A comparison of the restraint and seclusion experiences of patients with schizophrenia or other psychotic disorders.

OBJECTIVE: The purpose of this study was to understand how restrained and secluded patients felt about these interventions, and to compare the perceptions of the two groups. METHODS: Subjects were 25 restrained, and 25 secluded inpatients. A questionnaire was developed to explore patients' feelings and perceptions of the two interventions. Comparisons were made on the clinical data and the answers from both groups. RESULTS: Restrained and secluded patients seemed to view some aspects of their experience differently. Few (40%) of the secluded group reported finding positive aspects, compared to even fewer (20%) of restrained. Most patients in both groups felt negatively about staff involved, and disagreed with staff on the reported intensity of their documented threatening behavior. The interventions seemed to have only a brief modifying effect on patients' behavior following these interventions and did not seem to modify future behavior. CONCLUSIONS: Despite their differences, many patients in both groups reported negative feelings about the interventions and the staff involved. Both groups seemed not to perceive the procedural staff interactions as communication. Our study population seemed to be a subgroup of the admitted patient population who were repeatedly requiring seclusion or restraint. Screening this patient population during the admission process, and planning preventive and alternative interventions could decrease the need for restraint and seclusion.

Preliminary comparison of predictive and empiric lithium dosing: impact on patient outcome.

OBJECTIVE: To evaluate whether initiating lithium with predictive dosing compared with empiric dosing improves outcome in patients with manic symptoms. DESIGN: The study was a randomized, single-blind design and used the Modified Slattery predictive method. SETTING AND PARTICIPANTS: Eighteen inpatients at an urban psychiatric hospital with a Mania Rating Scale (MRS) score greater than or equal to 24 were enrolled. OUTCOME MEASURES: The study endpoint was defined as an MRS rating less than or equal to 14 or discharge from the hospital. Assessments (MRS, Brief Psychiatric Rating Scale, Clinical Global Impression, Systematic Assessment for Treatment of Emergent Events Scale, quality of life measures) were completed at baseline, on days 3 or 4 and 7 or 8, and weekly thereafter. RESULTS: The predictive group achieved a therapeutic concentration significantly sooner than did the empiric group (p = 0.004); however, the mean serum lithium concentration at discharge did not differ between the groups. The predictive group was taking significantly higher dosages of antipsychotics in chlorpromazine equivalents on day 3 or 4 (p = 0.05). Significantly fewer gastrointestinal/genitourinary adverse effects on day 3 or 4 were reported by patients in the predictive group (p = 0.04). No difference was found between groups with any rating scale or other pharmacokinetic or medication item. Even though the difference did not meet statistical significance, the predictive group's length of stay in the acute unit was three days shorter than that of the empiric group, which may represent significant cost savings. CONCLUSIONS: The preliminary data do not suggest that patient outcome is improved by using Modified Slattery predictive dosing; however, the suggestion of a shorter length of stay in a restrictive unit merits further evaluation.

The effect of intensive case management on hospitalization of patients with schizophrenia.

OBJECTIVE: The study aim was to determine if a community-based psychiatric rehabilitation program with intensive case management was more effective than traditional outpatient services in reducing hospitalization of chronic schizophrenic patients. METHODS: One hundred twelve schizophrenic patients enrolled in the intensive case management program were matched by age, number of previous hospitalizations, and days spent in the hospital with 112 schizophrenic patients who received medication services and minimal case management. The two groups were compared on the amount of services used and the number of hospitalizations and hospital days over a 24-month study period. RESULTS: Patients in the intensive case management program had been enrolled for a mean of 10.96 months, with a range from one to 24 months. They used significantly more mental health services during the study period compared with the patients in the control group. However, no significant differences were found between the two groups in number of hospitalizations and hospital days. Both groups showed an increase in the number of hospitalizations over the study period. CONCLUSIONS: A community-based psychiatric rehabilitation program with intensive case management was no more effective than medication services and minimal case management in reducing hospitalization among chronic schizophrenic patients.

Evaluation of the interaction of lithium and alprazolam.

A potential pharmacokinetic interaction between lithium and alprazolam was studied in 10 normal subjects. Pharmacokinetic parameters were determined from the following regimens: single-dose alprazolam, multiple-dose lithium, and multiple-dose alprazolam with lithium. Steady-state alprazolam clearance during multiple dosing with lithium was not different from that with the single dose of alprazolam. Lithium renal clearance decreased when it was coadministered with alprazolam (31.2 vs. 22.4 ml/minute, p less than 0.05). There was a small but significant increase in the steady-state area under the curve for lithium in the presence of alprazolam (10.3 vs. 11.1 mEq/hour/liter). The small increase in the serum lithium concentrations and decrease in lithium renal clearance was probably the result of lower urine flow rates (1.46 vs. 0.98 ml/minute, p less than 0.05) with the combination of the drugs. This is supported by a weak but significant linear relationship between urine flow rates and lithium renal clearance (N = 57, r = 0.353, p = 0.007). The percent of daily lithium dose recovered at steady-state from the 24-hour urine collection decreased significantly from 93.6% to 78.2% in the presence of alprazolam. This suggests that alprazolam may decrease lithium absorption. The results of this study do not support a definitive interaction of lithium and alprazolam and there is little clinical significance to the small rise in serum lithium concentrations.

Validation of individual items of the Depression Adjective Check List (Form E) across three populations.

Investigated the individual item response patterns of the Depression Adjective Check List (DACL) from E across three study populations by means of 34 stepwise regression analyses where the DACL adjectives were the dependent variables and the population group, sex, race, age and education were the independent variables. The study groups were: An area probability sample of Kansas City residents (N = 3,313), adult applicants to an urban community mental health center (N = 1,087) and a national probability sample (N = 3,007). Thirty-two of the 34 analyses produce the population as the most significant contribution to the prediction equation. Additional findings are discussed.

Depressed mood and subsequent physical illness.

The authors describe the results of a matched case-control analysis in which 82 pairs of subjects were selected from a large-scale community study carried out in two general populations. Cases were those of persons hospitalized during an interval between two interviews for an illness starting during that interval or persons who died during the interval. Controls were persons with no new illnesses or hospitalizations during the interval. No relationship between measures of depressive symptomatology or depressed mood and subsequent physical illness was shown. This result corroborates the findings of prospective studies in more selected populations and suggests that it is unlikely that depressed mood is related to subsequent physical illness.

Correlates of depressive mood among normals.

In order to determine the correlates of depressive mood, members of a women's volunteer organization were surveyed by a mailed questionnaire that included the Depression Adjective Check List (DACL) Form E and 14 depression-related measures. Correlations are presented and discussed. Highest correlations are with measures whose relationship to depressive mood are most clear.

Three utilization styles at an urban mental health center.

The authors report a study of utilization of services based on data obtained on two patient groups at an urban mental health center: a one-year applicant population, consisting of an unduplicated count of all adults applying for psychiatric care during a one-year period; and a one-day prevalence population, consisting of all persons on a psychiatric roster on a single selected day. Juxtaposing diagnosis, applicant-to-prevalence ratios, and treatment or services used, they found three styles of utilization of services--the intensive user, as exemplified by the neurotic in psychotherapy, the casual user (the schizophrenic attending medication clinic), and the pseudo user (the alcoholic using detoxification services). The intensive user represents a minority utilization style, while the last two styles are predominat at the center. Taken together they characterize the typical patient as a therapeutically passive user of services.

A comparative study of neurotics seen in a community mental health center and in private practice.

Differences that emerge in comparisons of persons applying for psychiatric care at a mental health center with those applying to the private sector are comfounded by marked diagnostic differences beyond obvious social class differences. To circumvent that problem and to ascertain what differences, if any, persist after diagnosis is held constant, the authors examined demographic and psychosocial characteristics of neurotics in a one-year adult applicant population, the only major diagnostic group treated in large numbers and similar proportions by the center and the private sector. Findings showed that significantly more neurotic applicants in the private sector are medical referrals, are members of intact nuclear families, and do not have previous inpatient experience.

Good patients and bad. Therapeutic assets and liabilities.

This is an extension of an earlier article that identified three utilization styles at an urban mental health center where, apart from a minority of intensive users, casual users, and pseudousers predominate and, combined, characterize the therapeutically passive user. The present article compares center data to added data from the private sector, where the intensive user predominates. Center/private differences are examined, and correlates of differing utilization styles are identified, such as sex, diagnosis, marital/living arrangements, referral source, and social engagement factor. The later is associated with differences not attributable to diagnostic severity of social impairment. The growing division of labor, wherein the privates sector is engaged in intensive psychiatric treatment while the center increasingly operates an emergency/crisis/maintenance service, is shown to reflect a gross public/private maldistribution of therapeutic assets and liabilities.