Clients/patients with a principal diagnosis of affective disorder served in the inpatient, outpatient, and partial care programs of specialty mental health organizations, United States, 1986.

Of the 1.7 million persons under care on April 1, 1986 in the psychiatric inpatient, outpatient, and partial care programs of specialty mental health organizations nationwide, approximately 365,500 persons, or 22 percent, had a principal diagnosis of affective disorder. The vast majority of these persons, 84 percent, were under care in outpatient programs; 10 percent, in inpatient programs; and 6 percent, in partial care programs. Approximately 833,000, or 21 percent, of the 3.9 million persons admitted during 1986 to these same psychiatric programs had a diagnosis of affective disorder. Fifty-nine percent of persons with affective disorders were admitted to inpatient programs; 37 percent, to outpatient programs; and 4 percent, to partial care programs. Overall, most persons with affective disorders admitted to and under care in each of the three program types were female, white, and between the ages of 25 and 64. Most persons admitted to and under care in inpatient and partial care programs had a history of prior inpatient mental health care, while most persons in outpatient programs had never been treated in an inpatient psychiatric care setting. The principal source of payment used by persons with affective disorders varied by type of program setting. Blue Cross or other commercial insurance was the most common source of payment used by persons within inpatient programs, personal resources were used most often by persons under care in outpatient programs, and some type of public funds was used most often within partial care programs. Most persons with affective disorders were referred to inpatient and outpatient programs by family or friends, or were self-referrals. Most persons in partial care programs with affective disorders were referred to the program by an inpatient, outpatient, or another partial care mental health service. Services received by persons with affective disorders also varied by program setting. In general, drug and individual therapy were the leading types of treatment provided in inpatient programs. Individual therapy was the leading type of treatment provided, followed by drug therapy, in outpatient programs. Within partial care programs, no single type of treatment predominated.

The social control of human biomedical research: an overview and review of the literature.

Social control mechanisms have become an important element of human medical research in the United States. At first largely intraprofessional, controls over human experimentation have moved increasingly in the direction of externally developed, bureaucratically administered, and formally sanctioned rules. This paper examines intra- and extraprofessional methods of control over biomedical science and reviews available research assessing their effectiveness in promoting researcher adherence to high ethical standards concerning the use of human subjects. Research suggests that intraprofessional controls (including medical training, peer influence, ethical codes, and disciplinary boards), are, on their own, inadequate to ensure investigator ethicality. However, studies examining external controls over biomedical research (government regulations, institutional review boards, judicial and state law), also suggest that extraprofessional regulations are often ineffective. Further study of both forms of scientific social control is needed, as well as research examining their interactive effects on investigators' ethical attitudes and practices.

Informed consent in psychiatric research: preliminary findings from an ongoing investigation.

Preliminary findings from an investigation of informed consent processes in four psychiatric research projects (two being carried out at a university medical center and two at a public psychiatric hospital) are reported. Study methods include the systematic observation of investigator/subject information disclosure sessions using audio and videotape, as well as the use of standardized interaction rating forms and subject understanding interviews. In an attempt to determine if subjects' understanding of research can be improved through increased subject education, several modes of information disclosure are compared. Partial results from the public psychiatric hospital portion of the investigation suggest low subject understanding in many areas with subjects often demonstrating difficulty differentiating between treatment and biomedical research. Subjects' problematic understanding of research purposes and methodology was compounded by investigator disclosures which often emphasized the therapeutic, personalistic and nonresearch-oriented aspects of the project. Nevertheless, even when information disclosures were significantly improved, subject understanding in many cases continued to be low--suggesting that additional factors aside from the quality of investigator disclosure are involved in psychiatric subjects' comprehension and understanding of research. The implication of these findings for informed consent, regulation of biomedical research and the protection of human subjects are discussed.

KIE: Preliminary findings from a multi-institutional investigation of the informed consent process in drug studies with psychiatric patients are reported, and several modes of information disclosure are compared in an attempt to determine if subjects' understanding of research can be improved through increased education. Many prospective subjects were found to lack adequate understanding of the nature and purpose of the research in which they were asked to participate. The subjects' problematic understanding was compounded by investigator disclosures which often emphasized the therapeutic, personalistic, and nonresearch-oriented aspects of the project. Understanding often continued to be low, however, even when information disclosures were significantly improved, suggesting that additional factors are involved. The implications of these findings for informed consent and the regulation of human experimentation are discussed.

Drug information disclosed to patients prescribed antipsychotic medication.

Despite the growing interest in the process of informed consent, little research has actually examined what information clinicians give to patients concerning psychiatric treatment. In this paper, the neuroleptic drug disclosure practices of 60 North Carolina psychiatrists are examined, utilizing survey data collected in 1979. Although the vast majority of psychiatrists surveyed reported that they routinely provided information to their patients regarding the reason for the chemotherapy, signs of drug toxicity, and minor side effects, information on major side effects and tardive dyskinesia was reported to be far less routinely supplied. Physician and patient/treatment context characteristics influencing the scope of physicians' drug information disclosure were examined through the use of bivariate correlation and multiple regression techniques. Patient racial and diagnostic characteristics, as well as physician medical and psychiatric journal use, were found to be significant predictors of drug disclosure in the multivariate analyses. Patient social class, patient legal status, and treatment setting were significant predictors of drug disclosure in the bivariate, but not in the multivariate analyses. Study limitations and implications are discussed.

Factors associated with antipsychotic drug prescribing by southern psychiatrists.

The relative influence of physician, patient, and treatment setting characteristics on antipsychotic drug prescribing are examined using survey data collected in 1979 employing a sample of 61 North Carolina psychiatrists and 1003 of their patients. Antipsychotic drug prescribing is conceptualized as a three-stage, sequential decision-making process, beginning with the clinician's decision to prescribe any psychopharmaceutical, moving on to the decision to prescribe an antipsychotic agent, and finally to the determination of antipsychotic drug dosage. Regression analyses utilizing each of these three decision points as a dependent variable indicates that patient characteristics, particularly those clinically associated with the patient's mental illness, are the major determinants of psychiatrists' drug prescribing. In addition, a number of "clinically suspect" patient characteristics (race, occupation, and marital status) are found to be significant during certain stages of the prescription process. Despite the influence of these suspect patient variables, study findings in general suggest that antipsychotic medication is prescribed in a clinically appropriate manner.

Labeling theory and community care of the mentally ill in California: the relationship of social theory and ideology to public policy.

The practical merit of a labeling theory approach to mental illness is examined and assessed through an exploration of its application in terms of public policy, i.e., community mental health policy in the state of California since 1968. Primary focus is placed on the impact of the deinstitutionalization of mental health services in that state, and the release of former mental patients into the community. Similarities in the fundamental ideological underpinnings of labeling theory, an associated conspiratorial model of mental illness, and contemporary California mental health policy, are presented and examples of policy input by labeling theorists and researchers are detailed. The impact of the California policy on the mentally ill is generally negatively assessed in terms of three major criteria: (1) rehabilitation; (2) reintegration; and (3) quality and continuity of care. The "translation" of several theoretical misconceptions regarding mental illness, caused by putting labeling theory into official policy, is suggested to lie at the root of many of the policy's implementation problems. The uses of social science theory and research are discussed, and caution is advised in the translation and application of social scientific theory and research to public policy proposals and programs.