatment approaches; character pathology entails dissatisfaction with the level of structure and control; violence-agitation poses particular problems for teamwork; and suicidal-depressed behavior is unrelated to dissatisfaction with any dimension of treatment. The authors propose that these various problems in treatment are, in part, mediated by patterns of countertransference which they described in the prior paper. These findings should help staff members to focus their attention on areas of treatment in which problems are bound to arise in work with different types of difficult patients.     

Methodological problems in evaluating hyperbaric treatment of multiple sclerosis. A case study

The paper describes a number of methodological problems experienced in a long-term evaluation of hyperbaric treatment for MS. Among the problems discussed are those relating to the locus and logistics of assessment, the reliability of 'subjective' assessments, the feasibility of 'objective' measurements, the identification of outcome categories and patient drop-out and selectivity.     

Time-limited, group psychotherapy for borderline patients

Preparation for treatment, group process and time boundaries are presented as components of a treatment model designed to respond to specific problems inherent in the nature of borderline personality disorder. A pilot study of the proposed treatment model is underway and one case illustration from this study is described to illustrate the adaptation to this treatment of a borderline patient with an extensive prior history of individual treatment.     

A survey of treatment modalities used by mental health clinicians and activity therapists.

An art therapist conducted a survey of 150 mental health clinicians and activity therapists to find which of ten treatment modalities they preferred to use with ten types of psychiatric patients. The final sample consisted of 68 respondents: 34 clinicians, 17 activity therapists, and 17 art therapists. The three respondent groups agreed on the same optimum treatment modality for five patient groups. Art therapists felt art therapy was most effective in treating the youthful drug abuser, the child with educational problems, and the moderately depressed patient. Clinicians and activity therapists agreed on other treatment modalities for those patients.     

A national evaluation of treatment outcomes for cocaine dependence.

BACKGROUND: This national study focused on posttreatment outcomes of community treatments of cocaine dependence. Relapse to weekly (or more frequent) cocaine use in the first year after discharge from 3 major treatment modalities was examined in relation to patient problem severity at admission to the treatment program and length of stay. METHODS: We studied 1605 cocaine-dependent patients from 11 cities located throughout the United States using a naturalistic, nonexperimental evaluation design. They were sequentially admitted from November 1991 to December 1993 to 55 community-based treatment programs in the national Drug Abuse Treatment Outcome Studies. Included were 542 patients admitted to 19 long-term residential programs, 458 patients admitted to 24 outpatient drug-free programs, and 605 patients admitted to 12 short-term inpatient programs. RESULTS: Of 1605 patients, 377 (23.5%) reported weekly cocaine use in the year following treatment (dropping from 73.1% in the year before admission). An additional 18.0% had returned to another drug treatment program. Higher severity of patient problems at program intake and shorter stays in treatment (<90 days) were related to higher cocaine relapse rates. CONCLUSIONS: Patients with the most severe problems were more likely to enter long-term residential programs, and better outcomes were reported by those treated 90 days or longer. Dimensions of psychosocial problem severity and length of stay are, therefore, important considerations in the treatment of cocaine dependence. Cocaine relapse rates for patients with few problems at program intake were most favorable across all treatment conditions, but better outcomes for patients with medium- to high-level problems were dependent on longer treatment stays.     

Some problems encountered in the psychoanalytic treatment of overt male homosexuality

This article describes certain theoretical and clinical problems commonly met with during the psychoanalytic treatment of adult homosexual patients. Difficulties discussed are selected out of extensive clinical experience and are described under several headings: general problems, such as selection of patients, motivation for seeking therapy, problems at the outset; the working alliance and its maintenance; transference problems and the issue of analyzability; problems secondary to deficiencies in the structure of the ego of the homosexual patient; the imperativeness of the homosexual impulse and the problem of acting out; extrinsic problems.     

Private and Public Ownership in Outpatient Substance Abuse Treatment: Do We Have a Two-Tiered System?

As investor-owned organizations increase their presence in the mental health care sector, questions emerge regarding the effects of ownership type on service delivery. One important question is whether ownership is related to patient access to care for persons requiring treatment for substance abuse problems. Using data from a 1995 national survey of outpatient substance abuse treatment units, the authors investigate whether there are differences in measures of patient access to care among investor-owned, not-for-profit, and public provider organizations. Results indicate investor-owned units cater to and serve a clientele that differs from that of not-for-profit and public units, suggesting the presence of a two-tiered system of substance abuse treatment.     

The work of Australian psychiatrists, circa 1986

A random sample of psychiatrists was asked to supply details about their last 20 patients. Sixty percent responded. The median patient in treatment was aged 36 and saw a psychiatrist in office practice once a month over a three year period. Forty-one percent of the patient case load suffered from a psychotic disorder, 39% from a neurosis, and 6% from a personality disorder. Marital problems, problems in living and drug or alcohol dependence were infrequent reasons for consultation. Two positive conclusions were drawn: that the case load reflected the morbidity in the community, and that the prognosis for patients with personality disorders was better than usually expected. There were two areas of concern that may need attention: that insight and group psychotherapy require substantial numbers of treatment hours, and that behavioural psychotherapy is rarely used for patients with neurotic conditions.     

Contingency management treatment in substance abusers with and without legal problems

Drug and alcohol abusers frequently have legal difficulties, and the legal system often provides negative reinforcement for substance abuse treatment. In contrast, contingency management (CM) treatments utilize positive reinforcement procedures to improve patient outcomes. This study evaluated whether substance-abusing patients with legal problems at treatment entry had differential outcomes, in general and in response to CM, compared with those without legal problems. Data from three randomized CM trials (n = 393) were used in an evaluation of main and interactive effects of legal status and treatment condition, with respect to retention and abstinence. Compared with patients without legal difficulties, those with legal problems remained in treatment for shorter durations and achieved shorter periods of abstinence. CM was positively and significantly associated with longer durations of abstinence, regardless of legal status. Results suggest that substance abusers with legal problems have generally poor outcomes, but that CM is effective regardless of the patient's legal status.     

Quality assurance of psychiatric day hospital treatment: III. Health care system level

Four psychiatricday units at different hospitals in southern Norway have used the same quality control system. The system itself and its benefits for evaluation and estimation of treatment effect for the individual patient and for ward management are described in two previous papers. In this paper we compare data from different wards. The comparisons include ward size, number of patients treated, treatment length, cost per treatment, demographic variables, illness course variables, diagnoses, use of medication, ward atmosphere, complications during treatment, treatment results as for symptoms, interpersonal problems, global functioning, and patient satisfaction. Differences between the day units are discussed. It is concluded that the quality control system provides opportunities for highly useful feedback for each unit, for realistic estimation of the potential of such treatment, and for psychiatric health care planning.     

Intensive psychotherapy for the psychiatrist's family

A series of intensive psychotherapy cases of wives and children of psychiatrists reveals that the special problems they present may be divided into those at the onset of treatment, those in the process of the treatment, and special countertransference problems. Paradoxically, early recognition and acceptance of psychotherapy are a foremost problem involving the psychiatrist as father or spouse. During therapy, narcissistic injuries to the psychiatrist father or spouse and loyalty problems in the patient emerge as special problems. Countertransference revolves around peer relationships and "psychopolitics," as well as referrals of other patients.     

Therapeutic trials in tardive dyskinesia.

The search for a treatment of tardive dyskinesia has generally been guided by the putative biochemical mechanisms underlying the extrapyramidal disorders, but no markedly effective treatment has yet been found. The currently postulated mechanism in tardive dyskinesia involves namely an imbalance between the central dopamine-acetylcholine systems whose balance may also be influenced by neuroendocrine factors. The agents reported having some clinical efficacy in the management of this neurological complication act on these systems. The clinical investigation for the treatment of tardive dyskinesia is laborious and raises several problems that could account for the unpredictability and the discrepancies in results. These problems can be divided into three broad categories: patient variables, experimental treatment variables and methodological variables. These variables are discussed and some suggestions made.     

Randomised controlled trial of a treatment adherence programme for prisoners with mental health problems in Spain

The prevalence of psychiatric disorders is high among prisoners, who often need psychotropic medication, but compliance with treatment is often poor. This combination leads to poorer prisoner‐patient health and increased health costs.The aim of this study was to test the impact of a treatment adherence programme (TAP) on medication adherence and subjective well‐being among prisoners with mental health problems. We conducted a randomised controlled trial of a treatment adherence programme compared with treatment as usual (TAU) among 183 prisoners with mental health problems. Those in the TAP group showed greater treatment adherence and reported better subjective well‐being with medication than those in the TAU group. We conclude that the treatment adherence of prisoners who require medication for mental health problems may be improved through specific intervention programmes. This could make a positive contribution to individual health and well‐being.     

A Time-limited model of art therapy in general practice

Abstract

This article describes an innovative project which was inspired by a successful pilot study of art therapy in a rural GP setting (see Sowton, 1997). The present project was designed to provide art therapy as a complementary treatment for mental health problems in a Scottish urban primary care setting, and to implement an NHS priority by developing an innovative treatment for mental health problems. The project involved an independent formal audit using quantitative and qualitative measures. The article gives an overview of the prevailing conditions at the GP surgery, the contact between the therapist and the doctors, the types of referrals made, and the patients responses. The author shows how a flexible time-limited model was developed, which allowed the patient a short introductory period to overcome their fear of therapy and was followed by a longer period in which the patient could explore new options and build up strengths. Neither budgetary constraints nor the advocacy of alternatives to drug therapy are seen as the prime determinants of such therapy. Reference is made to counselling models developed in similar settings and it is concluded that art therapy can take its place alongside counselling as a suitable treatment for mental health problems in general practice.