Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients.

BACKGROUND: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. METHODS: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. RESULTS: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. CONCLUSION: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.

Suicide and mental disorders: a case-control study of young men.

OBJECTIVE: By means of the psychological autopsy method and a case-control design, the authors examined the association of specific mental disorders and comorbidity with suicide among young men. METHOD: Seventy-five men aged 18-35 years whose deaths were adjudicated as completed suicides by coroners of greater Montreal and Quebec City were matched to 75 living young men for age, neighborhood, marital status, and occupation. For each subject in both groups a key respondent best acquainted with the subject was interviewed by clinicians using standardized schedules. Information from the coroner and medical records was also collected. Two experienced psychiatrists, blind to outcome, established best-estimate DSM-III-R diagnoses. RESULTS: Six-month prevalence rates for all axis I diagnoses for the suicide and comparison groups were 88.0% and 37.3%, respectively; major depression was present in 38.7% and 5.3%, alcohol dependence in 24.0% and 5.3%, psychoactive substance dependence in 22.7% and 2.7%. Borderline personality disorder was identified in 28.0% and 4.0%, respectively. Of the suicide subjects, 28.0% had at least two of the following disorders: major depression, borderline personality disorder, and alcohol or drug dependence; the rate was 0.0% among the comparison subjects. CONCLUSIONS: In young men, completed suicide is linked to specific mental disorders, namely, major depression, borderline personality disorder, and substance abuse. Comorbidity involving any of these disorders is frequently associated with completed suicide.

[Evaluation of long-term effectiveness of a social reintegration program]. / Evaluation de l'efficacité à long terme d'un programme de réinsertion sociale.

This study evaluates the impact of a rehabilitation program developed by a specific unit (304) of Louis H. Lafontaine Hospital to prepare severely disabled long-term psychiatric inpatients for discharge. Patients who participated in the program were evaluated three years after their discharge and compared to control patients paired to them by age, sex and years of hospitalization and discharged from other units of the hospital. The results suggest that the rehabilitation program, if coupled with an adequately staffed residential environment giving patients continuous care, offers a better outcome, at least in the case of the severely disabled long-term psychiatric inpatients.

[Suicide among young male adults in Quebec: psychopathology and utilization of medical services]. / Le suicide chez les jeunes adultes de sexe masculin au Québec: psychopathologie et utilisation des services médicaux.

Seventy five young male adults between the age of 18 and 35 who had committed suicide were compared with 75 male adults still alive matched for age, residence, marital and employment status. For each group a principal respondent was interviewed in order to reconstitute the psychological profile of each individual, as well as their utilisation of health services. This was completed by the study of the coroner's reports and the medical records when available. At six months the prevalence for all axis I diagnosis was 88.8% for the suicide group and 37.3% for the control group. Among the subjects who had committed suicide 38.7% were afflicted by major depression, 24% by alcohol dependency and 28.7% were dependent on drugs. Borderline personalities were present in 28% of the suicide group compared to 5% in the control group. Forty five percent (45%) of the subjects who had killed themselves had consulted a mental health professional in the year preceding the suicide compared to 5% in the control group. However, 78.5% of the suicide group had consulted during the same period a health professional compared to 73.3% of the controls.

A quality control program for cine radiography.

We describe a ciné processing quality control program aimed at the consistent production of high quality angiograms. A year's experience with this protocol has demonstrated the difficulty and importance of maintaining a constant on-frame optical density to ensure consistently high quality. We monitored film processing, speed of the emulsion and the automatic brightness control of the angiographic imaging system several times a day. Variations in film speed and their causes observed in our institution demonstrate that parameters other than film processing should be carefully controlled. The cost of applying this protocol is about +190.00/month and it requires no additional personnel. The cost is offset by the improved quality of the angiograms, reduced repeat examinations, and the improved monitoring of the system making for more effective preventative and corrective maintenance.

Lithium carbonate addition in tricyclic antidepressant-resistant unipolar depression. Correlations with the neurobiologic actions of tricyclic antidepressant drugs and lithium ion on the serotonin system.

Preliminary reports suggested that the addition of lithium carbonate to the regimen of patients treated with, but not responding to, a tricyclic antidepressant (TCA) drug can induce a rapid alleviation of depression. We examined the effect of lithium carbonate addition in 39 patients with unipolar depression whose conditions were not improved by at least three weeks' TCA drug administration. In 30 of 42 observations, lithium carbonate brought about a greater than 50% improvement within 48 hours. In a second study, the effects of lithium carbonate addition were compared in five amitriptyline hydrochloride-pretreated and five placebo-pretreated patients who showed no improvement after a three-week treatment. All five patients receiving amitriptyline showed a greater than 50% improvement 48 hours after lithium carbonate addition, whereas only one patient in the placebo group showed a marked response. In a third study the effect of lithium carbonate withdrawal was studied in nine TCA-resistant patients who had shown a marked improvement 48 hours after lithium addition. Only five of these patients had a relapse five days after lithium discontinuation. Since animal studies have shown that TCA drugs sensitize forebrain neurons to serotonin and that lithium enhances the activity of serotonin-containing neurons, we propose that the antidepressant effect of lithium addition in TCA-resistant patients might be mediated by enhancing serotonin neurotransmission.