The positive family contribution of those with serious mental illness.

Fifty-five patients who met criteria for serious mental illness nominated a relative with whom they had lived for at least the previous 6 months to be sent a questionnaire that included a scale for rating patients' contribution to family life in 10 specific areas. Thirty-six relatives returned completed questionnaires. Patients rated their own contributions using the same scale. Overall, relatives rated patients' contributions as positive, and their ratings of patients when well generally agreed with patients' self-ratings. For women only, relatives rated contributions as significantly less when the patient was ill. Patients' self-rated level of psychological symptoms was the best predictor of relatives' overall satisfaction with them. Ratings of patients' contributions mirrored sex-role stereotypes.

Comorbidity of bipolar and personality disorder.

OBJECTIVE: The aims of this study were to determine the prevalence of personality disorder in a sample of patients with well-documented bipolar disorder, and to assess the effects of comorbidity. METHOD: The sample (n = 42) was drawn from patients currently case-managed within a community treatment program who fully met DSM-IV criteria for bipolar I disorder. The International Personality Disorder Examination, a structured interview, was used to diagnose personality disorder. The Brief Symptom Inventory assessed overall levels of psychological symptoms. RESULTS: Seven of the 13 men (55%) in the sample had 10 personality disorder diagnoses and 12 of the 29 women (41%) had 28 diagnoses, an overall prevalence of 45%. Hospital admission rates and all measures of psychological symptoms and impairment were significantly elevated in the comorbid group, who found medication significantly less helpful. CONCLUSIONS: Comorbid personality disorder was common in the sample studied, which was representative of Australian patients treated in public community psychiatry programs. However, only three (7%) had a personality disorder diagnosis recorded in their case notes, reflecting clinicians' reluctance to apply what is widely viewed as a pejorative and therapeutically nihilistic label. New treatments for personality disorder have proven effective within both public and private psychiatric settings, so that underdiagnosis represents undertreatment. The findings suggest that clinicians should be more vigilant for comorbid personality and bipolar disorder, and less reluctant to diagnose it.

The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder.

OBJECTIVE: The aim of this study to determine the prevalence of anxiety disorders in publically treated psychiatric inpatients with a DSM-IV diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. METHOD: Using the Structured Clinical Interview for DSM-III-R (SCID), 100 consecutive inpatients with a psychotic disorder were examined for the presence or absence of an anxiety disorder. Questionnaire measures of phobias, obsessive-compulsive and general anxiety symptoms were also applied. RESULTS: The prevalences of social phobia (17%), obsessive-compulsive disorder (13%) and generalised anxiety disorder in schizophrenia were relatively high, as were prevalences of obsessive-compulsive (30%) and panic disorder (15%) in bipolar disorder. The proportion of subjects with an anxiety disorder (43-45%) was almost identical across the three psychoses, with some evidence of gender differences. Although self-ratings of overall psychiatric symptoms were significantly elevated in those with anxiety disorders, hospital admission rates were not. CONCLUSIONS: Almost none of those with anxiety disorders were being treated for them, primarily because the severity of the acute psychotic illness required full diagnostic and therapeutic attention. Patients were generally discharged as soon as their psychotic episode was resolved, with little recognition of the presence of an anxiety disorder. Given that anxiety disorders are relatively responsive to treatment, greater awareness of their comorbidity with psychosis should yield worthwhile clinical benefits.

The brief admission unit in emergency psychiatry.

The study evaluates a Brief Admission Unit for clients of an emergency service located within a comprehensive community psychiatric program. Eighty-five clients completed the Brief Symptom inventory and a structured interview. Substance abuse disorder (n = 29) and major depression (n = 24) were the most common Axis I diagnoses, of which 30 subjects had two or more. Sixty subjects had an Axis II diagnosis. Mean duration of admission was 3.9 days, compared with the average in other acute units of 11.5 days. At discharge, half the subjects were rated as moderately to greatly improved and client satisfaction was high. The unit was crucial to the psychiatric emergency service and had a key role in relieving pressure on beds elsewhere within the system.

Training case managers in cognitive-behaviour therapy.

Four case managers with a nursing background took part in a 26 week in-service programme aimed at developing basic skills in cognitive-behaviour therapy. The programme occupied about 5 hours each week and included directly supervised therapy with at least 4 patients having serious mental illness. Patients' symptoms improved significantly after an average of less than 12 one hour therapy sessions. After the programme, case managers began treating patients autonomously, although all recognised the need for some continuing supervision and the necessity of referring unusually complex or challenging cases to clinical psychologists or others highly skilled in the area.

The influence of a therapeutic community on psychiatric disorder.

Forty-eight residents of a therapeutic community took part in a prospective study aimed at assessing overall outcome and which components of the program were most helpful. All subjects had a DSM-III-R axis II diagnosis, usually borderline personality disorder (N = 34). As well, subjects had a mean of 1.3 axis I diagnoses, underlining the severity of their psychiatric disorders. Significant symptom reduction on the Brief Symptom Inventory occurred at discharge after a mean stay of 64 days, with further significant falls at three month follow-up. These changes were paralleled in the Hostility and Direction of Hostility Questionnaire, a measure of personality. Hospital admission rates fell significantly in the year after discharge. Clients rated group therapy as the most helpful component of the program.

Behavioral disturbance in dementia.

Fifty-seven subjects with moderate to severe dementia (49 with Alzheimer's disease) were rated twice, 8 weeks apart, using the Mini-Mental State Examination (MMSE), the Blessed Information-Memory-Concentration Test (BIMC), and the Stockton Geriatric Rating Scale (SGRC). Only three subjects lived at home; the rest were in long-stay hospital beds or nursing homes. For 29 subjects, the first rating coincided with their referral to a comprehensive geriatric psychiatry service. The main hypothesis, that the level of behavioral disturbance would correlate positively with the level of cognitive impairment, was strongly confirmed. This finding may reflect the severity of dementia in the study sample. The correlations between MMSE and BIMC scores were .87 at entry and .92 at exit, suggesting that the two measures were broadly equivalent, although both had marked floor effects. Test-retest reliability was high for all three measures. Overall, medication was of limited effectiveness in managing severe behavioral disturbance, highlighting the need for introducing effective behavioral programs.

Borderline personality disorder: a challenge for mental health services.

OBJECTIVE: This study had two main aims: to determine the stability over time of the diagnosis borderline personality disorder (BPD) in a psychiatric hospital population; and to assess the quality and effectiveness of treatment offered within state mental health service. METHOD: The case notes of 47 psychiatric hospital patients followed up for 3 years after the index admission were analysed. RESULTS: The mean number of previous psychiatric hospital admissions was 9.0, and at least 74% of the sample had further admissions (mean 3.7) during the 3 year follow-up. Comorbidity with schizophrenia and schizoaffective disorder was rare, and was only 13% with major depression. Longitudinal stability of diagnosis was very high. CONCLUSIONS: The study firmly supported BPD as a valid diagnosis. Its treatment within the state mental health system was generally haphazard and ineffective. Post-discharge plans were implemented for only 3 subjects. Current moves toward community psychiatric treatment represent a unique opportunity for improving treatment of BPD by using existing resources more effectively.

Characteristics of police referrals to a psychiatric emergency unit in Australia.

The study examined characteristics of patients referred by police to a psychiatric emergency unit on the campus of a 400-bed psychiatric hospital in Adelaide, South Australia. Of all police referrals (N = 634) during a 21-month period, 437 cases were admitted to the hospital. Most police referrals were young, single, unemployed men. In a subsample of 61 patients, 72 percent had previous psychiatric admissions and 39 percent had been previously referred by police. Compared with nonpsychotic subjects, psychotic subjects used more mental health resources, had a longer index admission, and after the index discharge relapsed more rapidly and spent more days in the hospital.

Self reports of the interaction between substance abuse and schizophrenia.

Fifty-three psychiatric hospital inpatients with a dual diagnosis of substance abuse and schizophrenia were given the Brief Symptom Inventory and the Schizophrenia/Substance Abuse Interview Schedule. Mean age was 29; 49 were men. Only 11% were employed. Forty percent abused mainly alcohol, 40% cannabis and 8% amphetamines; 20% abused more than one substance. Mean onset age of drug abuse was 16 years; schizophrenia was diagnosed a mean of 5 years later, and subjects had been admitted to hospital an average of 7 times since then. Most believed that drug abuse initiated or exacerbated their schizophrenia; 80% took drugs primarily to relieve dysphoria and anxiety. Amphetamines improved subjective well-being significantly more than alcohol, but choice of drugs was determined mainly by price and availability. Only cannabis increased positive symptoms of schizophrenia and only amphetamines reduced negative ones. Effectively treating this population requires an integration of psychiatric and drug treatment services, ideally in a community context.

Semantic organization of hallucinated "voices" in schizophrenia.

The authors found that the different hallucinated "voices" of four schizophrenic subjects reported over 1-3 weeks expressed semantic content that was at least as persistent as clauses sampled from single 5-7-minute conversational discourses of four comparison speakers. The high degree of semantic recurrence of voices from one day to the next may contribute to the mistaken belief that these experiences derive from a particular nonself agent or speaker.

Electroconvulsive therapy in a psychiatric intensive care unit.

This study reviewed all patients (N = 37) treated with ECT in a psychiatric intensive care unit during 1989-91. Diagnoses were: psychotic depression (8); bipolar disorder, manic phase (13); schizoaffective disorder (14); and schizophrenia (2). All patients were very severely disturbed and had failed to respond to medication given at highest levels judged to be safe, usually over 3-4 weeks. Response to ECT was generally rapid and marked, allowing substantial reductions in medication. To achieve the same clinical outcome for each course of ECT, 50% more unilateral than bilateral treatments were required, suggesting that bilateral ECT has a more rapid effect in this highly disturbed population.

Depression and somatic symptoms: a cross-cultural study.

The study was carried out by the same research team in two metropolitan hospitals, one in Greece (N = 60) and one in Australia (N = 56). Subjects comprised patients consecutively admitted with a DSM-III-R diagnosis of depressive disorder, all of whom completed questionnaire measures of depression, anxiety and somatic symptoms. Clinical concepts and practices in the two hospitals were very similar. Overall levels of depression, anxiety and somatic symptoms in the two samples were almost identical, but there were differences in the pattern of somatic complaints: Greeks scored significantly higher on dizziness, paraesthesiae and masticatory spasms, and Australians scored significantly higher on drowsiness, hypersomnia and non-refreshing sleep, with the latter two items being the best discriminators of the two samples using discriminant function analysis. These findings, combined with factor analysis, suggested that symptoms associated with hyperventilation in the Greek sample, and with sleep disturbance in the Australian sample, explained most of the differences between them.

Profiles and predictors of assaultiveness for different psychiatric ward populations.

OBJECTIVE: The authors examined associations between patient-related characteristics and assaultiveness on six different psychiatric wards to determine 1) the relative contributions of demographic, disorder-related, and diagnostic variables to prediction of assaultiveness and 2) how ward composition and type of victim affect prediction of assaultiveness. METHOD: Hospital records of 1,025 inpatients residing in psychiatric wards within a 6-month time frame were reviewed for evidence of assaultiveness. Data on all 260 assaultive patients and a sample of 136 of the nonassaultive patients were analyzed with multiple regression to predict assaultiveness scores for each ward and each victim category. RESULTS: The findings indicated high rates of assaultive patients and assaults on fellow patients. Multiple regression results produced different predictors of assaultiveness for different wards but not for different categories of assault victim within each ward. Overall, age and sex consistently failed to predict assaultiveness, whereas greater assaultiveness was significantly associated with a greater proportion of time hospitalized since first admission. The most powerful unique predictors of assaultiveness scores were diagnostic distinctions derived from data on coexistent diagnoses. The most assaults were by acute patients whose diagnoses excluded organic mental disorder but included either bipolar disorder or personality disorder and longer-stay patients whose exclusive diagnosis was organic mental disorder. CONCLUSIONS: This identification, albeit modest, of risk factors for assaultiveness on different wards nevertheless provides information fundamental to the management policies of psychiatric institutions. The findings caution against aggregating different ward populations for research on assaultiveness and endorse the usefulness of coexistent diagnoses for predicting assaultiveness.

Student nurses' specialty choice: the influence of personality and education.

Before and after a nine week psychiatric-mental health (PMH) nursing program of their Diploma course, 51 second year student nurses completed a questionnaire on which they rated their interest in 14 nursing specialties. They also completed measures of personality and attitudes to psychiatric treatment. Factor analysis showed that students' initial specialty interests fell into three groups that were termed 'procedural', 'child/infant orientated', and 'action orientated'. After the PMH program, the popularity and interrelationships of specialty choice changed substantially. Community and psychiatric nursing became more popular, whereas some of the 'procedural' specialties became less so. Correlations showed that the more conservative nurses initially selected the more traditional nursing specialties, and there were statistically significant relationships between psychological defence style and specialty choice. These findings have implications for nursing specialty choice and recruitment.

Assaults by patients: the experience and attitudes of psychiatric hospital nurses.

Four hundred and twenty-five nurses working in a 420 bed metropolitan psychiatric hospital were asked to complete a questionnaire about their experience of physical assault by patients and their attitude toward the problem. 61% returned the questionnaire. The overall mean annual rate of assault per nurse was 2.0, with student psychiatric nurses (mean 6.7) significantly more at risk than any other group. Nurses working in the psychogeriatric area reported more than double the rate of assaults reported by nurses working in rehabilitation services. 60% of respondents were female; there were very few sex differences in attitudes to assault. Overall, nurses reported a high tolerance for assault, although they recognised it as an experience that was often very traumatic psychologically. Views about managing assaultiveness differed widely, and this lack of consensus probably hinders the development of optimal strategies to deal with what is a major problem in many psychiatric units.

Quality of life after gastric bypass for morbid obesity.

One year after gastric restriction surgery, 70 per cent of 118 women completed a questionnaire about lifestyle and eating behaviour changes. Mean weight loss was 35.4 kg. Patients reported a moderate reduction in appetite, and most avoided specific foods which they previously enjoyed, usually because of epigastric discomfort and/or nausea and vomiting. Patients had initiated or resumed a mean of 1.8 activities, most of which involved physical exercise. Sexual interest, enjoyment and frequency were all increased. Raised sexual satisfaction correlated strongly with overall outcome satisfaction. Seventy-two per cent of respondents rated themselves as very pleased, and 18 per cent as fairly pleased, with the overall results of the operation, and responses to the open-ended questions were often strikingly enthusiastic. However, most patients emphasized the difficulty of adjusting to radically new eating habits in the first 2-3 months after surgery, during which they experienced their greatest need for social support and encouragement.

Attitudes of psychiatric patients and their relatives to involuntary treatment.

In 1979 a Guardianship Board assumed responsibility in South Australia for the welfare of those mentally ill or handicapped people unable to look after their own health or safety, or to manage their own affairs. This study examines the attitudes to guardianship and involuntary treatment of 79 patients referred to the Board from a psychiatric hospital, all of whom were under guardianship at the time of the study. Forty-seven of their relatives took part in the project, which included measures of patients' psychiatric symptoms and relatives' punitiveness. Although almost 70% of patients objected to Guardianship in principle, they made more positive than negative statements about it. Nearly 60% rated involuntary treatment, including medication, as helpful. Patients reported a level of psychiatric symptoms less than half of that of a psychiatric outpatient sample. Relatives were strongly in favour of Guardianship, stating frequently that it allowed an improved relationship between themselves and the patient. Patients who believed that they were suffering from a mental illness were comparatively happy about being under Guardianship, and a belief that the patient was mentally ill was significantly associated with reduced extrapunitiveness in relatives.

Morbid obesity: effects on the marital system of weight loss after gastric restriction.

Eighty morbidly obese married women and 69 of their husbands completed a self-report measure of personal and marital adjustment before the women proceeded to gastric restriction surgery. Fifty-five women and 41 husbands repeated the measure 12 months after surgery, at which time the women had lost a mean of 35.4 kg. Women rated themselves as significantly more attractive and sociable, and rated their husbands as significantly less sociable and interesting, than before surgery. Husbands rated their wives as excessively sociable after surgery, the reverse of their previous view. The data offered some support for a family systems view of morbid obesity, but the systemic effect appeared weak, and is probably not a major contributor to wives' morbid obesity in most cases.

Medical visits and psychological disturbance in chronic low back pain. A study of a back education class.

Associations between the frequency of medical visits and psychological disturbance were explored using chronic low back pain patients from a back education class. Psychometric measures included the illness Behaviour Questionnaire (IBQ), somatic problems, and current mood. Males and females responded similarly on all psychological measures. Pain duration and IBQ disease affirmation significantly predicted visits to both general practitioners and specialists. Additional predictors for specialist visits included a self-rated pain/mood association, sex, age, and IBQ denial. Patients' expectations and attitudes about illness and treatment appeared most central to medical visits and several different forms of psychological disturbance accompanied increased visits.