A new look at an old issue: people with mental illness and the law enforcement system.

Most research on encounters between persons with mental illness and the law enforcement system has focused on the extent to which persons with mental illness are shifted between the mental health and law enforcement systems. This article focuses instead on the interplay between the mental health and law enforcement systems for a group of persons with severe mental illness who continue to be actively treated by an Assertive Community Treatment (ACT) program. To better understand the connection between these two systems, profiles were constructed for 100 ACT clients, including data about arrests, other contacts with the law enforcement system, and mental health treatment. Results indicate that although the majority of ACT clients had some contact with the law enforcement system, most police encounters and arrests were for minor infractions. Those clients with the most frequent and serious contacts also received more expensive and intensive mental health treatment. Implications for future research and program design are discussed.

The role of psychiatrists in community mental health centers: a survey of job descriptions.

There is little data about the role of psychiatrists within CMHCs. To gain perspective on this issue, job descriptions for medical directors and staff psychiatrists were collected from 214 CMHCs. The data demonstrated that most CMHCs want fully trained psychiatrists involved in a variety of activities in addition to prescribing medication. Policy development was specifically included as part of the medical director's job for 69% of the CMHCs, and 50% mentioned training as part of the staff psychiatrist's job. Although job descriptions may not accurately reflect the actual roles of the psychiatrist in all cases, these data suggest that CMHCs support a multifaceted role for their psychiatrists.

Estimated societal costs of assertive community mental health care.

OBJECTIVE: The study used a societal costs model to estimate costs of assertive community treatment for persons with severe mental illness. METHODS: Resource use and cost data were collected for mental health, health, social, and law enforcement, and other maintenance services and family services for 94 clients enrolled in a mobile community treatment program in Madison, Wisconsin. Data sources included self-reports of clients and family members, private and public agency records, and insurance claims files. To make more precise estimates, outcome definitions were broadened, data sources were cross-validated, and prices of services were calculated independently of agencies' charges for such services. RESULTS: Average societal costs for participants in the study were estimated at $23,061 in 1988 ($29,965 in 1994 dollars). Use of a less sophisticated model with less careful costing methods would have resulted in an estimated average cost at least 30 percent lower. Maintenance costs (cash payments from government programs, subsidies, and in-kind services) were the largest cost component, followed by mental health treatment, family burden, indirect treatment, and law enforcement. Most of the financing for these services came from the public sector (85 percent). CONCLUSIONS: Accurate, reliable, and consistent measurement of societal costs will aid in the complex task of rationing fixed health and mental health care budgets.

Coercion in the community: issues for mature treatment systems.

Coercion in community-based mental health treatment refers to much more than just court-ordered treatment. Mature systems can address these issues and adopt clinical approaches that decreased the need for coercion.

Efficacy of DMP 840: a novel bis-naphthalimide cytotoxic agent with human solid tumor xenograft selectivity.

DMP 840, a novel bis-naphthalimide, was evaluated for antitumor efficacy in several tumor models in mice. As measured by a tumor growth inhibition assay, i.v. administration of DMP 840 to athymic nude mice at doses at or below the maximum tolerated dose resulted in curative activity against four human solid tumor xenografts, MX-1 mammary carcinoma, CX-1 and DLD-2 colon adenocarcinomas, and LX-1 lung carcinoma, producing full or incomplete regressions and/or percent tumor growth inhibition of > or = 96%. The efficacy of DMP 840 in the models was dose dependent. The activity of DMP 840 against the human tumors surpassed that demonstrated by several clinically used and investigational anticancer agents. In long-term growth delay studies, DMP 840 induced full regressions in 20 of 20 mice bearing MX-1 tumors, and tumors in one-half of these mice remained regressed for over 5 months. In addition, DMP 840 was curative against exponentially growing DLD-2 tumors staged at 500 mg and MX-1 tumors staged at 1000 mg. The bis-naphthalimide was equally efficacious when administered i.v. or i.p. but was slightly less active after oral dosing. Against both the MX-1 mammary carcinoma and the DLD-2 colon adenocarcinoma, some measure of schedule dependence was observed; the optimum schedule was daily for 9 days. Against L1210 and P388 murine leukemias, DMP 840 demonstrated little or no activity and was inactive against B16 murine melanoma. Overall, these results suggest that DMP 840 may be a human solid tumor selective cytotoxic agent.

The psychiatrist's role in supported housing.

The role of a psychiatrist in relation to supported housing programs for persons with serious psychiatric disability has not been well defined. The psychiatrist clearly has an important role in prescribing medication in a way that supports the client's own goals and in helping arrange for medical care or hospitalization when needed. The psychiatrist's influence can help the community and the client accept supported housing, and the psychiatrist has broad expertise ranging from crisis intervention to transference issues that can be useful to clients and staff. At the same time, some professionals and advocates are concerned that a psychiatrist's involvement can interfere with the rehabilitative orientation of supported housing or impose an undue degree of paternalism. Psychiatrists who understand the fundamental values of supported housing and who can tolerate some role ambiguity can greatly assist their clients to live more independent lives in the community.

Developing a systems approach to caring for persons with borderline personality disorder.

Most community mental health centers have not established a treatment approach for seriously ill persons with borderline personality disorder that is multi-focused, coordinated, comprehensive, and continuous. The authors propose that the systems approach to caring for persons with schizophrenia (Stein, Diamond, & Factor, 1990) be modified and tested for its efficacy in helping seriously ill persons with borderline personality disorder. The rationale for proposing this model of care and its underlying principles and clinical components is described in this paper.

The chronically mentally ill group treatment for individuals with schizophrenia.

Comprehensive treatment programs for individuals with schizophrenia usually include a variety of groups, many of which have concrete tasks as a focus: medication management, social skills training, meal preparation, etc. These groups can simultaneously serve more general rehabilitative purposes if leaders apply principles of group leadership which recognize the neuropathological substrate of schizophrenia and which take into account the specific interpersonal characteristics and needs of individuals who have the illness. This paper presents a framework for leading task-oriented groups for individuals with schizophrenia and give examples from a medication group in a psychosocial rehabilitation program.

A model community psychiatry curriculum for psychiatric residents.

The ability of mental health practitioners to work well with persons with serious long-term mental illness has expanded significantly over the past two decades. Learning to do this well involves acquiring a broad base of knowledge and a complex range of skills. Such knowledge and experience must be incorporated into the basic residency curriculum for general psychiatrists, though with some notable exceptions this has not occurred for a number of important reasons, including money and the new image that psychiatry is trying to assume. The key elements of such a curriculum include 1) specific learning goals, 2) working within an effective treatment system with high quality clinical rotations, 3) good role models, 4) high quality psychiatric supervision, 5) a well-grounded didactic program, and 6) high quality clinical rotations. We discuss these elements in detail, and we describe the training program in community psychiatry at the University of Wisconsin Medical School Department of Psychiatry. Our residency training program and supervising faculty are affiliated with and partially funded by the Mental Health Center of Dane County to the benefit of both. This marriage between the public-sector mental health care provider and the academic psychiatric training program has created benefits for both parents plus a fertile environment for training future generations of psychiatrists.

A psychotherapeutic approach to task-oriented groups of severely ill patients.

This paper presents a conceptual approach for leading various types of groups of chronically mentally ill patients. Although these groups may have a concrete, task-oriented purpose, with skillful leadership they also function as psychotherapy groups. The developmental deficits in ego functions, object relations, and social skills that severely impair such groups can be compensated by non-interpretative actions of the therapists. The group leader must actively work to provide for the structure, stability, and safety of the group when group members are unable to provide these for themselves.