Lithium treatment of impulsive behavior in children.

Children who display sporadic unprovoked physical aggression and are refractory to usual treatment pose a difficult management problem. A group of 14 such children were matched with a control group; behaviors of both groups were observed and recorded for 3 months. The experimental group was then maintained on high doses of lithium carbonate for 3 months. Behavioral recordings were continued during this period and for 3 months after discontinuation of lithium. While on lithium, the children showed a substantial reduction in unprovoked aggressive outbursts. Because lithium was well tolerated and laboratory and clinical examinations did not show any adverse effects, it is suggested that lithium may be an important therapeutic agent in the treatment of aggression in children.

Psychiatry and the elderly in the Middle East: a report from Iran.

One of the more firmly established generalizations in mental health concerns the positive correlation found between aging on the one hand and levels of psychiatric distress and utilization of mental health services on the other. It is also generally believed that the young, being more resilient and healthier, possess a greater capacity to cope with psychiatric stress than the elderly. The causal inferences are often unavoidable. Since cross-cultural studies can examine naturally occurring differences in exogenous factors, they may help clarify some of the causal connections. This paper presents utilization rates as well as the results of psychiatric tests on older and younger populations of psychiatric patients and addicts in Iran. The psychiatric population includes both inpatients and outpatients from hospitals and clinics in Tehran, and the provinces. The addicts' population includes a nationwide sample of registered addicts as well as illicit addicts from Tehran and other provinces. Psychiatric profiles are constructed from Symptom-Checklist-90 (SCL-90) questionnaire translated and adapted for use in Iran. For each individual, nine primary symptom distress levels together with three global indices are obtained. Primary comparison is made across age variable with fifty-five years and over age group versus those below fifty-five years of age. Secondary comparisons include psychiatric versus addicts, inpatients versus outpatients, male versus female, as well as comparisons across other socio-economic variables. Findings are discussed in the light of prevalent socio-cultural factors.

Psychiatric profiles of adolescents in pre-revolutionary Iran.

In 1977 when this research was undertaken, Iran was witnessing the emergence of growing numbers of distressed adolescents. Psychiatric profiles of adolescent outpatients (N = 110) and undiagnosed adolescents (N = 406) were obtained using an adapted version of the Johns Hopkins Symptom checklist-90. These profiles are compared with those from the American adolescent psychiatric outpatients. The results show that Iranian adolescents register significantly higher distress levels on nearly all the scales. The findings are discussed in the light of prevalent child rearing practices, rapid socio-economic transition and political-cultured factors dominating the pre-revolutionary Iran.

Dilemmas of Iran's opium maintenance program: an action research for evaluating goal conflicts and policy changes.

Much of evaluative research in the drug abuse field to date has centered on the outcome comparison of different treatment and rehabilitation modalities. Consequently, despite avowed interest in policy research by the students of drug abuse to a great extent and, in part, due to lack of research opportunities, there have not been many action-oriented evaluative policy researches even in the industrially advanced countries. On the other hand, the piecemeal accumulation of information through numerous ad hoc drug-related research activities has signaled the need for more integrated research activities on a comprehensive scale, embracing both the demand and supply dimensions of drug abuse. In the absence of substantive inputs from drug policy research, there is a real danger than the call for comprehensive approaches may once again, by default, neglect the crucial dimension of macro policy. This paper presents the findings of an action research design for evaluation of Iran's opium maintenance program. As such, the paper's primary focus is on the impact of unintended and unanticipated consequences of Iran's opium maintenance program upon treatment and rehabilitation efforts for the drug addicts. The findings here are based on a two-wave study. The first wave was carried out in the early summer of 1976. The major conclusions of the first wave suggested the need for fundamental revisions in both the eligibility requirements for and the the distribution system of opium coupons to those who legally received opium, the registered addicts. The findings of this study convinced the government to initiate a number of changes in the eligibility requirements. In addition, the authors were given the responsibility to design a new system of opium distribution for registered addicts. The second wave of the study was conducted in the spring of 1977, some 6 months after the policy revisions, in order to monitor their effects.

Comparison of the effect of high and low doses of methadone on treatment outcome.

The results of a 2-year-study of the relationship between methadone dosage and treatment outcome are reported. For discharged patients, higher doses of methadone were significantly related to successful treatment and lower doses to treatment failure. Based on these findings and the review of literature as well as the senior author's clinical experience, a theoretical formulation is offered to provide a rationale for methadone maintenance treatment. The tenability of the formulation is readily testable by clinical research.

Who should be counselors in methadone maintenance programs: ex-addicts or nonaddicts?

Counselors play a central role in most methadone maintenance programs. Yet the choice of who should be employed as counselors is based on little more than personal whims of decision makers. And in evaluating the effectiveness of this highly controlled rehabilitative therapy, the influence of the counselors as an important factor is often ignored. The total changeover of the counselors from an ex-addict to a nonaddict group in an otherwise stable clinic provided an unusual opportunity to compared the performance of the two groups. Both the objective and subjective data supported the hypothesis that ex-addicts as a group compared unfavorably with a similar group of nonaddicts when employed as counselors in a methadone maintenance clinic.

Psychotherapy with patients from lower socioeconomic groups.

Patients of lower socioeconomic status are only infrequently considered for individual psychodynamic psychotherapy even where cost is not a factor. Reasons for this bias are examined and suggestions are made for correcting such inadvertent discrimination.

Methadone maintenance and the problem with alcohol.

There is a growing concern with the rapid pace of physical and psychosocial deterioration of methadone patients who abuse alcohol. The need for a sample method for determining the extent of the problem, as well as the presence of an alcohol problem in individual patients, led the authors to test the validity of the Michigan Alcoholism Sreen Test (MAST) in a small urban methadone maintenance clinic (N = 125). The MAST was administered to every patient by their counselors, and the nursing staff was asked to independently rate each patient according to Keller's definition of alcoholism. The authors compared the patients' MAST scores with the global ratings of the nursing staff. Forty-six percent (n = 58) of the patients scored in the alcoholism range of the MAST questionnaire, while 34% (n = 43) of the patients were diagnosed as alcoholics by the nursing staff. There was 75% (n = 94) agreement between the MAST findings and the nurses' global ratings (p less than .001). The authors suggest that the MAST could be an effective screening tool in the area of alcohol abuse in methadone clinics. Going beyond the data, the authors recommend reexamination by psychiatrists of their peripheral role in the treatment of these difficult and multihandicapped patients.

Cost-financed mental health facility. II. Utilization profile of a labor union program.

Specific data are presened concerning the utilization profile of a cost-financed mental health facility. The utilization is enhanced by a mental health education campaign, but total utilization remains within manageable limits (13 per 1000). The visit rate is 8.5 units per patient and remains well within the plan's dollar limits. Comparison between utilizers and the population from which they are drawn shows disproportionate numbers of males in contrast to other outpatient insurance studies. This may be a unique feature of work-related programs. "Acting out" disorders are more common among these workers than in other psychiatric programs in the same geographic area.

Cost-financed mental health facility. III. Economic issues and implications for future patterns of health care.

Data are presened concerning the economics of a cost-financed mental health facility and a lobor union insurance program. The total cost per insured enrolle for all mental health services did not exceed $5.41 per year. The cost per treated patient per year remained under $490. These data strongly support the feasibility of including mental health benefits in national health insurance. Costs are then compared between fee-for-service insurance and cost financing. Average costs per treated patient in the cost-financed facility were $302 over a 4-year period. Similar computations under fee-for services financing showed costs of $824. The difference reflects much greater use of hospitalizations in the fee-for-service system. These data and the data from the preceding two papers on the clinical and utilization partterns of cost-financed facilites suggest that these facilities are practical clinical forms. Implications for national health insurance, HMO legislation, and community mental health centers are explored.

Cost-financed mental health facility. I. Clinical care pattern in a labor union program.

Cost-financed mental health facilities create opportunities for new patterns of mental health service analogous to community mental health centers in some ways and to HMOs in others. This paper describes the first facility based on such financing. The concept of cost-financed mental health practice is introduced and defined as including a multidisciplinary team serving a defined population of enrollees through prepaid or prebudgeted financing. The financing may be capitation based or generated through an agreed-upon budget for predefined services. Ordinary fee-for-service insurance creates purchasing power but not care system. Cost financing can create service mechanisms. The paper describes the clinical system made possible through such financing. The direct patient service systems for the United Auto Workers at the Johns Hopkins Hospital funded through cost financing included an early case-finding program, intake and evaluations specially designed for blue-collar workers, a full range of continuous treatment modalities, and programs in chronic care and rehabilitation. Programs in prevention, consultation, and education were also included. Conern is described. The authors conclude that this clinical form has the potential to offer both the advantages of the community mental health center and of the private practice system.