Are human made disasters different?

The author distinguishes natural from human made disasters, and identifies their traumatic effects. He stresses the impact on both individuals and communities. Lessons learned from the NYC World Trade Center bombings are offered. He concludes with a universal prescription for responding to disasters.

Are publicly-insured psychiatric outpatients in Japan satisfied?

Japan has a government financed outpatient program for people with mental disorders, called the 'publicly-insured' program. This study was performed to examine whether the target patient population used this publicly-insured program properly and to compare the degree of satisfaction of publicly-insured psychiatric outpatients with generally-insured psychiatric outpatients. The characteristics and satisfaction of 97 (43.9%) publicly-insured psychiatric outpatients and 124 (55.1%) generally-insured outpatients in Japan were studied. Psychiatrists rated sociodemographic and diagnostic information and patients were asked to complete the Japanese version of Client Satisfaction Questionnaire (CSQ-8J). The publicly-insured were longer-term and lower functioning patients and were significantly more dissatisfied with the services they received than the generally-insured patients. The publicly-insured program was successful in that patients with lower functioning (the primary target population of this program) were cared for and because they received treatment for longer periods of time. However, the program does not sufficiently satisfy the consumers of the services, despite its high costs. In this respect, this program needs to focus more on patients' points of view. More information on programs their enrollment procedures for patients may be helpful in educating consumers and citizens, clarifying expectations of services, and in influencing satisfaction.

Factors affecting psychiatric nurses' intention to leave their current job.

Using the National Institute for Occupational Safety and Health job stress questionnaire, the authors examined psychiatric nurses' intention to leave their job in relation to their perceived risk of assault, their job satisfaction, and their supervisory support. Respondents were 1,494 nurses (response rate, 76.5 percent) employed in 27 psychiatric hospitals in Japan. Forty-four percent reported intention to leave their job, and 89 percent of those perceived a risk of assault. Younger age, fewer previous job changes, less supervisory support, lower job satisfaction, and more perceived risk of assault were significant predictors of intention to leave. Organizational efforts are necessary to retain frontline professional staff.

Psychosocial treatments in schizophrenia: a review of the past 20 years.

Pharmacotherapy can improve some of the symptoms of schizophrenia but has limited effect on the social impairments that characterize the disorder and limit functioning and quality of life. Through computerized literature searches and bibliographies of published reports we identified peer reviewed studies of group, family, and individual therapy with schizophrenia and schizoaffective disorder patients. We identified 70 studies: 26 on group therapy, 18 on family therapy, and 11 on individual therapy. Additionally, treatment models were compared in 4 studies and combined in 11 others. Controls were included in 61 and all studies included medication. Benefits in symptoms as well as social and vocational functioning were associated with psychosocial treatments. Family therapy demonstrated the most promising findings and traditional social skills treatment yielded the least robust results. Adjunctive psychosocial treatments augment the benefits of pharmacotherapy and enhance functioning in psychotic disorders. Although these positive results have led to increased enthusiasm about psychosocial treatments for schizophrenia, questions remain about comparative benefits of specific treatment methods and additional benefits of multiple treatments.

A self-report symptom and problem rating scale to increase inpatients' involvement in treatment.

OBJECTIVE: The study sought to determine whether psychiatric inpatients who completed a self-report symptom and problem rating scale on admission and reviewed the results with a clinician would perceive at discharge that they had been more involved in their treatment than patients who did not complete the scale. METHODS: In a quasiexperimental design, 109 inpatients were assigned to one of three groups. Patients in one group met individually with a psychiatric resident to review their responses to the Behavior and Symptom Identification Scale (BASIS-32), a self-report outcome assessment tool. Patients' views of their difficulties were then used by the treatment team to build a therapeutic alliance and to inform treatment planning. The remaining two groups received treatment as usual by either a psychiatric resident or an attending psychiatrist. Patients' perceived involvement in decisions about their treatment, perceptions of other aspects of care, and treatment outcome were compared. RESULTS: Patients in the intervention group rated their involvement in decisions about their treatment significantly higher than patients in either of the comparison groups. Patients in the intervention group more frequently reported that they were treated with respect and dignity by the staff than did patients in the comparison group treated by attending psychiatrists. Compared with patients treated by attending psychiatrists, patients treated by residents, whether they received the intervention or not, were more likely to say that they would recommend the hospital to others. Treatment outcome did not differ among the groups. CONCLUSIONS: The results suggest that an outcome assessment tool can be used to engage patients in the treatment process.

Mental health services reform in Japan.

Economic and social pressures are driving Japan to reform its mental health services. Traditionally, psychiatric services in Japan have been custodial. Reimbursement has been principally fee-for-service, with incentives that encourage hospital-based care. Reform measures are beginning to promote the concept of "normalization," in which the mentally ill are seen to be disabled, like persons with physical disabilities. New practices including deinstitutionalization, differentiation of services, revisions in payment, and quality assessment are being introduced. This article provides an overview of the current status of Japanese mental health services, summarizes policy dilemmas, and identifies priority areas for intervention.

Guidelines for prescribing psychiatrists in consultative, collaborative, and supervisory relationships.

Most psychiatrists enter into a variety of professional relationships with other clinicians in which they prescribe medications or make recommendations about pharmacotherapy. This paper describes a set of guidelines for prescribing psychiatrists involved in consultation, collaboration, and supervision with other clinicians. The guidelines were developed by psychiatrists for the Harvard Risk Management Foundation. The terms consultation, collaboration, and supervision are defined, and the psychiatrist's roles and responsibilities in each type of arrangement are described. The guidelines limit consultation and collaboration to relationships with professionals who are licensed or credentialed. Based on the definitions, the paper describes a structure for working with other clinicians, which begins with a thorough assessment of the context and circumstances of the clinical situation. The guidelines strongly encourage structured communication among clinicians and with the patient and significant others, as well as clarification by clinicians of their respective responsibilities for treatment and follow-up.

Assessing outcomes in clinical practice.

We are witnessing a remarkable explosion in interest and activity in quantifying outcomes and using these measures to enhance the value of clinical care. Outcomes assessment has become an imperative for clinical practice. This paper first will offer criteria for an ideal system of outcomes assessment. The paper will then review the principal domains of assessment for psychiatric practice and provide examples of instruments available in each domain. We will then describe the use of two instruments, one for clinical outcome and one for interpersonal aspects of patient satisfaction, developed and used at McLean Hospital. The relation between outcomes assessment and outcomes management will then be discussed. Finally, we will discuss the fundamental questions a clinical group or facility might consider in choosing outcomes measurement instruments.

The impact of preadmission approval and continued stay review on hospital stay and outcome among children and adolescents.

Managed care has emerged as the centerpiece of the health care industry's efforts to control costs and ensure appropriate use of hospital services. This study assesses the impact of managed care by preadmission approval and/or continued stay review on length of psychiatric hospitalization and clinical outcome of children and adolescents. The sample included 277 cases hospitalized in nine psychiatric specialty hospitals in 1990. Demographic and clinical characteristics, hospital ownership type, and preadmission approval or continued stay review were used as independent variables in a multiple regression model to predict length of stay and clinical outcome. Results indicate that the model accounted for 27% of the variance in length of stay. Previous psychiatric hospitalization and for-profit hospital status predicted longer hospitalization. Clinical outcome was not significantly predicted by the model. Managed care did not predict either length of stay or clinical outcome. Implications for health care reform are discussed.

False allegations of sexual misconduct: clinical and institutional considerations.

That some therapists engage in sexual misconduct with patients has been unequivocally established. In recent years, however, some patients' allegations of sexual misconduct have been determined to be false. This paper describes four cases in which hospitalized psychiatric patients made false allegations. Such allegations may result from patients' seeking to gain monetarily or in other ways or from a desire for retaliation or revenge against a clinician who they believe has scorned, abandoned, or otherwise mistreated them. In other cases, especially among patients with a history of severe trauma, a patient's psychopathology may be inadvertently stimulated by diagnostic, treatment, or milieu activities. The authors recommend specific institutional responses to allegations of sexual misconduct, such as forming a clinical investigative team, conducting a physical examination, and reporting the charge to outside agencies or investigators when appropriate. Because false claims can have disastrous effects on all involved, clinicians should understand the presentations of such claims and the motivations behind them, and institutions should carefully develop a set of procedures for responding to them.

Acute and chronic psychiatric care: establishing boundaries.

Despite advances in psychiatry, a proportion of those with mental illness have episodes of severe illness, and a few of these patients may attain only partial recovery. In this respect, mental illness is similar to physical illness and systems of acute and chronic care are essential. As mental health care financing and delivery systems undergo further flux and reform, we will require clear, consensually developed definitions of levels of care, especially because of the complexities created by a legacy of a 2-tiered, public and private mental health system. This paper first will offer definitions and examples of acute and chronic illness and care. We will also address certain problems inherent to such a classification. We will then consider principles of and potential plans for a system of financing and care for the chronically mentally ill. Two existing plans will be reviewed as illustrations of innovations in chronic care. As health reform changes the financing and delivery of care for the mentally ill, an opportunity exists to integrate public and private monies and services and to improve upon the care of the acutely and chronically mentally ill.

The imperative of outcome assessment in psychiatry.

This report describes the current conceptualization of outcome assessment in psychiatry and focuses on how assessment instruments can be built into psychiatric facility-based practice. First, the domains of clinical assessment are outlined, with an emphasis on three elements: level of psychiatric symptoms, clinical functioning, and patient satisfaction. Examples of outcome instruments then are provided as well as the elements of their successful implementation. Finally, the value of linking outcome assessment to data on patient characteristics and service utilization are discussed in order to gain insight into the relationship between treatment and outcome. The clinical, fiscal, and regulatory imperatives emerging for outcome assessment call for its demystification and widespread application.

Managed mental health care and professional compensation.

Managed care and organized systems of care are restructuring the delivery of care in the United States. As care is reorganized, physician practice styles, autonomy, and compensation are undergoing profound changes. To successfully integrate physicians into the new managed systems of care, their organizational relationship to and their compensation within these systems must be carefully considered. This paper first explores physician motivation as it is related to compensation. The paper then describes a variety of emerging organizational designs aimed at aligning the interests of physicians and hospitals. The author considers fully integrated, physician-hospital organizations with target income compensation arrangements to be most suitable to the collective success of professionals and organized systems of care. The paper concludes with a discussion of the many dilemmas and challenges posed by the intertwining of managed care, organized networks of care, and professional compensation.

Managing suicidal inpatients.

Suicidality is the most common and vexing challenge presented by psychiatric inpatients. Although clinicians' ability to predict suicide is limited and suicide may inevitably occur, conscientious assessment of risk, effective distinction among various characteristics of the suicidal crisis, and thoughtful policies and procedures will help keep many patients from fatal outcomes.