Long-stay patients in state psychiatric hospitals at the end of the 20th century.

OBJECTIVES: The purpose of this study was to assess the characteristics of long-stay patients in contemporary state psychiatric hospitals and to identify factors representing possible barriers to alternative placements for these patients. METHODS: All patients in inpatient units of the Massachusetts Department of Mental Health who had been hospitalized for at least three years as of April 1, 1999, were assessed by their treatment teams with a standardized data collection instrument. Domains assessed included medical problems, need for nursing care, psychiatric diagnosis, and history of problematic behaviors. RESULTS: The 330 individuals identified as long-stay patients had an array of medical problems and nursing care needs that likely would have been manageable in other long-term-care settings. A total of 276 patients had at least one significant medical problem. However, some patients exhibited behavioral problems that might have complicated such placements, especially when behavioral problems co-occurred with the need for medical supervision. A total of 228 patients had exhibited a significant problematic behavior in the previous 30 days. CONCLUSIONS: Although the number of long-stay patients in state psychiatric hospitals declined dramatically during the second half of the 20th century, a small group of patients still requires care in this setting. State psychiatric hospitals continue to occupy a significant niche in the mental health system.

Excluding institutions for mental diseases from federal reimbursementfor services: strategy or tragedy?

A key component in the dehospitalization of persons with chronic mental illnesses and their translocation to a wide range of settings has been the shift from state to federal funding encouraged by the Social Security Administration's restrictions on funding for institutions for mental diseases (IMDs), usually referred to as the IMD exclusion. The overall effect of the exclusion, which limits federal funding for mentally ill patients receiving care in many settings, including state psychiatric hospitals, has been to create incentives for states to move patients out of state hospitals, which has contributed to homelessness and inappropriate incarceration. The author traces the background and development of the IMD exclusion, starting with the federal government's actions in the 1840s ensuring that the states, not the federal government, would continue to fund care for their seriously mentally ill citizens. He also analyzes Congress' many missed opportunities to pass legislation that would have modified, or perhaps even made moot, the IMD exclusion, including the Clinton administration's efforts at health reform, the quest for parity of insurance coverage for mental illnesses, and the initiation of public-sector managed care. The consequences of the continuation of the IMD exclusion are explored, and the intended fiscal consequences are contrasted with the unintended clinical outcomes.

At the margins of human rights and psychiatric care in North America.

The roots and expanse of the rights of psychiatric patients in North America are broad and diverse. This paper focuses on four rights that are pushing at the contemporary margins of patients' rights. First, the right to treatment, a moral position casting about for legal grounding. Second, the rights of psychiatrically hospitalized patients, articulated in statutes, court decisions, organizational standards and patients' bills of right. Third, patient participation in treatment planning, a process involving both rights and responsibilities. Fourth, the right to involuntary outpatient treatment, a process sometimes viewed as a deprivation of and other times as an expansion of rights for patients. These rights are addressed in the context of the question, are we going in the proper direction?

The use of advance directives by persons with serious mental illness for psychiatric treatment.

OBJECTIVE: A health care proxy is an advance directive that allows an individual to indicate in writing who can act on his behalf when he lacks the capacity to make health care decisions, and what limitations he is placing on this authority. Of great interest in medical settings, health care proxies are beginning to receive more attention in psychiatric settings. Are these proxies useful when applied to psychiatric treatment decisions? This paper examines health care proxies in Massachusetts and their potential use for decisions about psychiatric interventions at one Massachusetts state hospital. METHOD: A point in time study of a state hospital's entire census was done by reviewing all patients' records for demographic, diagnostic, and legal data, and for the presence and content of the state required health care proxy form. RESULTS: Of the 161 patients in the hospital, 71 (44%) had full guardians and were ineligible to complete their own proxies. Of the remaining 90 patients, 53 (33% of the total population) had a proxy form in their chart, but 34 (21%) of these patients refused to sign them. Of the 19 (12%) signed proxies, 16 (10%) of the patients were deemed competent to have executed meaningful health care proxies. CONCLUSIONS: This preliminary analysis reveals that only 10% of a state hospital population had meaningful health care proxies. Further outcome studies are needed to determine if the process of offering health care proxies and the presence of properly executed proxies are meaningful and beneficial to chronically ill psychiatric patients.

The last half-century of psychiatric services as reflected in psychiatric services.

The last half-century of psychiatric services in the United States is examined through developments and trends reported in the 50 years of publication of Psychiatric Services. The journal, earlier named Mental Hospitals and then Hospital and Community Psychiatry, was launched by the American Psychiatric Association in January 1950 and marks its 50th anniversary this year. The author organizes his review of psychiatric services largely around the locus of care and treatment because the location of treatment--institution versus community--has been the battleground for the ideology of care and for the crystallization of policy and legal reform. He uses "dehospitalization" to describe the movement of patients out of state hospitals, rejecting the widely used term "deinstitutionalization" as inappropriate; one reason is that the term wrongly implies that many settings where patients ended up were not institutional. Also covered in detail, as reflected in the journal, are community care and treatment, economics, patient empowerment, and the interface issues of general hospitals, outpatient commitment, and psychosocial rehabilitation. The author notes that some concepts, such as outpatient commitment and patient empowerment, emerged earlier than now assumed, and that others, like psychosocial rehabilitation, recurred in slightly different forms over time. He concludes that even after 50 years of moving patients out of state hospitals and putting them somewhere else, mental health policymakers and practitioners remain too myopically focused on the locus of care and treatment instead of on the humaneness, effectiveness, and quality of care.

Cost considerations of medical therapy for glaucoma.

PURPOSE: To determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy. METHODS: The actual volume of various glaucoma medications was determined for all commercially available sizes of the tested products. The drops per ml on the basis of the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price in the United States. RESULTS: The generic timolol products dosed twice daily and the once-daily gel-forming solutions (range, $0.30 to $0.46/day) were similar on a cost-per-day basis compared with the brand name metipranolol (Optipranolol; Bausch & Lomb Pharmaceuticals, Tampa, Florida, at $0.43/day) and timolol (Timoptic; Merck, West Point, Pennsylvania, at $0.46/day and Timoptic XE at $0.38/ day). Betaxolol (Betoptic S; Alcon Laboratories, Fort Worth, Texas, at $0.65/day), carteolol (Ocupress; CibaVision, Duluth, Georgia, at $0.57/day), levobunolol ($0.61/day), and brand name levobunolol (Betagan; Allergan, Irvine, California, at $0.81/day) all were dosed twice daily and were more costly on a per-day basis. The topical carbonic anhydrase inhibitors brinzolamide (Azopt; Alcon, at $0.96/day) and dorzolamide (Trusopt; Merck, at $1.02/day) were dosed three times daily and were similar on a cost-per-day basis. The combination product Cosopt (timolol 0.5% + dorzolamide 2.0%, Merck, at $1.12/day) was less costly than separate bottles of a topical carbonic anhydrase inhibitor (three times daily dosing) and a beta-blocker ($1.26 to $1.83/day), often even if the topical carbonic anhydrase inhibitor was dosed two times daily ($0.94 to $1.49). The selective alpha2-agonist brimonidine (Alphagan; Allergan, at $0.90/day) twice daily and the prostaglandin analog latanoprost (Xalatan; Pharmacia & Upjohn, Kalamazoo, Michigan, at $0.92/day) once daily were similarly priced. CONCLUSIONS: All generic timolol, Optipranolol, Timoptic, and Timoptic XE ranged between $0.30 and $0.46 per day. Betaxolol, Ocupress, generic levobunolol, and Betagan were more costly, ranging between $0.57 and $0.81 per day. Cosopt ($1.12/day) was less costly than separate bottles of a topical beta-blocker and a topical carbonic anhydrase inhibitor dosed three times daily ($1.26 to $1.83/day) and often twice daily ($0.94 to $1.49). Alphagan and Xalatan were similarly priced ($0.90/day and $0.92/day, respectively). This study is based on a best-case scenario for all medicines and does not account for wasted doses, the frequency of refills, or a medication's success or failure rate. New adjunctive glaucoma regimens exhibit similar costs per day compared with more traditional regimens.

Late-onset paranoid psychosis as a distinct clinicopathologic entity: magnetic resonance imaging data in elderly patients with paranoid psychosis of late onset and schizophrenia of early onset.

OBJECTIVE: The aim of this study is to equalize the influence of age-related changes and to test the hypothesis that specific structural brain changes are mediating the development of unique clinical features in late-onset paranoid psychosis (LOPP). BACKGROUND: Findings of unique white matter lesions have been recently described in patients with LOPP. These findings have not been consistent, however, when age-matched normal subjects have been used as a control group. METHOD: Magnetic resonance imaging data were compared in 13 patients with LOPP, mean age 66.33, and 35 elderly patients with early-onset paranoid schizophrenia (PSCH), mean age 63.89. Patients in the LOPP group differed from the PSCH group by the mild degree or absence of negative symptoms, the absence of formal thought disorders, and by prevalence of female patients. RESULTS: Analysis of the magnetic resonance imaging data revealed statistically significant differences between the LOPP and PSCH groups. White matter hyperintensity was almost threefold more frequent in LOPP than in PSCH groups, 69.2% versus 22.9% respectively. Ventricular enlargement and cortical atrophy were more frequent in the PSCH group, reaching, for moderate to severe abnormalities, 28.6% for ventricular enlargement and 22.9% for cortical atrophy; moderate to severe abnormalities were absent in all 13 patients of the LOPP group. CONCLUSIONS: These data point to the possibility that late-onset paranoid psychosis is a distinct clinicopathological entity, with white matter hyperintensity mediating the development of LOPP in a significant percentage of the cases. The vascular origin of white matter lesions in LOPP is suggested.

Mothers with mental illness: I. The competing demands of parenting and living with mental illness.

OBJECTIVE: The purpose of this study is to understand the parenting experiences of women with mental illness from the perspectives of mothers and case managers employed by the state department of mental health. METHODS: Six focus groups of mothers and five focus groups of case managers met to discuss the problems facing mothers with mental illness and to recommend solutions. Focus-group transcripts were coded and items grouped by themes in qualitative analyses to explore the conflicts mothers face in meeting the dual challenges of parenting and living with mental illness. RESULTS: Mothers and case managers identified sources of conflict in four thematic categories: the stigma of mental illness, day-to-day parenting, managing mental illness, and custody of and contact with children. CONCLUSIONS: Many of the issues of mothers with mental illness are generic to all parents; others are specific to the situation of living with mental illness. Mothers with mental illness must play a role in developing standards for clinical care and the research agenda in this area.

Mothers with mental illness: II. Family relationships and the context of parenting.

OBJECTIVE: This study explores the experiences of mothers with mental illness regarding their family relationships. METHODS: Six focus groups of mothers with mental illness and five focus groups of case managers met to discuss problems facing mothers with mental illness and to recommend solutions. Focus groups were audiotaped, and transcripts were coded and analyzed qualitatively to describe ways in which husbands and partners, grandparents, and other family members contribute to the context of parenting for mothers with mental illness. RESULTS: Mothers with mental illness and case managers described a range of relationships and attitudes of family members and provided examples of the ways in which family members contribute both positively and negatively to parenting. CONCLUSIONS: Although family members may seem to be natural supports for mothers with mental illness, their involvement in the context of parenting may not be entirely positive. The contributions of family members to the context of parenting for mothers with mental illness must be considered by treatment providers if unintentional negative outcomes are to be avoided.

The effects of public managed care on patterns of intensive use of inpatient psychiatric services.

OBJECTIVE: The study examined the characteristics of frequent users of inpatient treatment under public-sector managed care in Massachusetts between 1992 and 1995 and explored whether their pattern of inpatient utilization affected their overall use of hospital days. METHODS: Individuals with five or more admissions in any of four fiscal years (1992 to 1995) were identified using the Massachusetts Department of Mental Health client tracking system. The demographic and clinical characteristics of these patients and the types of hospitals they used were compared with those of all patients in case management programs who had a hospital admission but who did not meet study criteria for multiple admissions. RESULTS: Compared with other patients, patients with multiple admissions were more likely to be young Caucasian females with personality disorder and a history of substance abuse but not a current substance use disorder. They tended to be lower functioning as measured by the Georgia Role Functioning Scale (GRFS) and to have higher levels of distress, as measured by the global personal distress portion of the GRFS. They made up 6 to 8 percent of all clients with a psychiatric admission who were enrolled in a case management program, but they accounted for 21 to 27 percent of all admissions in the four fiscal years. Patients with multiple admissions had significantly longer lengths of stay when admitted to a hospital where they had not been previously admitted in the past 12 months. CONCLUSIONS: States setting up public-sector managed care or revising existing public-sector managed care contracts should ensure that subpopulations of persons at high risk for multiple admissions receive special attention. They should also create networks of inpatient providers to enable frequent users of acute care facilities to return to the same facility that previously discharged them.

A national survey of "consumer empowerment" at the state level.

OBJECTIVE: A national survey was conducted to determine the extent of consumer empowerment in the public mental health system. METHODS: A questionnaire was sent to mental health authorities in all U.S. states and territories asking whether consumer empowerment or responsibility was defined in statutes, regulations, or policies and whether consumers or family members were employed in central or field offices of the authority. A rating scale measured the extent of consumer empowerment, and correlations were examined between this rating and other variables. RESULTS: The survey achieved a 100 percent response rate. Twenty-two states (39 percent) addressed consumer empowerment and 16 (28 percent) consumer responsibility in a statute, regulation, or policy. Twenty-seven states (48 percent) had paid positions for consumers in central offices, and three (5 percent) had such positions for family members. Half the states had paid positions for consumers in field offices, and 12 states (24 percent) had such positions for family members. The extent of a state's consumer empowerment had no relationship to region of the country or the state's mental health budget. A significant positive relationship was found between extent of empowerment and the size of the state's population and the quality of its mental health services. CONCLUSIONS: State mental health authorities vary widely in their direct involvement with consumer empowerment. Results indicate that mental health authorities need to make a greater commitment to the achievement of such empowerment if it is to become a meaningful part of government involvement with mental health services.

The rights of state hospital patients: from state hospitals to their alternatives.

During the 1980s and 1990s the locus of psychiatric treatment in many states shifted from state hospitals to the psychiatric units of general hospitals. The extent to which the rights guaranteed to psychiatric inpatients by state mental health agencies will survive this "privatization" process is unclear. The authors explore this issue by providing a "status report" of patient rights, identified through a national survey. They discuss the problems of preserving these rights as an ever greater proportion of care is provided in general hospitals under the mechanism of managed care.