Post-traumatic growth among veterans in the USA: results from the National Health and Resilience in Veterans Study.

BACKGROUND: There is increasing recognition that, in addition to negative psychological consequences of trauma such as post-traumatic stress disorder (PTSD), some individuals may develop post-traumatic growth (PTG) following such experiences. To date, however, data regarding the prevalence, correlates and functional significance of PTG in population-based samples are lacking. METHOD: Data were analysed from the National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 3157 US veterans. Veterans completed a survey containing measures of sociodemographic, military, health and psychosocial characteristics, and the Posttraumatic Growth Inventory-Short Form. RESULTS: We found that 50.1% of all veterans and 72.0% of veterans who screened positive for PTSD reported at least 'moderate' PTG in relation to their worst traumatic event. An inverted U-shaped relationship was found to best explain the relationship between PTSD symptoms and PTG. Among veterans with PTSD, those with PTSD reported better mental functioning and general health than those without PTG. Experiencing a life-threatening illness or injury and re-experiencing symptoms were most strongly associated with PTG. In multivariable analysis, greater social connectedness, intrinsic religiosity and purpose in life were independently associated with greater PTG. CONCLUSIONS: PTG is prevalent among US veterans, particularly among those who screen positive for PTSD. These results suggest that there may be a 'positive legacy' of trauma that has functional significance for veterans. They further suggest that interventions geared toward helping trauma-exposed US veterans process their re-experiencing symptoms, and to develop greater social connections, sense of purpose and intrinsic religiosity may help promote PTG in this population.

Health and disability costs of depressive illness in a major U.S. corporation.

OBJECTIVE: Employers are playing an increasingly influential role in determining the scope and character of health coverage in the United States. This study compares the health and disability costs of depressive illness with those of four other chronic conditions among employees of a large U.S. corporation. METHOD: Data from the health and employee files of 15,153 employees of a major U.S. corporation who filed health claims in 1995 were examined. Analyses compared the mental health costs, medical costs, sick days, and total health and disability costs associated with depression and four other conditions: heart disease, diabetes, hypertension, and back problems. Regression models were used to control for demographic differences and job characteristics. RESULTS: Employees treated for depression incurred annual per capita health and disability costs of $5,415, significantly more than the cost for hypertension and comparable to the cost for the three other medical conditions. Employees with depressive illness plus any of the other conditions cost 1.7 times more than those with the comparison medical conditions alone. Depressive illness was associated with a mean of 9.86 annual sick days, significantly more than any of the other conditions. Depressed employees under the age of 40 years took 3.5 more annual sick days than those 40 years old or older. CONCLUSIONS: The cost of depression to employers, particularly the cost in lost work days, is as great or greater than the cost of many other common medical illnesses, and the combination of depressive and other common illnesses is particularly costly. The strong association between depressive illness and sick days in younger workers suggests that the impact of depression may increase as these workers age.

A clinimetric approach to the components of the patient-physician relationship.

Although patient-physician relationships have been expressed with diverse concepts and models, we have formulated a clinimetric classification derived from several years of observation and discussions at weekly house-staff conferences devoted to "difficult" patients. The observed phenomena are classified into the following components: (1) background factors intrinsic to patient and physician before they meet, (2) individual anticipations and hopes for what may happen, (3) extrinsic features of the setting, (4) individual reactions during the encounter, and (5) the consequences thereafter. These interacting components are usually too complex for characterizations based on single models for the relationship or single titles (such as "hateful" or "noncompliant") for the patient. The components can serve as a "review of systems" for identifying manifestations, sources, and solutions to such common problems as discordant hopes, the physician's unawareness of the patient's pertinent extramedical status, psychiatric and mental-status challenges, and cogent factors in chronic illness.

Collaboration with police officers within a partial hospital program.

After an incident of violence in an urban community mental health center, city police officers were hired to provide extra-duty coverage to one of its satellite programs. The boundaries between clinical and security functions were not clarified initially, leading to unclear expectations regarding roles and responsibilities when handling patient dyscontrol episodes. The relationship between the clinical staff and the police developed over the course of a year, in three distinct phases, into one that is mutually supportive and beneficial. This experience is described, with an aim of identifying the challenges and advantages of participating in this type of collaboration. A conceptual framework for this interprofessional system is presented.

Normalizing acute care: a day hospital/crisis residence alternative to inpatient hospitalization.

Normalization is the use of culturally valued means to enable people with disabilities to live culturally valued lives. In this article, the authors describe an effort to bring normalization practices to acute psychiatric care. They describe a day hospital/crisis respite diversion program that serves as an alternative to acute inpatient hospitalization and sketch the research project that fostered it. The authors argue that a day hospital/ crisis respite provides effective clinical care comparable to inpatient hospitalization but achieves greater potential for recovery through a normalizing philosophy and practice. An implication of this finding is that such programs based on the principle of normalization may be both cost effective as well as more empowering for patients.

Cognition, negative symptoms, and diagnosis: a comparison of schizophrenic, bipolar, and control samples.

Forty-six schizophrenic, 22 bipolar, and 26 normal control subjects were administered negative and positive symptoms scales and tests of cognitive function. Test performance was related to diagnosis and to positive and negative symptom ratings within the schizophrenic group. Bipolar patients were significantly superior in cognitive status when compared with all schizophrenic patients, but less so when compared only with those who did not have key negative symptoms (affective nonresponsivity and poverty of speech). The schizophrenic patients with negative symptoms displayed severe impairment, performing significantly worse than the control, bipolar, and other schizophrenic subjects. Negative symptoms thus are significantly implicated in the cognitive inferiority of schizophrenic to bipolar patients. Although the data suggest bipolar patients may also have cognitive deficiencies, these findings are inconclusive and require cross-validation.

Managed care, health care reform, and academic psychiatry.

Although the process of national health care reform has slowed, state-based reform initiatives and market forces driven by managed care are dramatically reconfiguring the health care environment This decentralized process of health care reform poses numerous threats to academic departments of psychiatry, which must develop strategic plans to cope with the changes. The authors outline the effects of health care reform on clinical service, education, and research and discuss strategies of response in each domain, including examples from their department at Yale University. An active response to health care reform provides academic departments of psychiatry an opportunity to participate in shaping the future of psychiatry while reorganizing their teaching and research programs. (Academic Psychiatry 1997;21:72-85).

Day hospital/crisis respite care versus inpatient care, Part I: Clinical outcomes.

OBJECTIVE: The authors investigated the clinical feasibility and the outcome for patients of a program designed as an alternative to acute hospitalization. METHOD: This was a random-design study comparing a conventional inpatient program for urban, poor, severely ill voluntary patients who usually require hospitalization to an alternative experimental program consisting of a day hospital linked to a crisis residence. Patients were assessed with standardized measures of symptoms, functioning, social adjustment, quality of life, and satisfaction with clinical services upon admission to the study, at discharge from the index admission, and at follow-ups 2, 5, and 10 months after discharge. RESULTS: One hundred ninety-seven patients were enrolled in the 2-year research program and followed for 10 months. Of the voluntary patients who would have been admitted to the hospital, 83% were appropriate for the experimental program. The clinical, functional, social adjustment, quality of life, and satisfaction outcome measures were not statistically different for the patients in the two treatment conditions; however, there was a slightly more positive effect of the experimental program on measures of symptoms, overall functioning, and social functioning. CONCLUSIONS: The experimental condition, a combined day hospital/crisis respite community residence, seems to have had the same treatment effectiveness as acute hospital care for urban, poor, acutely ill voluntary patients with severe mental illness.

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs.

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.

Differences in social environment between inpatient and day hospital-crisis respite settings.

OBJECTIVE: The study compared the social environment of a conventional psychiatric inpatient setting with that of a combined acute day hospital and crisis respite program that functions as an alternative to hospitalization for patients judged appropriate for acute inpatient admission. METHODS: As part of a randomized controlled study comparing the clinical effectiveness and cost-effectiveness of the two settings, the quality of the social environment in the two settings was assessed using the Multiphasic Environmental Assessment Procedure, an empirical measure of established reliability and validity that is based on objective ratings and perceptions of staff members and patients. RESULTS: Compared with the inpatient setting, the day hospital-crisis respite program had higher expectations for patients' functioning, a lower tolerance for deviance, and more flexibility in patients' choice of activities. The day hospital-crisis respite program also had a more attractive physical environment, and respondents rated its social milieu as more cohesive, less conflictual, and more comfortable. This setting also promoted higher levels of patient functioning and activity and more utilization of health services, assistance with daily living skills, and social and recreational resources and encouraged fuller integration of patients in the community. CONCLUSIONS: The social environment of the community-based day hospital-crisis respite program embodied several principles of community support systems, including provision of treatment in a less restrictive setting, avoiding disruption of patients' ongoing involvement in the community, promoting activities in the community, offering patients respect and opportunities for self-determination, and enhancing their dignity.

Working memory, attention, and communication disturbances in schizophrenia.

The authors hypothesized that schizophrenic communication disturbances reflect specific cognitive deficits in the areas of working memory and attention. They examined the cognitive correlates of communication disturbances, as measured by linguistic reference performance, in schizophrenic (n = 48), bipolar (n = 24), and nonpsychiatric control (n = 23) individuals. Reference performance ratings in the schizophrenic patients were associated with scores on tests of working memory and attention and were not related to performance on concept formation or verbal fluency tests. In contrast, in the bipolar and nonpsychiatric individuals, reference performance was associated with concept formation and verbal fluency test scores but was not related to performance on tests of working memory. Implications with respect to the processes underlying schizophrenic communication disturbances are discussed.

Resident and faculty evaluations of a psychiatry night-float system.

This study used self-report questionnaires to examine resident and faculty perceptions of a new night-float schedule for coverage of a psychiatric emergency room compared with a traditional night-call system. The residents reported improved well-being, educational experience, and performance of clinical duties under the night-float system compared with a traditional call schedule. The faculty had a generally favorable impression of the new system. Night-float systems may provide a means of improving psychiatric residents' emergency room and outpatient experiences without compromising patient care, although further studies are needed to measure fully the cost-benefit ratio of such programs.

Case management in psychiatry: an analysis of tasks.

OBJECTIVE: The authors analyze the concept of case management from the perspective of the task areas of psychiatry and demonstrate the importance of case management in the organization of psychiatric services. METHOD: The relevant literature was reviewed, and a functional analysis of current practices is provided. RESULTS: Case management is an ambiguous concept without a clear base in a professional discipline, and thus there is ongoing uncertainty about its mission, practice, and training, as well as authority and accountability issues. The activities of the case manager in both the private and the public sectors entail work in the task areas of medical care, rehabilitation, social control, growth and development, and social welfare. In all of these areas, the case manager may function in boundary management and in system enhancement and development as well as provide clinical services. CONCLUSIONS: Case management has considerable potential as a means of organizing and delivering mental health services in a cost-effective manner as long as its purpose, practice, and organizational structures are consistent. Psychiatrists should be involved in the organization of case management services.

A comparison of the structured clinical interview for DSM-III-R and clinical diagnoses.

The relationship between diagnoses generated by the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID) and by nonstructured psychiatric interviews was examined. The purposes were to evaluate which DSM-III-R diagnoses were most reliably chosen, and to compare diagnostic practices between two clinical sites. Diagnoses generated by researchers using the patient version of the SCID and by psychiatric interviews were compared for 100 patients. The participants had been randomly assigned to one of two acute treatment sites within the same institution, as part of a larger study of an alternative to inpatient hospitalization. Overall reliability between the SCID and the clinicians, as determined by weighted Kappa, was poor. There was considerable variability among the major diagnostic categories, with higher agreement for schizophrenia and bipolar disorder than for others. The agreement for schizoaffective disorder was extremely low. There were also significant differences in the patterns of diagnosis between the two sites. The patient version of the SCID appears to produce results that are very different from clinical practice, which, in turn, may be influenced strongly by location.

Can digit symbol-verbal fluency comparisons facilitate detection of pseudodementia? A preliminary study.

Depressive psychomotor retardation may impair performance on timed tests. By comparison word association measures of verbal fluency are reportedly unaffected by depression. Comparisons of a brief psychomotor test with a measure of verbal fluency may therefore prove useful when there is a concern that depression may be undermining adaptive functioning, assuming both measures display: (1) broad-spectrum sensitivity to brain impairment, (2) differential vulnerability to depression, and (3) moderate correlation in nondepressed persons. Digit Symbol (DS) and the "FAS" measure of verbal fluency are sensitive to genuine dementia, satisfying the first criterion. We found that depressed schizophrenics performed at significantly lower levels on DS, but not on FAS, than nondepressed schizophrenics. The two groups differed significantly on a discrepancy score derived by subtracting FAS from DS scores; normals obtained discrepancy scores highly similar to those of nondepressed schizophrenics. As the normals had higher DS and FAS scores, this discrepancy-score similarity suggests that this index may have wide application. The third criterion is satisfied by the findings of a 0.64 correlation between DS and FAS scores adjusted for age (DS and FAS) as well as gender and educational attainment (FAS) in nondepressed samples. Implications for further research and clinical applications are discussed.

Defining managed care in public-sector psychiatry.

Although managed care is an established force in the private sector, there is growing interest and experimentation with this concept in the public sector. This interest has been generated by the increased demand for services, the shrinking resource base due to cutbacks in state budgets, and the fragmentation of care that has accompanied the shift from a centralized, hospital-based model to a decentralized, community-based model for treating individuals with serious mental illness. But despite this interest, no consensus exists about the form or functions of managed care in the public arena. Simply importing private-sector versions of managed care is inadequate given the substantial differences in the patient population and service delivery mechanisms. The authors present a functional analysis of managed care in the public sector. Drawing on their conceptualization of managed care, they outline a functional approach to evaluating the strengths and weaknesses of treatment systems, innovations such as privatization and capitation, and recent health care reform proposals.