A comparative study of psychiatric outpatient treatment in two geographically defined populations

Asignificant change in the pattern of psychiatric care has taken place over the last decade, including the reorganization of the traditional mental hospitals, the establishment of psychiatric wards in general hospitals, the trend toward outpatient as opposed to inpatient care, and the increasing recognition of the importance of community psychiatry.^1–4 But few attempts have been made to discern whether categories of patients get the same treatment at different types of outpatient clinics. It would be interesting to know if, for example, a psychotic patient will get similar treatment and have a similar chance for admission in a community-oriented clinic and an outpatient clinic affiliated with a hospital.The present investigation was carried out in order to describe the demographic and diagnostic characteristics of psychiatric patients treated at two types of outpatient clinics and to compare the psychiatric service of a clinic affiliated with a psychiatric ward at a general hospital to a clinic forming part of a community psychiatric project. Recent data concerning general information about both these services have been published by Kastrup et al.⁵ and Nielsen.⁶     

Treatment prevalence in a community mental health service with special regard to depressive disorders

In the community psychiatric service in Samsø, 1.24% of the male population and 3.1% of the female population were in treatment on April 1. 1976. Approximately two-thirds of the patients had 1 or 2 referrals, the rest had 3 or more. Of the 1222 consultations, 74% were home visits. Thirty-one percent had a treatment period of less than 1 year. Only 35% of the patients in treatment had previously been hospitalized in psychiatric hospitals and 21% were in a psychiatric hospital on prevalence day.Patients with manic-depressive psychoses comprised 38% of those in treatment, giving a treatment prevalence for manic-depressive disorders of 7.7 per 1000 population.A number of the patients with manic-depressive disorders had previously been treated under the diagnoses of depressive or anxiety neuroses. It is our experience that many patients with signs of depressive neuroses are, in fact, manic-depressive and respond very well to tricyclic antidepressive drugs.When comparing the incidence for manic-depressive disorders in the Samsø clinic, the Århus county register, and Danish psychiatric hospitals we found a significantly higher incidence in Samsø with 2.38 per 1000 compared with 0.62 per 1000 for the Århus county register and 0.28 for Danish psychiatric hospitals.The purpose of the present study has been to analyze a number of conditions concerning the patients in treatment on April 1. 1976, in a community psychiatric service in a Danish geographically delimited rural population. In Denmark such one-day prevalence studies have previously been made for psychiatric hospitals.^1–4 but not in a community psychiatric service.     

The decision to use ECT: A retrospective study

There is a paucity of literature on electroconvulsive therapy (ECT) utilization in hospitals. No mention occurs in major psychiatric texts.^1,2 Fink³ found only three studies.^4–6 Hedlund et al.⁷ reported on the declining use of ECT in Missouri from 1971 to 1975. All these studied agree that there are low use rates in public hospitals (0.1%–1.7%) and much higher rates in private hospitals (5.2%–28.0%).ECT has been used in two different settings at Long Island Jewish-Hillside Medical Center, a private, nonprofit voluntary hospital. The Hillside Division has 202 psychiatric beds with treatment provided by salaried staff. Long Island Jewish (LIJ) has 490 beds, 20 of which are for treating psychiatric inpatients by private attending physicians. Between April 17, 1973, and July 19, 1976, 69 of 4,236 Hillside inpatients (1.16%) and 115 of 969 LIJ inpatients (12.1%) received at least one ECT treatment. The Hillside rate was indistinguishable from the public hospital rate and significantly different (χ² ? 247.5, df = 1, p < 0.0001) from the higher LIJ rate which was consistent with rates found in private hospitals.This retrospective study was undertaken to assess preliminarily what factors may have affected the decision to use ECT at the Medical Center, with the expectation that it might help explain the different utilization rates reported in the literature.Another purpose for the study related to the problem of predicting improvement from using ECT. Attempts at predicting improvement have met with variable success.^8–11 Mendel^12–15 has developed and validated a weighted factor index to predict improvement which appeared promising. We attempted to replicate his approach on the Hillside sample. Replication for the LIJ ECT-treated patients was not possible due to insufficient data.     

Psychiatric disorders and the need for mental health services among a sample of orthopedic inpatients.

This report concerns psychiatric disorders and the need for mental health services among patients admitted to a general orthopedic surgery service. The planning of mental health services for medical and surgical inpatients in terms of current community mental health concepts is discussed.It has been observed that patients being treated for medical or surgical conditions have a higher than expected incidence of psychiatric disorders.^1–6 Previous studies of inpatients with orthopedic or other surgical conditions report a wide range (19%–86%) of psychiatric disorders depending upon the diagnostic criteria employed. In spite of the documented need for mental health services among such patients, primary physicians are often reluctant to request psychiatric consultation, and the psychiatrist is usually consulted only when a patient presents a difficult management or diagnostic problem.^3,7,8 Thus, many other medical or surgical patients could benefit from mental health consultation if their needs could be identified.In recent years, psychiatrists have become more involved in the functioning of general medical services, with consideration being given to the application of the principles of community mental health to the consultation services.^2,4,9–12 Psychiatrists have participated in indirect consultation through the medical and nursing staff in addition to providing direct consultation within medical and surgical settings. In planning this type of consultation service, more information is needed about the kinds of mental health problems experienced by medical and surgical patients.     

Neurological side effects of lithium: Organic brain syndrome,seizures, extrapyramidal side effects,and EEG changes

The precise mode of action of lithium carbonate on the central nervous system (CNS) is still far from clear. However, there have been some speculations based on the electroencephalogram (EEG) findings to suggest that lithium has both cortical and subcortical effect on the CNS.¹Rochford et al.² found that 36.8% of young adult psychiatric patients showed neurological abnormalities, but only 5% of normal controls showed such deficit. However, they found no neurological impairment, whether diffuse or localized, including EEG abnormalities, among patients with affective disorders. This investigation, which included 65 patients of both sexes and extended over a period of 1.5 yr was intended to examine the earlier claims^3–5 that CNS dysfunction plays an important role in the pathogenesis of functional psychiatric disorders.These findings have important implications in that one may anticipate a higher incidence of lithium-induced neurotoxicity in the treatment of psychiatric patients suffering from other than primary affective disorders.⁶ This article reviews the neurological complications arising from lithium carbonate treatment of primary affective disorders and schizoaffective disorders.     

An epidemiologic study of deaths of psychiatric inpatients.

There have previously been several studies of deaths of psychiatric inpatients, mainly in northern European countries and the U.S.^1–10 Alström,⁶ Odegard,⁷ and Malzberg⁸ reported that the patients admitted for the first time to mental hospitals have a relative risk of death four to ten times higher than that of the general population and concluded that this was attributable to conditions specifically associated with the hospital facilities and with the hospitalized patient group.The physical conditions of mental hospitals have undergone major changes over time and so have the psychologic and social characteristics of hospitalized patient groups. As a result, factors associated with patients' deaths have also been subject to changes with this passage of time. From the epidemiologic point of view, studies of psychiatric patients who have died in mental hospitals may therefore raise interesting questions.Using two sources of information, i.e., death certificates and mental hospital discharge records, the author has investigated all psychiatric patients who have died in the mental hospitals of Kanagawa Prefecture for 3 years. These deaths have then been related to total deaths in the general population of the Prefecture in the same period.     

A study of the inpatient service of a Nigerian psychiatric hospital

Psychiatric hospitals and psychiatric units of teaching hospitals are gradually replacing the “civil asylums” in prisons, for the care of mentally ill patients in Nigeria.According to Boroffka,¹ 15 of such asylums still exist in addition to eight psychiatric hospitals and four psychiatric units situated in teaching hospitals. The phasing out of these asylums is due partly to the availability of more effective treatment for mental disorders and increasing numbers of psychiatrists in the country.Apart from Anumonye² and Jegede and Adaranijo,³ who have described the pattern of psychiatric practice in a psychiatric unit of a teaching hospital with four beds, no comprehensive information exists on the types of psychiatric patients requiring admission, either for a long- or a short-term stay and the management pattern and the relationship of such management to the underlying psychiatric illness. The present study is a preliminary report of a long-term longitudinal study, which aims at investigating both of the above problems, using the inpatients of a large psychiatric hospital.     

Characteristics of patients completing referrals from an emergency department to a psychiatric outpatient clinic

Many patients referred from emergency departments for psychiatric outpatient treatment fail to make contact with the facilities to which they have been referred.^1–4 Completion rates in the range of 7.1%–63% have been typically reported.^2,3,5 While diverse explanations such as the method of referral³ and characteristics of facilities¹ have been suggested as determinants of the low completion rate, research has focused largely on demographic characteristics of the patients referred.^3,5,6 For example, patient's sex,^2,5 socioeconomic status,¹ race,⁵ and age^2,3 have been found to relate to the completion of referrals made in the emergency department.While the clinical characteristics of psychiatric emergency department patients have received some attention, studies have focused more on describing these patients^6–9 than on investigating the relationship between their characteristics and successful completion of referrals. Furthermore, studies which have attempted to relate clinical characteristics to completion rates,^2,4,10 along with those focusing on demographic characteristics, have tended to overlook the question of whether patients who failed to complete their referrals to a particular facility actually made contact with some other psychiatric facility.The purposes of the present study are (1) to investigate both the demographic and clinical characteristics of patients who successfully complete referrals from a psychiatric emergency department to a psychiatric outpatient clinic and (2) to determine by means of a thorough follow-up the characteristics of patients who failed to complete the referral but sought treatment elsewhere in the community.     

General hospital psychiatry: Are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.     

Psychiatric diagnostic predispositions to alcoholism

Various authors have described pre-alcoholic psychopathology in female problem drinkers;¹ however, actual studies of rigorously defined antecedent and concurrent psychiatric disorders have been few. More recently, several authors have reported that both affective disorder and antisocial personality are quite prevalent as primary diagnoses in hospitalized alcoholic women,^2,3,4 but the risk of subsequent alcoholism in women with these and other psychiatric syndromes needs to be clarified. In this study we investigate the prevalence of alcoholism in three populations of women with serious psychopathology. The first is a sample of psychiatrically hospitalized women with a history of depression at some time in their lives (hospitalized sample); second is a felon sample of women on probation and parole (felon sample); and third is a sample of female narcotics addicts admitted to the United States Public Health Service facility at Lexington, Kentucky for detoxification and treatment (Lexington sample). Our data set is unique in that despite being collected at different times and at different locations, uniform diagnostic criteria and uniform interview schedules were employed.^5,6     

Depressives syndromes in a primary care setting: Evaluation,classification, and outcome

Fifteen percent of the general population may experience a major disorder of mood during their lives.¹ Their care falls to the greatest degree upon the primary physician.² A general practitioner may be chosen for the first contact by an estimated 88% of individuals fearing an experiencing psychologic disturbance.³ As many as 63% of community based mentally ill (n = 490,000) may receive their psychiatric treatment from a general practitioner.⁴ This prevalence is further enhanced by the observation that psychiatric patients represents a high medical utilization group when contrasted with nonpsychiatric controls.⁵Since the depressive syndrome is of diverse etiology, and may present under the guise of a physical complaint, a comprehensive evaluation should include a personal and family history, physical and mental status examination, and appropriate laboratory tests. While family practitioners may spend from 17% to 27% of patients care time dealing with emotionally related problems,⁶ some 60% of the American Academy of Family Physicians reported “insufficient training in medical school” to deal with their patients' emotional problems. A comprehensive data base (Table 1) was contrasted with the practices of second and third year family practice residents by a prospective study of recently diagnosed “depression” at a community primary care center.     

A legal-questionnaire study of psychiatric inpatients and medical surgical outpatients

Prior to the Vietnam era a high percentage of patients hospitalized in Veterans Administration Hospitals for psychiatric illness could be described as marginal men.¹ These patients are characterized by poor occupational history, poor marital adjustment, a nomadic existence, dependency on an institutional way of life, and alcoholism. Both authors have noted that this type of patient seems to have more than his share of legal problems. Oftentimes the legal problems seem to be of top priority to the patient, i.e., unless they are solved, the patient cannot expect to make an adjustment within the community. A literature review revealed no information on the extent of this problem. The social psychiatric kinds of intervention employed in the treatment of these patients requires that all social factors be considered simultaneously with psychodynamic and biological factors in the patient's course. As part of an attempt to develop more meaningful interventions with this patient population,² we designed a survey to determine the extent of legal problems. It attempts to answer the following questions: Are psychiatric patients more prone to have legal problems than a medical surgical outpatients population? Are there any particular kinds of legal problems which differentiate the psychiatric population from the medical surgical out-patient population?     

Cancer and mental illness

The relationship between mental illness and neoplastic disease has been the subject of controversy for decades.^1–3 Early studies using proportionate mortality rates (i.e., the proportion of cancer deaths to total deaths in a given population) were interpreted as evidence that psychotic patients have a significantly lower rate of cancer than the general population.^3–5 These studies have been extensively criticized on the grounds that since psychiatric patients tend to have increased mortality from a variety of causes (e.g., pneumonia) relative to the general population, if cancer mortality were more equal in incidence between patient and general population groups, the proportionate mortality data would spuriously suggest reduced cancer risk among patients.^4–6Other reports using age specific or age adjusted mortality data, with three exceptions,^7–9 have indicated an equal or slightly increased incidence of cancer mortality among psychiatric patients as compared to the general population.^{4–6,10–15} However, several of these studies have suggested that the relative risk of cancer is greater among female patients than among male patients, with male patients having relative risk equal to or less than the male general population.^11–13,15 In addition, a number of reports have commented that paranoid schizophrenics have an increased risk for cancer while other categories of schizophrenia are associated with reduced risk.^1,4,5 To our knowledge, this hypothesis has not been further replicated. To complicate the picture, recent reports have raised the question of whether neuroleptic treatment might predispose to breast cancer through its dopamine blocking effect of raising serum prolactin.^16,17 Virtually none of the studies examines cancer rates by age, sex, and diagnosis, however; thus there is little opportunity to identify more subtle trends. The present study, part of a larger study of mortality among psychiatric inpatients, provided the opportunity to investigate these issues in a relatively large sample.     

The revolving door patient

The introduction of effective psychopharmacological treatments for psychiatric disorders in the 1950s has revolutionized psychiatry and psychiatric care.¹ Not only have they fostered the move of psychiatry back to medicine,^2–4 but they have also been instrumental in the move towards deinstitutionalization.⁵ This trend towards early discharge of patients from hospitals has developed under the banner of “community care,” and has given rise to the problem of the so-called revolving door patient. This problem has been accentuated by the failure to adequately recognize the chronic and/or relapsing nature of many psychiatric disorders, and by the failure of the community to provide adequate alternative care.^6–8 Thus, many chronic psychiatric patients now find themselves living a lonely existence in an uncaring community^9.10 or are a tremendous burden on their families.¹¹Revolving door patients make up over half of all admissions to psychiatric hospitals. A review of studies up to 1974 on the problem of recidivism found that only one variable, namely, number of previous admissions, predicted rehospitalization, and it was argued that focusing on psychopathology or diagnosis was too narrow a focus.¹² A further study in which 36 of 107 patients were readmitted found that these patients were more likely to be unemployed and tended to be single, separated, or divorced.¹³ A subsequent study found that 9%–14% of all admissions were readmissions within 1 month of discharge, and that compared with the total population admitted, these patients who were of no particular diagnosis contained a high proportion of young and divorced or separated patients.¹⁴ Another study found an inverse relationship between length of hospital stay and rate of rehospitalization across diagnosis.¹⁵The present article looks at the preceding variables in relation to readmission by comparing data on those with and without previous hospital admissions over a 10-week period, and by noting who over the following 6 months were readmitted to this hospital.     

Psychiatrists' evaluations of emergency involuntary hospitalization

Debate continues over the ethics, constitutionality, and therapeutic benefit of emergency involuntary hospitalization of the mentally ill (EIH). Critics of EIH have been concerned not only with the adequacy of treatment afforded to patients so hospitalized, but also with the fundamental abridgement of liberties they regard as inherent in the practice itself.^1,2 Whereas most defenders of EIH admit that the quality of care received by such patients is far from adequate in many state hospitals, they continue to argue the case for EIH as a necessary and indeed humane management option for the treatment of gravely disabled and/or dangerous persons.³Much of the debate over EIH has come from persons whose claim to speak for organized psychiatry is in doubt. Surprisingly, in spite of the social significance of and professional interest in the controversy, little is known about the attitudes of the broad spectrum of practicing psychiatrists. What little data exist suggest that psychiatrists do support the continued availability of EIH. In an interview study of 30 hospital staff psychiatrists, Kumasaka and Stokes⁴ reported that approximately 80% regarded this option as indispensable in psychiatric practice.The reliability and generalizability of such data must be ascertained through study of larger and more representative groups of practicing psychiatrists. Whether their views are representative of the range of editorial opinion expressed about EIH remains uncertain, as does the potential differentiation of opinion across the subdisciplines of psychiatric practice.In an effort to address these questions, this paper presents findings of a survey of psychiatrists' evaluations of EIH, both in principle and in practice. Data were gathered from psychiatrists practicing in Connecticut and Washington, D.C., to determine the generalizability of attitudes across two jurisdictions that differ in statutory criteria and procedures for EIH.     

Behavioral precipitants of restraint in the modern milieu

Physical restraint of the psychiatric patient is a persisting reality in the acute management of uncontrolled, disruptive, or violent behavior. Depite advances in pharmacologic and milieu management, the “quiet room”, locked seclusion, or mechanical restraint often remain the last resort in control of the acutely disturbed patient. In this era of nonrestraint, little is taught or written of the practice of restraint. The literature contains few systematic studies of its persistence in modern milieu wards. The practice of restraint is viewed in resident education as an embarrassing anachronism, yet persists in some form in most clinical settings. This incongruity between teaching and practice led us to systematically survey our own use of physical restraint in an acute inpatient milieu. The diagnosis of patients restrained and the behavioral precipitants of restraint are the focus of this report.The modern therapeutic milieu stands in philosophic opposition to physical restraint by virtue of widespread acceptance of dynamic management of violent patients and confidence in the efficacy of pharmacologic treatment. The clinical belief that dynamic understanding in experienced hands can render a potential combatant “quickly cooperative”¹ is widely held. Following Connolly's famous admonition that “restraint and neglect are synonymous,”² the milieu staff shares responsibility for the patient's disruptive behavior. Violence and impulsive behavior are not so much the product of autistic process as they are defensive responses to “ambiguous, confusing, belligerent or threatening treatment.”¹ A violent outcome and resort to physical restraint implies staff failure and a punitive response to fear of the threatening patient. In his study of factors sustaining the practice of locked seclusion at the Boston Psychopathic Hospital, Greenblatt identified the “evils” of “overroutinization of use, lack of knowledge concerning the patient's feelings, poor communication about these feelings among the staff and lack of adequate motivation for serving the basic psychologic needs of the patient.”³ Attention to these dynamic considerations in a therapeutic milieu augmented by the use of potent pharmacologic agents has greatly reduced but not eliminated the use of physical restraint. The question of who is restrained on the modern milieu ward and why must be asked in this dynamic context.     

The effect of psychiatric hospitalization in crisis.

Heber butts,² a Navy psychiatrist, reported in 1912, that “there is being established at the Naval Hospital, Washington, D.C., a psychopathic ward for the observation and treatment of certain insane officers and enlisted men of the Navy and Marine Corps. This ward, I am certain, will prove an excellent adjunct to the service in adding to the efficiency of its Medical Corps. Cases of slight or temporary mental disorder can easily be cared for in this ward until they get well; they will be at all times under the immediate control of officers of the service, and they will escape the stigma of having been an inmate of an insane asylum. In this way, the best interests of the mentally sick officers and men will be subserved. It is my opinion that a small percentage can, after their recovery, properly be restored to duty, but the great majority will, I think, be found unfit for further continuance in the service.”Thus, the incorporation of a psychiatric ward with a general hospital to provide short-term treatment and expeditious disposition consistent with the mental status of the patient has been practiced for over 60 years by the Navy Medical Department.Several researchers have indicated that acute psychiatric intervention^5–8 and brief hospitalization^4,9 are applicable as a therapeutic procedure for treating patients, but the long-term effectiveness of brief psychiatric hospitalization has not been reported. Recent research has shown that Navy psychiatrists recommended 32% of the sailors be returned to duty following their hospitalization.³ In that report, the mean length of time hospitalized was 60 days.This is a report of patients admitted to the Psychiatric Service at the Navy Regional Medical Center, San Diego, Calif., who were hospitalized 48 hr or less. These patients have been followed up to measure the effect of that brief psychiatric hospitalization on subsequent job performance. The report will deal in depth with the short-term admissions and comparisons will be made with patients who were hospitalized for a period exceeding 48 hr in order to determine with which patients short-term treatment may be effectively used. A comparative evaluation of long-term versus short-term treatment is not intended.     

Etiology and treatment of childhood depression: a biopsychological perspective

Depression in children has become a well-accepted entity today, ^1–6 but its existence was denied by even experienced clinicians a generation ago. It is a disorder with diverse physical manifestations. These include disturbances of appetite, abnormalities in body weight, and multiple somatic complaints, such as headaches and vague abdominal⁷ and chest pains.⁸The Diagnostic and Statistical Manual of Mental Disorders (3rd ed), (DSM-III),⁹ describes the criteria for a diagnosis of major depressive disorder as follows: a dysphoric mood or pervasive loss of interest or pleasure, plus four of the following eight symptoms: (1) changes in appetite or weight, (2) sleep difficulty, (3) loss of energy, (4) psychomotor agitation or retardation, (5) loss of interest or pleasure in usual activities, (6) feelings of self-reproach or guilt, (7) complaints or evidence of diminished ability to concentrate or think, and (8) recurrent thoughts of death or suicide. Although no distinction is made among children, adolescents, and adults concerning the essential features of depressive disorders, the text of DSM-III does describe differences in associated features for different age groups.Affective disorders are classified as either primary or secondary,¹⁰ depending on whether or not the individual had a preexisting psychiatric disorder.¹¹ Carlson and Cantwell⁵ have recently shown that this dichotomy may also be a useful one for childhood depression. Another familiar classification employs the unipolar—bipolar dichotomy.^12,13 The endogenous-reactive classification offers a third, albeit controversial, view of categorizing depressive disorders.¹¹ Malmquist's¹⁴ classification of depression has as its basis an association with organic disease, deprivation syndrome, difficulty with individuation, latency type, or adolescent types.Currently, affective disorders are considered to comprise a heterogenous group in adults. All of the preceding classification schemes have some^15–26 degree of validation behind them from family studies, natural history studies, biologic correlates, and responses to various types of treatment.In this paper, we discuss the etiology and treatment of childhood depression from both biologic and psychologic perspectives.     

Mental illness and mortality

For well over a century there have been studies^1–10 demonstrating that the mentally ill carry a greater than expected risk of early death. The observed to expected risk has ranged from fifty fold to two fold and has diminished over time. Organic brain disease usually has been found to have the worst prognosis. All types of physical disease, apart from cancer, have been found in excess, although in the earlier studies tuberculosis was the most noteworthy. The effect has been examined with differing methodologies on psychiatric populations in diverse clinical settings and in various countries in Europe and North America, but certain findings have been consistent. The excess mortality has been greatest in women, younger patients and within the first year after admission. The last result has led to the speculation that the patients, although diagnosed as being psychiatrically ill, were really suffering from physical disease.A confounding feature of this type of research has been that several psychiatric diagnoses are known to have an increased “unnatural” mortality risk. Thus, in comparison with the general population it is known that psychiatric patients are more likely to die by suicide¹¹ and accidents.¹² In order to examine the relationship between mental illness and death nowadays, when psychiatric patients spend only short intervals in hospital, it seems useful to look at “natural” and “unnatural” causes of death separately. Psychiatric patients, in general, are no longer subject to the ill effects of chronic institutionalization and should be receiving the health care provided for the general population. It was hypothesized that psychiatric patients would not show an excess mortality due to natural causes.