Empowering individuals as carers of their own health.

Self-care as both treatment and prevention is assuming new importance for several reasons: chronic illness, which calls for self-care is becoming a more serious global problem; illnesses that are related to unhealthy behavior are more common; medical care is becoming more participative because of increased individualism; the costs of care make it necessary for more care to be assumed by patients; and new technology expands what people can do for themselves. Self-care is relevant to the enhancement of health, the prevention of illness; the management of disease, particularly chronic illnesses; and rehabilitation to reduce disability. Barriers to self-care include mental attitudes of depression and denial, addictions, cultural factors, low intelligence and illiteracy, and family conflict. Self-care is enhanced by a sustaining relationship with a health professional, trustworthy information, patient education that is culturally sensitive, technological aids, financial and other positive incentives, and peer group support. Self-care is a growing dimension of health care that needs and deserves further research and innovation.

Seclusion and restraint: a review of recent literature.

An October 1998 Hartford Courant investigative series highlighted alleged cases of brutality and death suffered by involuntarily secluded, restrained, and/or emergently medicated patients. The resulting public and professional furor prompted a spate of new federal regulations and legislative initiatives setting national standards for reporting and clinical oversight. These events provide stimulus for this literature review. Rates, duration, and methods of seclusion and restraint still vary widely. Little evidence is available to guide clinical practice regarding relative benefits and risks of various methods to control acute adult patient aggression; even less evidence exists in child and adolescent populations. Further efficacy and effectiveness studies are needed to address this issue. Various programmatic efforts successfully reduce seclusion and restraint-at times dramatically-and can be used as examples of systematic quality improvement so "best practices" may evolve and spread throughout psychiatric inpatient settings.

Service quality in health care.

Although US health care is described as "the world's largest service industry," the quality of service--that is, the characteristics that shape the experience of care beyond technical competence--is rarely discussed in the medical literature. This article illustrates service quality principles by analyzing a routine encounter in health care from a service quality point of view. This illustration and a review of related literature from both inside and outside health care has led to the following 2 premises: First, if high-quality service had a greater presence in our practices and institutions, it would improve clinical outcomes and patient and physician satisfaction while reducing cost, and it would create competitive advantage for those who are expert in its application. Second, many other industries in the service sector have taken service quality to a high level, their techniques are readily transferable to health care, and physicians caring for patients can learn from them.

The public sector-private sector interface: current issues, future trends.

The public and private sectors will both be forced to change as they forge new relationships in order to manage the Medicaid benefit. These changes will affect both their organizational cultures and their technical capabilities.

Prevention of psychiatric disorders.

Psychiatric disorders are highly prevalent and cause an enormous burden of suffering, loss of productivity, morbidity, and mortality. This article will review prevention of psychiatric disorders in a manner that is relevant to the mental health clinician. Clinicians may increasingly play a role in preventive interventions through (1) identifying individuals at risk, (2) consulting with agencies, school personnel, and employers who may identify individuals at risk, (3) providing treatment that can reduce the chronicity, severity, and total duration of psychiatric illness, and (4) providing mental health care to a specific population within our evolving health care system, in which health promotion and disease prevention play an increasingly important role. Appropriate literature was located by searching the English-language citations since 1985 in Index Medicus (search terms included prevention, preventive psychiatry, early intervention, mental disorders, risk factors, and primary prevention), reviewing several textbooks on psychiatric preventive services, and finding additional sources cited in the reference sections of these publications. This paper presents the public health model of disease prevention, which divides prevention activities into primary, secondary, and tertiary interventions. The model is applied to childhood psychiatric disorders and to adult-onset schizophrenia, depressive disorders, and substance use disorders. The review concludes with a discussion of the implications for the clinician and for public health policy.

Providing treatment to persons with mental illness.

The RWJF Program on Chronic Mental illness created centralized mental health authorities in nine cities as a demonstration project. Evaluation teams, selected after the project began, and a national program office, established to provide technical assistance and to communicate progress and results, worked in tandem with the program staff. The project was evaluated as "logic model" to determine the feasibility of centralized authorities and to estimate their effect on various outcomes. One finding was that service reorganization does not cancel out the need to supply funds or mental health care. The problems of delay in the publication of results and of public officials' reluctance to act without "definitive" research data are described, as are the remedies for these difficulties.