Families' perceptions of burden of care for chronic mentally ill relatives

Eighty-six family caregivers participated in small group interviews about their experience of burden in caring for mentally ill relatives. Families experienced profound burdens as a result of their interactions with the mental health care system, particularly in negotiating crisis situations; acting as patient advocates and case managers; obtaining adequate community resources, continuity of care, and information; dealing with legal barriers; and communicating with mental health professionals. Recommended methods of reducing family burden and improving the care of the mentally ill who reside in the community are family education, inclusion of the family in treatment decisions, changes in current mental health laws, redirection in professional training, and development of mobile crisis teams.     

A comparative trial of home and hospital psychiatric care. One-year follow-up.

The effectiveness of community-based treatment stressing home care was compared with hospital-based psychiatric care. One hundred and fifty-five patients destined for inpatient psychiatric care were randomly assigned to Home Care (76 patients) and to Hospital Care (79 patients). Symptoms, role functioning, and psychosocial burden on the family were similar at admission, one month, three months, six months, and one year. The mean in-hospital stay of Hospital Care patients was 41.7 days compared with a mean stay of 14.5 days for Home Care patients. The difference in the amount of ambulatory care received by patients in the two groups was not significant. The evidence is consistent: community-based psychiatric care is an effective alternative to hospital-based care for many but not all severely disabled patients. The active ingredients of successful community treatment are known, yet the lag in implementing these programs persists.     

Schizophrenia. A comparative trial of community orientated and hospital orientated psychiatric care

Sixty-five schizophrenic patients presenting for admission were randomly allocated into two groups. Control patients received standard hospital care and after-care. Experimental patients were not admitted if this could be avoided; instead they were taken back to the community by the Community Treatment Team who provided them and their relatives with comprehensive community treatment and a 24-h crisis service. During the 12 months study period 68% of the schizophrenic patients in the experimental group were not admitted; 10% were admitted two or more times and for 5 weeks or longer. All the schizophrenic patients in the control group were admitted--two-thirds or more times and for 5 weeks or longer. It was feasible to treat most schizophrenic patients in the community. Community treatment was considered by patients and their relatives to be the more satisfactory and helpful form of treatment and achieved a superior clinical outcome.     

The inpatient care of the chronically mentally ill

The inpatient treatment of the chronically mentally ill as it has been practiced in the past, is practiced at the present, and may be practiced in the future is discussed. The reasons for admitting the chronically ill to inpatient services; the steps of such treatment and treatment modalities employed; and considerations for discharge are presented. In addition, the indications as well as pros and cons for long-term inpatient hospitalization are included.     

Self-help: an association for relatives and friends of the mentally ill.

The support and practical help available to family and friends can be crucial to the successful community rehabilitation of many discharged psychiatric patients. This paper describes the self-help found within a group for family and friends of the mentally ill, sponsored by a voluntary agency. Conclusions are drawn about the roles professionals can play in such a program.     

Etiological and prevention views of clinicians with mentally ill relatives

In a survey of 84 experienced mental health professionals with family members suffering from long-term psychotic disorders, more than 70% ranked biogenetic variables as primary, regardless of familial relationship to the patient. Family interactions and parenting were minimized as etiological factors. Biochemical/genetic research, psychopharmacological research, and research on high-risk children were the highest ranked prevention priorities.     

The organization of the psychiatric service and criminality committed by the mentally ill

IntroductionOver the past 40 years, a marked deinstitutionalisation in favour of social and community psychiatry has taken place in many countries. During this same period of time, there has been an increase in the number of mentally ill criminals. The purpose of this study is to analyse the correlations between the reorganization of the psychiatric treatment system, the growing number of forensic patients and the increase in serious crime, homicide, arson and violence associated with the mentally ill.Materials and methodsUsing registers and other data sources, we estimated the annual positive or negative growth rate of consumed psychiatric beds and in social and community psychiatry (explanatory variables) and in prevalence and incidence of forensic patients, homicide, arson and violence (response variables) from 1980 to 1997 for each of the Danish counties. We analysed the immediate effect of the changing treatment structure by relating response variables to explanatory variables. The long-term effect was analysed in the form of between county analysis with both single and multiple regressions.ResultsBed closure had no immediate effect on either the number of forensic patients or serious criminality. The between county analysis shows, however, that over time the (negative) growth rate in number of consumed beds is significantly correlated with the (positive) growth rates for forensic patients, homicide and arson. Social and community psychiatry have little effect, if any.DiscussionThe study is based on historical data, but the results are still valid. We have used two sets of data firstly the number of forensic patients and, secondly the reported number of crimes associated with the mentally ill. The uniformity of the results leads us to consider them for certain: That the decreasing effort invested in inpatient treatment is causing an increase in the crime rate among the mentally ill.ConclusionMany forensic patients suffer from schizophrenia. These patients are not only offenders, but also the victims of an inadequate treatment system. Modern inpatient treatment facilities should be established.     

Level of caregiver burden among relatives of the mentally ill in South Verona.

Identifying the burden of care on relatives of the mentally ill remains an integral part of research in community psychiatric services. The present study aimed to assess the level and extent of burden on relatives in South Verona (northeast Italy). The South Verona catchment area provides a comprehensive, community-based psychiatric service with minimal reliance on the hospital. Patients were selected from the South Verona Psychiatric Case Register and 40 of their relatives were interviewed using structured assessments measuring objective burden, patient behaviour, coping strategies, satisfaction and needs for services. Both positive and negative aspects of burden were apparent, 92% of relatives continued to maintain contact with friends/relatives, 72% had no change to their family income, and 52% could manage any household disruptions during a crisis. The main negative effects for relatives included reduced leisure activities (57%) and psychological problems (67%). The greatest burden was on relatives of patients who were male (P = 0. 016), unemployed (P = 0.013) and diagnosed with psychosis (P = 0. 041). The implications of employment for patients and its association with lower levels of caregiver burden are discussed.     

Clinical care update: The chronically mentally ill

The service systems which assist the long-term mentally ill to function in the community have been routinely described as fragmented and uncoordinated. The development and implementation of case management has been seen as one response to this dysfunctional system. This article examines case management from the perspective that case management is a needed function no matter how coordinated and integrated the system.From this perspective, case management is driven by the clients' goals and not the systems' goals. Case management is viewed as a process by which the person with severe psychiatric disability is supported in negotiating for the various services that they want and need. Four unique activities are identified as performed by the case manager: Connecting with Clients, Planning for Services, Linking Clients with Services, and Advocating for Service Improvements.Case management must be seen as a uniquely human response to the client's specific service needs and overall goals. For persons with long-term psychiatric disabilities, case management brings to life the human dimension of the human service system.     

Ethnic differences in emergency psychiatric care and hospitalization in a program for the severely mentally ill

Ethnic differences in rehospitalization were examined in a program of intensive services for severely mentally ill hospital recidivists. The purpose was to determine whether ethnicity-related differences in psychiatric admissions observed in national data would appear among clients at great risk for hospitalization but enrolled in a program of case-managed care to promote community adjustment and tenure. After accounting for differences in prior emergency visits and hospitalizations as well as sociodemographic and clinical differences, blacks were found more likely than whites to visit the psychiatric emergency room and to be hospitalized. The marked needs of the severely mentally ill and the intention to address these needs with services did not obviate the continuing importance of racial differences in explaining reliance on inpatient sources of care.The authors gratefully acknowledge the assistance of Amy Wachtel, David Fariello, and Jeff Kline in the collection of the data used in the analysis reported here. A version of this paper was presented at the Annual Meeting of the Society for the Study of Social Problems in Washington, Dc on August 9, 1990     

Community care for the chronically mentally ill

This article has presented the background, history, examples, and analyses of community care programs for the chronically mentally ill. From these data, it is concluded that such programs are as if not more effective an cost-efficient than conventional inpatient programs plus conventional follow-up for this population. The future, however, may depend much more on current political and economic trends than the scientific data available.