Hospital-based multidisciplinary training in the care of seriously mentally ill patients

A four-week training program at a state hospital in Virginia familiarized undergraduate and graduate students in medicine, occupational therapy, pharmacy, psychiatric nursing, psychology, and social work with the range of care for chronic mentally ill patients. Designed to improve the training of mental health professionals and recruit mental health professionals to work in public mental health settings, the program included lectures, group discussions, field trips to community-based treatment and rehabilitation facilities, and supervised clinical experiences. Students who participated in the program reported being less discouraged about working with chronic mentally ill patients and more likely to choose careers in public psychiatric settings.     

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Nigeria

Nigeria, with a population estimated at 80 million, has fewer than 100 psychiatrists and psychologists and only 20 psychiatric facilities. Most chronic mental patients are cared for by their relatives, by traditional healers, or by religious healers affiliated with the new Christian churches, which have proliferated in recent years. Lack of organized social welfare services makes the family the only consistent source of social support for the mentally ill; patients who lose contact with their families often become homeless wanderers. Although the majority of the mentally ill in Nigeria are cared for outside the mental health system, recent developments, such as the establishment of mobile clinics and village-based psychiatric units, show great potential for advancing the treatment of chronic mental illness in Nigeria.     

Mental illness and admission to general hospitals: a register investigation

Admissions to psychiatric departments and general hospitals in an 8-year period were studied for the 17- to 49-year-old population in 2 Danish municipalities. Information was extracted from the National Patient Register and the Danish Psychiatric Register, registers containing information on all admissions to nonpsychiatric and psychiatric departments, respectively, in Denmark. Fourteen percent of the patients who had been admitted at least once to a general hospital (or 7.5% of the background population) had an indication of a mental disorder. They comprised one fourth of all general admissions of the population during the 8-year period. Patients who had been admitted to a general hospital had a 4 times greater risk of having been admitted to a psychiatric department than the rest of the population and the risk increased markedly with number of general admissions. A pronounced association was found between the number of admissions to general hospitals and psychiatric departments; i.e., both types of admissions clustered in some individuals. The excessive general admissions of psychiatric patients were found to be correlated to all types of psychiatric diagnoses, but was less prominent in nonorganic psychoses. The implication is that there is a very close association between somatic and psychiatric morbidity and that the mentally disturbed use a great part of the nonpsychiatric health services.     

Treatment, care, and rehabilitation of the chronic mentally ill in Sweden

For the last 20 years in Sweden, there has been a trend to integrate psychiatry with general medical services. However, mental hospitals remain the dominant resource for psychiatric care, with psychiatric units in general hospitals providing less than 20 percent of psychiatric hospital beds. The imbalance between the high number of inpatient facilities and the low rate of outpatient visits is beginning to be corrected by the newly introduced sector system, which allocates mental health care resources among geographic zones. The sector system has been criticized, however, because some believe it is fostering disintegration of existing resources and loss of research opportunities. A general spirit of improvement exists, but at the same time the public budget is being squeezed.     

Health care utilization by persons with severe and persistent mental illness

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.     

Treatment of offenders with mental disorders: focusing on prison psychiatry

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.     

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.     

Thioproperazinbehandling,en “pilot study”

Nordentoft M. Deinstitutionalization and homelessness among the mentally ill – a historical review.

The number of psychiatric beds has decreased dramatically in the Western world during the past three decades. At the same time there has been a shift in psychiatric care from being mainly custodial in big asylums to a more active, often psychotherapeutically oriented treatment in the psychiatric departments of general hospitals or in community mental health centers. This development has benefited many psychiatric patients, but during the same period severely ill psychiatric patients, mostly schizophrenics, have dropped out of psychiatric care and are now in increasing numbers to be found in jails, in board-and-care homes, or homeless in the streets. It is stressed that there is a need for analysis of the cause of homelessness among psychotic patients and of development of aid programs that can be accepted by this specific group of patients.     

Development of Community Care for People with Schizophrenia in Chile

Chile has greatly reformed its approach to psychiatric care in the last two decades, having transitioned from a model centered around a psychiatric hospital to one in which mental health care is based in the community. During this period, patients were moved from large psychiatric hospitals into ambulatory clinics, and the number of people who were in hospitals for extended periods decreased. At the same time, mental health service networks—consisting of ambulatory clinics, day hospitals, rehabilitation centers, and community group homes—were created, each responsible for a specific population. The reform process, however, has occurred in different, unequal degrees throughout the country. The purpose of this investigation is to compare the characteristics, resources, and results of the mental health service networks that have successfully transitioned to and developed in the community with respect to those that are still centered in a hospital. The structural aspects were evaluated with the EvaRedCom-TMS (Evaluación de Redes de Servicios Comunitarios para Trastornos Mentales Severos), and the level of functioning was measured with World Health Organization's International Classification of Mental Health Care. Area networks with higher levels of community-based services show better indicators of geographic and financial accessibility, use less human resources (particularly psychiatrists and nursing assistants), have an equal level of specialization, and yet show better treatment adherence among the patients (84.2 percent versus 41.8 percent), despite the fact that the patients have worse socioeconomic and clinical indicators than area networks with lower levels of community-based services. In conclusion, the community-based psychiatric care model is more effective than the hospital-centered model.     

中国精神卫生机构中的专业人员数量和特征

背景：精神障碍在我国疾病总负担中占有相当大的比例,但可提供于精神障碍患者心理卫生服务的专业人员数量,分布和特点还是未知数。目的：全面了解我国精神卫生机构人力资源分布现状和特点。方法：从卫生部统计信息中心获得2010年在中国精神卫生机构中工作的卫生技术人员的数量和特征,比较七个地理区域精神卫生专业人员的人口比例和特征。结果：在757家精神卫生机构内,649家（86％）是精神病院。在这些机构内卫生技术人员共计68,796人（5．16人／lo万人口）,包括精神科医师20,480人（1．54人／lo万人口）和注册护士35,337人（2．65人／lo万人口）。超过80％的卫生技术人员都工作在精神病院。29％的精神科医生人仅具有技校学历,而14％的精神科医生没有学位。在护士中有46％的护士没有学历。我国经济比较落后的北部地区精神科医生或护士的工龄较其长。在我国相对较富裕的东部和东北部地区,精神卫生机构中执业医师和注册护士的人口比例要高于平均水平。结论：我国几乎所有的精神卫生技术人员都工作在精神科专科医院。训练有素的卫生技术人员在数量和地区的分布上远远无法满足人们对卫生健康的需求。与其他中上等收入国家相比,我国每10万人口拥有的精神卫生资源较少,所能提供精神卫生服务的专业人员范围也较窄。     

On the admittance of forensic patients to general psychiatric wards

In Germany, due to an increasing number of "hospital order sentences," the capacities of forensic hospitals are exhausted. In the late 1990s,general psychiatric hospitals admitted a remarkable number of mentally disturbed offenders. In this study,data of 140 patients treated in general psychiatric hospitals in the German lower Rhine region are presented. These patients clearly differ from those treated in forensic hospitals. Approximately 60% of them suffer from schizophrenic psychosis. Only a few reveal a long antisocial background, a severe personality disorder, or a sexual offence as an index crime. Though the staff in the general psychiatric units often complain about the circumstances of patients' admittance to the hospitals, in about half of the cases they do not agree with a transferring of their patients to a forensic hospital. The results of this study are discussed in regard to general questions of organizing forensic psychiatric treatment.     

Has the public taken notice of psychiatric reform? The image of psychiatric hospitals in Germany 1990–2011

Purpose

In the context of mental health care reform in Germany, psychiatric hospitals have been transformed in terms of their infrastructure, staffing levels and therapeutic culture. The question arises as to what extent these improvements had an impact on the public image of these institutions.

Methods

In 1990 and 2011, population surveys were conducted in the “old” states of Germany, using the same sampling procedure, interview mode and measures.

Results

Over the last two decades, attitudes toward psychiatric hospitals have improved considerably. This improvement was particularly pronounced among those who had been in treatment for mental health problems. The public is now more inclined to regard psychiatric hospitals as similar to other hospitals, more ready to expect effective treatment in psychiatric hospitals, and less inclined to support the stereotype that psychiatric hospitals are primarily places where patients are locked away. However, there was a stronger tendency to agree with the notion that psychiatric hospitals are necessary to protect society from persons with mental illness.

Conclusions

The improvement of psychiatric care seems to pay off as regards the image of psychiatric hospitals among the general public. Further efforts are necessary to reduce the stigma attached to mentally ill people.     

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.     

Excluding institutions for mental diseases from federal reimbursementfor services: strategy or tragedy?

A key component in the dehospitalization of persons with chronic mental illnesses and their translocation to a wide range of settings has been the shift from state to federal funding encouraged by the Social Security Administration's restrictions on funding for institutions for mental diseases (IMDs), usually referred to as the IMD exclusion. The overall effect of the exclusion, which limits federal funding for mentally ill patients receiving care in many settings, including state psychiatric hospitals, has been to create incentives for states to move patients out of state hospitals, which has contributed to homelessness and inappropriate incarceration. The author traces the background and development of the IMD exclusion, starting with the federal government's actions in the 1840s ensuring that the states, not the federal government, would continue to fund care for their seriously mentally ill citizens. He also analyzes Congress' many missed opportunities to pass legislation that would have modified, or perhaps even made moot, the IMD exclusion, including the Clinton administration's efforts at health reform, the quest for parity of insurance coverage for mental illnesses, and the initiation of public-sector managed care. The consequences of the continuation of the IMD exclusion are explored, and the intended fiscal consequences are contrasted with the unintended clinical outcomes.     

Crossing state lines of chronic mental illness

A federal law passed in 1986 required states to develop service plans incorporating each state's own definition of chronic mental illness. This study considered whether the state definitions can be used to identify comparable populations of chronic mentally ill patients and to obtain a meaningful national estimate of the number of such patients. The study applied definitions of chronic mental illness used in ten states to a representative sample of patients receiving public mental health services in West Philadelphia over a two-year period. The prevalence estimates of patients defined as chronically mentally ill ranged from 38 percent using the Hawaii definition to 72 percent using the Ohio definition. The National Institute of Mental Health definition, used as a reference point, produced a prevalence estimate of 55 percent. The authors conclude that the considerable variance among the states in prevalence estimates renders the sum of state counts of chronic mentally ill patients of limited use.     

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period. METHODS: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers. RESULTS: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years. CONCLUSIONS: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.     

Accueil familial thérapeutique. Historique et évolutions récentes

The aim of foster care is to treat patients in a stable environment provided by foster home caregivers paid by a hospital. This mode of treatment has its distant origin in the legend of Saint Dymphna, Irish princess. This princess, exposed to the incestuous ardours of her father the king, decided to flee with her confessor, Gerebene. They landed in Flanders Geel, where she was eventually found by her father and beheaded in the public square. At the same moment an insane recovered his health. Since then, Geel became a pilgrimage for the mentally ill, who stayed there in a family for a fee. In France, the first mental health Act dates back to June 30, 1938. It required that each “department” or district has a psychiatric hospital. At the end of the xixth century, these institutions were overcrowded with chronic patients, incapable of returning to normal life. The psychiatrist August Marie created institutions then called “Family colony” to accommodate these patients. These institutions located in the Centre of France, treated as many as 1345 patients (Dun-sur-Auron) and 1145 patients (Ainay-le-Château). A new act codified this practice in 1989, defining a recruitment procedure for caregivers, specifying the facilities they should offer and the continuity of care they had to insure. Various mental hospitals then created Foster Care units. The hospitals ensuring foster care have to comply to quality controls by the High Health Authority. They offer hospitalization units for the treatment of acute psychiatric of medical episodes. Foster care thus includes these partners: a patient, a caregiver, a mental health and medical team. According to a report in 2011, 3800 patients were treated by foster care that year. The cost is estimated at the rate of 240 € per day, much lower than traditional hospital treatment, but with a better quality of life for beneficiaries.     

Treatment of patients with personality disorders in specialized units for psychotherapy in Bavarian psychiatric hospitals

Data about patients with personality disorders treated in specialized psychotherapy units in bavarian psychiatric hospitals during the second half-year 2001 (n = 256) were collected by a questionnaire. Diagnostic, therapeutic and social characteristics were registered. Treatment possibilities of the psychotherapeutic units und special qualifications of the staff were investigated as well. - RESULTS: The investigated population of personality disorders is mentally seriously handicapped has high rates of suicide-attempts and co-morbidity with other mental disorders. The units for psychotherapy offer a wide range of different psychotherapeutic treatments. The staff is well trained in psychotherapeutic qualifications. These results show, that bavarian psychiatric hospitals play an important role in psychotherapeutic treatment of severely ill in-patients.     

Social skills training for psychiatric patients, II: Clinical outcome studies

In this second paper on social skills training for psychiatric patients the author critically reviews the controlled clinical outcome studies of social skills training in a number of psychiatric populations: mentally retarded persons, depressed patients, psychiatric outpatients, and psychiatric inpatients. He points out that more research is needed to determine the effectiveness of social skills training, especially for patients with debilitating chronic mental illness.     

Mental health services in Slovenia

BACKGROUND: Development of mental health services in Slovenia has some originalities described in the present article. Slovenia is a small Central European country with a population of 2 million. Its mental health system has been influenced by the western de-institutionalization movement and eastern models of care which are predominately institutional. AIMS: Mental health reform in the 1970s was a silent one with displacement of long-term psychiatric patients to old-people's homes, asylums and to their families. During the last decade community mental health services have been established in the non-government sector, primarily as social institutions providing support to patients with severe mental illness. Psychosocial rehabilitation movement changed some therapeutic approaches in hospitals and has been gaining more and more influence in the NGO services. RESULTS: The article describes Slovene psychiatric hospitals and community rehabilitation services. Mental health services in Slovenia are compared to services in Slovakia, the United Kingdom and The Netherlands. CONCLUSIONS: The authors are proposing guidelines for future development of mental health services for the severely mentally ill in our country in order to improve the present deficient state of care.