Health care of the chronically mentally Ill: The culture broker model

The chronically mentally ill tend to receive inadequate medical care for nonpsychiatric illnesses and to have poor health care status. Their medical problems lead to excessive morbidity and mortality and adversely affect their adjustment to psychiatric illness. The authors argue that many of the barriers to medical care for these patients can be overcome by using case managers as culture brokers—persons who provide bridges between the worlds of the chronically mentally ill and medical providers. This paper presents the culture broker model and its roots in anthropology, and illustrates its application to the medical care of the chronically mentally ill with case examples.     

A comparison of schizophrenic patients in different community support treatment approaches

Recent advances in the care of the chronically mentally ill in the community have resulted in a community support system approach to maintaining chronically mentally ill persons outside the hospital. Yet, very little is known of what a community support system actually is for the chronic mental patient. This paper looks at three different sorts of community support programs and compares a sample of patients within them with respect to network variables, role performance, and demographic variables. Implications regarding the use of network oriented approaches are discussed and directions for further research are explored.     

Predictors of cancellation in an oregon involuntary commitment program

The problem of attrition from mental health care programs before such services begin is poorly understood. The present research has identified several variables which predict first appointment cancellations for Oregon involuntary committment petitioners in behalf of potential clients. The value of such variables is discussed in terms of petitioner attrition from involuntary commitment programs, mental health needs of those petitioning for the involuntary commitment of allegedly mentally ill persons, increased mental health program efficiency, and economic benefits for underbudgeted and understaffed mental health care programs. Recommendations to improve community mental health programs in general, and involuntary commitment programs in particular are presented.     

Utilization of acute inpatient psychiatric services: “Heavy users” in New York State

The severely and persistently mentally ill (SPMI) population are often forced to rely on emergency/acute inpatient services. The authors analyze Medicaid expenditures and state hospital utilization data to identify and describe the characteristics of heavy users of these services. Also described is New York State's intensive case management (ICM) initiative targeted at this heavy user group. It is postulated that ICM will alter the utilization patterns of participants from over-reliance on the most costly services and more effectively and efficiently serve the SPMI population, specifically the heavy user subpopulation.     

Continuity of care for the severely mentally ill: concepts and measures

Very few useful measures of service functioning are as yet available for the evaluation of mental health services. Continuity of care has been identified as the strategic first choice for the development of such process measures. The term continuity has been used to refer to a variety of important aspects of service functioning, including whether services maintain contact with patients, whether patients consistently see the same staff, success of transfer between services, degree to which plans for services are followed through, integration between service providers, and comprehensiveness in meeting patient's individual needs. In this paper, we reviewed the main theoretical definitions of continuity of care for the severely mentally ill, and discussed the work that has attempted to operationalise these definitions and to apply them in the study of mental health services. We concluded that whilst continuity of care has had a central place in theoretical discussions of community service planning, progress in developing and applying practical measures has so far been sporadic and limited. Obstacles to such research have included great diversity in definitions of continuity and the confounding influence of individual patient characteristics on the relationship between service process and outcome. Despite these limitations, research in this field has indicated that developing and applying measures of continuity of care may be feasible and produce useful results, with findings of some of the studies suggesting a relationship between continuity of care and individual outcome.     

Economic predictors of admissions to inpatient psychiatric treatment in Sweden

Abstract.Background: The ecological association between contracting labor markets and admissions to inpatient psychiatric treatment has been widely replicated, but little understood, in the United States. Its explanations include the uncovering mechanism that assumes a contracting labor market does not increase the incidence of illness, but rather decreases the ability of chronically ill persons or their families to pay the direct and indirect costs of outpatient care. Without such care, some of these persons supposedly become more ill and eventually require inpatient treatment subsidized by the state. This explanation would not apply to a society with universal access to high quality mental health services. The uncovering mechanism, therefore, would be less compelling if the ecological association were found in such a society. We apply time-series methods to data for the 336 months beginning January 1973 to determine if the association appears in Sweden.Results: Consistent with the findings from the United States, inpatient admissions of Swedish men and women move inversely over time with changes in the number of each employed.Conclusions: The uncovering mechanism cannot explain the Swedish findings. Its rivals, including the argument that economic contraction either increases the incidence of illness or reduces tolerance for the persistently mentally ill, deserve more attention at least in countries with universal access to care. We offer research strategies for discriminating between these remaining rivals.     

Applying the Readiness to Change Model to Implementation of Family Intervention for Serious Mental Illness

Family intervention for serious mental illness is known to be highly efficacious in reducing patient relapse, improving social functioning, enhancing caregivers knowledge of mental illness, and ultimately reducing overall costs of care. However, very few families receive services. The reasons for this gap between empirical findings and program implementation are complex and not yet fully understood. Prochaska and DiClementes Readiness to Change Model provides a helpful structure for understanding key issues for the four relevant stakeholders (patients, family members, clinicians and administrators). Staging each stakeholder group and applying corresponding interventions (processes of change) are useful in a sites implementation of family services.     

Effects of fiscal retrenchment on public mental health services for the chronic mentally Ill

In reviewing the public mental health services of 11 California counties during a period of fiscal retrenchment, we found several common trends: a greater focus on the severely mentally disabled; an increase in utilization of hospital-based care, residential treatment, day treatment, and case management services; and a decrease in the capacity of traditional outpatient services. Although the severely mentally disabled are receiving a higher priority for service, the findings imply that these service systems continue to inadequately address the need for long-term maintenance and supportive services to this population.This study was supported by grant MH 343743 from the National Institute of Mental Health. Reprint requests should be sent to Mr. Surber, Room 7M, 1001 Potrero Avenue, San Francisco, CA 94110.We use the term chronic mentally ill in this paper to be consistent with the other articles in this issue, although we generally prefer the term severely mentally disabled to describe this population.     

Diagnosing Depression in African Americans

Since the 1970s, articles have noted the increased presence of psychotic symptoms among depressed African Americans, the presence of diagnostic bias identified when structured clinical interviews are used, and the identification of misdiagnosis of affective illness among chronically, mentally ill, African Americans. This paper reviews this literature and describes three alternative presentations of depressive illness among African Americans that differ from the DSM IV criteria for Major Depressive Disorder: the stoic believer, the angry, evil one with a personality change, and the John Henry doer. Clinicians are encouraged to recall these presentations of depression when evaluating African American patients.     

Staff model HMO's and managed mental health care: One plan's experience

HMO staff model mental health programs have particular expertise in providing these services in an integrated fashion within the context of a total medical care system. Carve-out approaches to managed mental health care risk losing the added value found in primary care based integrated mental health services. Employers as purchasers of care are seeking demonstrated value in services, and the rise of specialty mental health managed care firms is bringing the efficiencies of managed mental health care familiar to HMO's to a broader audience. Faced with employer concerns, and this new competitive environment, many HMO's are examining their mental health services to determine how these services may respond to the needs being expressed by employers today for new program options. The Community Health Plan's (CHP) experience is presented to illustrates one approach HMO's are taking in today's competitive health care environment.     

Training in Community Psychiatry: New Opportunities

The authors describe the impact on training that accompanied an assignment of senior (PGY-4) residents to work one-half day each week for a six month period at a community-based agency concerned with the care of persons with severe and persistent mental illness who were formerly homeless. As the goals and methods of psychiatric training are rethought and adapt to programmatic shifts and economic pressures, new opportunities open up to move treatment and training to the front lines in the community where an innovative therapeutic armamentarium for persons with severe and chronic mental illness is developing.     

Attitudes toward mental illness: Recognition,desired social distance,expected burden and negative influence on mental health among Turkish freshmen

Summary Attitudes toward three types of disorders and a normal subject portrayed in vignettes were assessed among university students. The variables assessed were: perception of mental illness in the vignettes; desired social distance; emotional and physical burden expected; and expected negative influence on one's mental health from association with the type of persons portrayed in the vignettes. Analysis revealed that, in terms of variables assessed, the most negative ratings were recorded for the paranoid schizophrenic case and the most positive recorded for the normal subject. The simple schizophrenia and the anxiety neurosis/depression cases fell between the other two cases. Finally, with a few exceptions, all the variables assessed were significantly correlated with each other.     

Styles of Case Management: The Philosophy and Practice of Case Managers

A great deal of discussion and research has gone into defining and clarifying the role of case manager (CM) for persons with severe mental illness. This three state survey examines the philosophy and activities of practicing CMs in an attempt to identify current styles of case management. A cluster analysis based on CM rankings of five CM functions suggested four styles of case management: supportive social worker, individual therapist, therapist broker, and community advocate. Overall, CMs rated supportive interventions as most important and formal psychotherapy as relatively unimportant. CM style was related to CM activity (i.e., distribution of effort). Differences between states are noted and implications for future research are discussed.     

The state mental hospital in transition: A review of principles

It is proposed here that the state hospitals will, through a transitional experience, become true community-oriented treatment facilities with the full range of services associated with a comprehensive community mental health center. The state hospital will have to continue to act in the role of a chronic disease hospital. It will have to continue to care for and innovate new treatment techniques for the hard-core refractory group of patients who suffer from persistent and severe disorganization of personality and severe asocial behavior due to psychotic causes. Even here one should be careful in the use of terms like chronic and intractable. Rehabilitation programs for these patients may in fact turn out to be feasible and the state hospitals may be the research centers where these solutions are found.     

Adopting innovations--lessons learned from a peer-based hospital diversion program

Moves to bridge the gap between research and practice have heightened interest in how service innovations are adopted. This paper reports on a peer-based hospital diversion program that provided short-term respite care, clinical monitoring, connection or re-connection to other mental health services, and peer support. The program was successful in providing services to the target population and was viewed as highly desirable by service recipients and clinical agencies. However, full adoption of this innovation was not realized and it closed barely a year after opening. Lessons learned from both the life and death of this program are offered.     

Chronic mental hospital dependency as a character defense

Summary Prolonged hospitalization may cause atrophy of the patient's self-confidence, through excessive dependent gratifications of an oral-receptive nature. Hospital dependency results, and the possibility of discharge arouses such anxiety that the patient exhibits increased psychotic behavior with the effect of maintaining the hospital adjustment. Certain persons are excessively predisposed by previous experience to develop this dependency. The basic predisposition, however, is rooted in the normal course of childhood development.Hospitalization results in three major gains for the mentally disturbed patient: (1) primary relief from anxiety caused by instinctual impulses overwhelming the ego defenses; (2) secondary gains resulting from the socially-recognized sick role; and (3) the satisfactions of becoming an accepted member of a stable social system. If a mental patient is hospitalized, the danger of chronic dependency must be recognized and guarded against. Limited hospitalization is an important therapeutic modality, but as with other therapies, excess may cause secondary complications.Therapy of the chronic patient seeks first to convert dependence on the hospital as an ego-fortifying agent into a general confidence that help will be available if needed. Subsequently, the therapy aims to work through the secondary gains of illness byh viewing psychotic behavior as resistance to giving up the hospital. For the purpose of therapy, the chronic patient is viewed as environmentally-oriented, his behavior as based in present reality; and his active co-operation as essential to any change.The author, now program chief, mental health section, County Department of Public Health and Welfare, San Mateo, Calif., takes full responsibility for the contents of this paper, but wishes to acknowledge his intellectual debt to the staff of the Winter Veterans Administration Hospital, Topeka, Kansas.     

Community absorption of the mentally ill: The new challenge

In 1975, twelve years after enactment of the Community Mental Health Centers Act, we find one of the greatest obstacles to fulfillment of our hopes to be pervasive hostility to acceptance of the mentally ill in many communities. The River Region Program has hurdled this obstacle by breaking the artificially large mental health catchment areas into manageable segments of 16 smaller service areas close to the people it serves in seven counties of Kentucky. In each of these service areas it has involved a broad spectrum of citizens in the planning of every service. All of this is of particular relevance today in light of the Supreme Court's D,onaldson decision, that mentally ill persons cannot be confined involuntarily if they are not dangerous and can live safely in the outside world. The outside world must be prepared to receive these people, and we in the mental health field must do our job in this vital preparation.Mr. Gorman originally presented this paper as a speech at the Annual Dinner, of the River Region Mental Health — Mental Retardation Board in Louisville, Kentucky, on June 20, 1975.     

An Ethnographic Study of the Longitudinal Course of Substance Abuse Among People with Severe Mental Illness

A two-year ethnography conducted among 16 dually diagnosed clients yielded two longitudinal findings. First, four positive quality of life factors were strongly correlated with clients' efforts to cease using addictive substances: (1) regular engagement in an enjoyable activity; (2) decent, stable housing; (3) a loving relationship with someone sober who accepts the person's mental illness; and (4) a positive, valued relationship with a mental health professional. Second, the study revealed that five negative background factors in participants' childhood homes were predictive of long-term continuation of substance use: (1) substance abuse in childhood home, (2) childhood household in dire poverty, (3) non-functional household members, (4) reporting of abuse imputed to care-givers, and (5) serious mental illness in household. The implications of these findings for treatment are discussed.     

Clinical and Human Resource Planning for the Downsizing of Psychiatric Hospitals: The British Columbia Experience

Riverview Hospital, B.C.'s only and Canada's largest remaining provincial psychiatric hospital began a formal planned downsizing process in 1992. This initiative was an important element in the Province's strategic plan to shift to a more community-focused mental health system and to bring tertiary psychiatric services closer to home by redeveloping Riverview Hospital on three sites. The paper summarizes the literature pertaining to the downsizing of psychiatric hospital services in relation both to clinical and human resource planning. It describes the mental health system in B.C. and the service system context in which this exercise is occurring. It is based on the first three years of experience in identifying the major challenges and the strategies developed to meet these challenges. It draws some conclusions about the effectiveness of these strategies and it speculates about the likely future challenges as the downsizing process continues.     

The whys and why nots of consumer participation

This paper takes another look at the role of the consumer in the planning and delivery of services, including mental health services. It raises the issue of consumer representation, explores the antecedents of national legislation requiring consumer participation, indicates problems related to participation and details some solutions. In particular, the paper questions the effect of such participation on the delivery of mental health services and challenges Nader's Raiders who question the representation on boards of Charity minded housewives, businessmen, lawyers, ministers, judges, and professional persons...