Getting ready for recovery: reconciling mandatory treatment with the recovery vision.

Considering treatment of serious mental illnesses, it might appear that the recovery model would be incompatible with any form of mandatory treatment. The authors suggest that this is not so. With individuals whose psychotic illness substantially impairs decision making, mandatory treatment may offer the best hope of getting well enough for recovery to be possible. It is essential, however, that any program involving involuntary community treatment involves recovering individuals who have themselves experienced a serious mental illness. The authors propose the use of a consumer-run guardianship program and a capacity review panel as two possible ways to achieve such participation.

The incarceration of individuals with severe mental disorders.

This study examines the extent to which severely mentally disabled (SMD) patients in one county mental health system were incarcerated in the local jail and examines characteristics of a sample (N = 30) of such individuals. We found that in the study year, 7.9% of known SMD patients had at least one incarceration in the county jail. Diagnoses were predominantly in the schizophrenia spectrum with 70% also actively abusing substances at the time of incarceration. The majority of crimes were non-violent and substance abuse related. Half of the sample was judged to be candidates for diversion programs. Our findings are consistent with recent literature confirming that substance abusing SMD individuals are at high risk of incarceration and could benefit from integrated mental health and substance abuse treatment.

Economic evaluation of risperidone in an outpatient population.

OBJECTIVE: To study the impact of risperidone use on the cost of services provided to severely mentally disabled outpatients and on hospital avoidance, and to analyze patterns in the use of concomitant medications as a surrogate marker of changes in adverse effects or patient well-being. METHODS: The patients were 31 clients of community mental health centers who had received risperidone for at least three months and for whom there were at least three months of available data on medication use and costs prior to risperidone treatment. The actual average monthly costs of community mental health services obtained from a county mental health board were compared with service costs prior to use of risperidone, using the patients as their own controls, and compared with a control group. RESULTS: Compared with the pre-risperidone period, the average cost per month of providing mental health services increased by 73.7% during the risperidone treatment period. Compared with the pre-risperidone period, the average total cost of treatment (including medications) increased by 113.3% during the risperidone treatment period. The average total cost of medication increased by 422.8% during the risperidone treatment period compared with the pre-risperidone treatment period. CONCLUSIONS: From the perspective of the community mental health board, risperidone treatment did not reduce the cost of services provided to these clients, but substantially and significantly increased total costs, including medication.

What happens when effective outpatient civil commitment is terminated?

Outpatient civil commitment can be effective in slowing the revolving door for selected patients, but it may not be the best mechanism for ensuring treatment over time.

Diversity in case management modalities: the Summit model.

Though ubiquitous in community mental health agencies, case management suffers from a lack of consensus regarding its definition, essential components, and appropriate application. Meaningful comparisons of various case management models await such a consensus. Global assessments of case management must be replaced by empirical studies of specific interventions with respect to the needs of specific populations. The authors describe a highly differentiated and prescriptive system of case management involving the application of more than one model of service delivery. Such a diversified and targeted system offers an opportunity to study the technology of case management in a more meaningful manner.

The effectiveness of outpatient civil commitment.

The effects of outpatient civil commitment on community tenure and functioning were studied in a group of 20 patients with a history of recurrent hospitalizations, noncompliance with outpatient treatment, and good response to treatment. During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment. They significantly increased the number of appointments kept with their psychiatrist. It appears that when used judiciously, outpatient civil commitment is a helpful tool in maintaining hospital recidivists in the community.

Documenting informed consent for treatment with neuroleptics: an alternative to the consent form.

Clinicians can comply with Ohio state regulations for documenting patients' informed consent for treatment with neuroleptic medication by checking a box in the medical record stating that a periodic discussion of informed consent has occurred and writing a note about the discussion in the narrative record. The authors discuss clinicians' experience with this alternative to the conventional consent form in a large community support agency. Although the approach has been largely successful, implementation has been hindered by some clinicians' incomplete understanding of the informed consent process. Continued training is needed to bring the ideal of informed consent into clinical practice.

Pharmacotherapy of impaired affect in recovering schizophrenic patients.

BACKGROUND: Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken. METHODS: In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks. RESULTS: For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression. CONCLUSION: Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.

CMHC practices related to tardive dyskinesia screening and informed consent for neuroleptic drugs.

OBJECTIVE: The authors conducted a national survey of community mental health centers to determine their policies and practices about screening patients for tardive dyskinesia and obtaining informed consent for use of neuroleptic drugs. METHODS: Clinical directors of 235 centers in the United States, selected by geographic region and population, were surveyed through a nine-item questionnaire. RESULTS: Although nearly all the 160 respondents reported that they screened patients for tardive dyskinesia, only about two-fifths had formal screening policies, and about two-fifths had screening programs. The Abnormal Involuntary Movement Scale examination was used by almost two-thirds of respondents who screened patients, and about one-fifth relied on unstructured observation. Slightly more than half of respondents specified a frequency for screening examinations, at a modal interval of six months. Seventy percent used nonpsychiatric clinicians for screening. Almost three-quarters of the respondents had informed consent policies for use of neuroleptics. Urban centers tended to be more aware than rural centers of the American Psychiatric Association's tardive dyskinesia screening guidelines. They also used fewer nonmedical practitioners for screening and were more likely to obtain informed consent for neuroleptics. CONCLUSIONS: Despite the existence of APA guidelines and state policies and regulations about tardive dyskinesia screening, a national effort to educate clinicians about prevention of tardive dyskinesia is still needed.

The least restrictive alternative in the postinstitutional era.

The legal concept of the right of psychiatric patients to treatment in the least restrictive alternative has come to mean treatment anywhere but in the state hospital, as illustrated in two large communities in Ohio and Massachusetts. Oversimplified application has led to the use of treatment setting as the only measure of restrictiveness. Patient's characteristics and needs have been ignored, along with the possibility of wide variation in program quality within each class of facility. The role of the state hospital has become uncertain, making it difficult to attract and keep qualified professional staff. The authors argue for an expanded view of the concept that includes consideration of patients' needs. They contend that the concept should not be used as a sole reason to avoid admitting patients to state hospitals or to continue the down-sizing of public institutions.

An integrative ideology to guide community-based multidisciplinary care of severely mentally ill patients.

Most practitioners working in community support settings understand the need to provide a comprehensive array of well-coordinated services to individuals with severe mental disabilities. However, a lack of consensus about the conceptual basis of mental health care, especially between advocates of psychosocial rehabilitation and psychiatric practitioners who favor a more medically oriented approach, has hindered efforts to optimize the effectiveness of the multidisciplinary teams found in most community support programs. The authors articulate 18 basic assumptions that have been helpful in their clinical practice in building an integrative ideology among professionals with disparate training and orientations. The assumptions attempt to balance the reality of psychiatric disorders with a fundamental interest in maintaining the autonomy and dignity of people with severe mental disorders.

Akathisia: clinical phenomenology and relationship to tardive dyskinesia.

Akathisia and tardive dyskinesia (TD) are disorders of movement that are often associated with administration of antipsychotic medication. We surveyed 196 outpatients in a schizophrenia clinic, all receiving antipsychotic medication, for the presence of these disorders. Clinical global ratings of akathisia were reliable. Akathisia was found in 36% of patients, and TD in 23.5%. Akathisia was disproportionately common in patients receiving high-potency neuroleptics. The data affirmed recent revisions in the dose-equivalence formulas used with fluphenazine decanoate. Akathisia and TD did not seem to be interrelated. Because akathisia is common and often limits medication dose and contributes to noncompliance, psychiatrists must take this into account when prescribing antipsychotic medication.

The scale for treatment integration of the dually diagnosed (STIDD): an instrument for assessing intervention strategies in the pharmacotherapy of mentally ill substance abusers.

The authors developed a series of 15 multiple-choice vignettes which pose common dilemmas in the pharmacotherapy of patients suffering from psychoactive substance use disorders coexisting with other mental disorders. Fourteen judges standardized the treatment options along a 'treatment integration continuum'. The authors surveyed 112 psychiatrists with the vignettes and 3 subscales of the Substance Abuse Attitude Survey. Ten of the 15 vignettes were taken to form the normally distributed Scale for Treatment Integration of the Dually Diagnosed (STIDD), which is described in terms of its reliability, validity and potential use as a teaching and research tool.

Who should perform the AIMS examination?

Psychiatrists and nonphysician mental health professionals working in community mental health centers have difficulty establishing the scope of their expertise, defining the limits of their roles, delegating responsibility, and sharing professional liability. The clinical, political, and administrative aspects of these tensions are examined in the context of arguments for and against physicians' delegating to nonphysician mental health professionals the task of screening CMHC patients for tardive dyskinesia using the Abnormal Involuntary Movement Scale. In 43 percent of mental health centers in Massachusetts surveyed by the authors, nonphysicians perform tardive dyskinesia screening. The authors suggest that the benefits of involving nonphysicians in tardive dyskinesia screening in the CMHC setting outweight the disadvantages.