Acutely psychotic patients receiving high-dose haloperidol therapy.

Despite the trend towards lower neuroleptic dosing in the treatment of psychosis, there continue to be patients who are administered doses that are higher than recommended. Thirty-six acutely psychotic patients receiving parenteral haloperidol were evaluated by the Brief Psychiatric Rating Scale, the Schedule for Affective Disorders and Schizophrenia-Change Version, and the Nurses' Observation Scale for Inpatient Evaluation, as well as by drug levels in plasma. Patients were compared on the basis of total haloperidol dose in the first 24 hours: regular dose (RD: 10-30 mg) and high dose (HD: 40-80 mg). At baseline, patients in the HD group scored significantly higher on the Brief Psychiatric Rating Scale factor Hostile-Suspiciousness and the Nurses' Observation Scale for Inpatient Evaluation factor Irritability. Assignment to regular-dose and HD groups could not be accounted for on the basis of age, gender, weight, or duration of illness. Moreover, drug levels in plasma indicated that the HD patients did not require higher doses on the basis of differences in haloperidol levels.

Prevalence of neuroleptic-induced dystonia in mania and schizophrenia.

In a prospective study of 41 acutely psychotic patients, neuroleptic-induced dystonic reactions occurred in 62.5% of the manic patients (10 of 16) and 66.7% of the schizophrenic patients (10 of 15), a nonsignificant difference. These findings contradict a recent report suggesting a higher risk for this side effect in mania.

PRN medication for psychiatric inpatients.

Little is known about the extent of the use of prn psychotropic medication in psychiatric inpatient units. A survey of the prn prescription and administration of psychotropic drugs in a psychiatric teaching hospital revealed that a large number of inpatients were prescribed and administered such drugs on a prn basis. Although 50% of the prescriptions were never administered, only 25% were actively discontinued by physicians. A diagnosis of personality disorder was the factor most frequently associated with the rate of prn prescriptions and of administrations. A large number of prn prescriptions had no instructions for indications, minimum time spacing between doses or maximum daily dosage. It is suggested that hospitals monitor the prn use of psychotropic medications in their inpatient units, and explore the reasons for such use. Psychotropic drug use on a prn basis should preferably be reserved for emergencies, and the instructions of prn prescriptions should be clear and detailed.

The teaching of consultation-liaison psychiatry in the undergraduate curriculum of Canadian medical schools.

The teaching of consultation liaison psychiatry in the undergraduate curriculum of the 16 Canadian medical schools and the views of the directors of undergraduate psychiatric education were surveyed with a 25-item questionnaire. Some teaching in consultation liaison psychiatry is provided by 14 medical schools. The predominant format of teaching is that of supervised experience, and systematic evaluation of this teaching is uniformly absent. The amount of consultation liaison teaching was small. More than 90% of the students were assigned primarily or exclusively to an inpatient service during their psychiatric clerkship. The majority of the respondents thought that the response of staff and students to the teaching of consultation liaison was good or excellent, that this teaching should be an obligatory part of the curriculum, that it would increase in the next five years, that insufficient staff was a factor impeding it, and that an increase in staff psychiatrists specializing in consultation liaison psychiatry would facilitate this teaching in their department. It is suggested that the consultation liaison psychiatry teaching of medical students should be increased, in the short term by making greater use of services and resources. In the longer term, however, such increase would be dependent on the growth and development of consultation liaison services in the teaching hospitals across the country.

The psychiatric training of medical students.

Undergraduate psychiatric education should be concerned mostly with those aspects of psychiatry required for the proper practice of medicine. Psychiatric concepts and techniques are applicable to all medical practice and relevant to the daily work of every physician or surgeon. Therefore, in the psychiatric training of medical students the focus should be primarily on teaching "psychiatry of medical practice" and much less on teaching "specialty psychiatry." The teaching of psychiatry for medical practice will be best accomplished by selecting patients who are more like those the student will see later on as a practising physician. A systematic effort should be made to develop joint teaching with other departments, if we are to hope that students will carry over the approach we teach them to other subjects of medicine. Counselling and psychotherapy are essential skills for every physician or surgeon; medical students should be taught these skills by psychiatrists who are not just skilled psychotherapists but are also comfortable in their role as physicians in view of the importance of this role for the development of the identity of the medical student as a physician. The quality of the psychiatric training of medical students is dependent to a large extent on the priority accorded to undergraduate teaching by the department of psychiatry; competing activities, however, can result in undergraduate teaching being given less than top priority. Long-standing difficulties which psychiatry and psychiatrists experience in the medical school may impede undergraduate psychiatric education; these difficulties can be lessened by the closer involvement of psychiatrists with other physicians in the clinical and educational programs.

The etiology of violent behavior. An overview.

Society often considers violent people to be mentally ill, and a significant number of patients exhibit violent behavior. For the assessment of violent individuals, a thorough understanding of the complex biopsychosocial causes of violence is required. This paper critically reviews recent investigations of the multiple causes of violence to clarify those aspects that can be helpful to clinicians in their inquiries.

Concepts and practice of prognosis in psychiatry.

The frequency with which prognosis is made in psychiatry is not known. This paper reports a study of the frequency and content of prognosis as recorded by staff psychiatrists and residents in a psychiatric teaching hospital. In addition, a review was carried out on the use of prognosis in ten psychiatric textbooks. The findings suggest that closer attention should be given to the teaching of prognosis. There is a clear need to consider moving away from the close dependence of prognosis on diagnosis, and from the unidimensional view of prognosis. Reasons are given for developing a prognosis, and suggestions are made regarding the organization of the prognostic statement.

Planning for psychiatric emergencies.

Hospital emergency services have been used increasingly in recent years. This has resulted in questions as to the true nature of patients' complaints and the appropriateness of this type of care. Since the increase in the number of psychiatric emergency patients has paralleled that for patients at other types of emergency clinics a study was conducted at the Clarke Institute of Psychiatry, Toronto, to examine the situation prior to the inception in 1977 of a crisis intervention unit. It was found that most patients had both psychiatric and social difficulties, and it was considered that planning should concentrate on strategies for efficient management of the clinical problems.

Recurrent psychiatric hospitalization.

Undue emphasis has been placed on rising rates of readmission to psychiatric facilities. After a decade of preoccupation with discharge rates, readmission statistics have been singled out in the last 15 years as the key factor for assessing hospital effectiveness. A study of a group of patients at high risk for recurrent hospitalization revealed that these patients were characterized more by features relating to environmental supports than by diagnosis. The operational definition for recurrent hospitalization (five or more admissions during the 2-year period preceding the latest admission) was effective in identifying this group; this is the first reported instance in which the definition has specified a certain number of admissions within a time-limited period. The findings of this study, as well as of an analysis of case histories and consumer opinion, led to the design of a pilot program for persons undergoing recurrent hospitalization. Readmission statistics are useless or misleading as measures of hospital effectiveness and efficiency; what matters is the way the former patients function in the community after discharge. Rather than simply trying to reduce the readmission rate psychiatric facilities should be examining the types of persons who are hospitalized recurrently to develop programs aimed at improving the functioning of these people in the community.

Locked wards in Canadian mental hospitals: the return to custodialism.

In 1975 a survey of the open- and locked-ward practice of 38 of the 44 Canadian public mental hospitals showed that more than one third of the wards are locked 24 hours a day. This survey is the only one known to have been conducted in the last 16 years and the first to have obtained data from all 10 provinces. Hospitals with fewer than 300 beds have a significantly smaller proportion of locked wards than those with more than 600 beds.The custodial, antitherapeutic environment was the most frequently cited disadvantage of the locked ward, and facilitation of the therapeutic milieu was the most commonly cited advantage of the open ward. The most commonly cited problem of the open ward was the inability to protect the community from the dangerous, violent patient. The most frequently cited factor required to open the wards was a higher nursing staff:patient ratio, but it is suggested that this is an erroneous opinion. What is required is the organization and involvement of the patients in meaningful activities throughout the day, hospitals with fewer beds, and better relations with the community to foster public tolerance.National organizations concerned with mental hospital practice have no data on the open- and locked-ward practice in this country. There are pressures, channelled through the political and judicial systems, to lock the wards, and the Law Reform Commission of Canada has recently recommended transferring mentally ill prisoners to mental hospitals.

Part-time hospitalization programs: the neglected field of community psychiatry.

Part-time hospitalization for persons with psychiatric disorders is underdeveloped, underutilized and often poorly understood, but should be encouraged in view of the unsatisfactory living conditions of patients discharged from hospital who still require care, the reductions in psychiatric impatient populations and numbers of beds, the increasing costs of health services and the current fiscal restraints. Day and night hospitals can provide an alternative to inpatient or outpatient treatment, rehabilitation for the long-term patient or treatment for the patient in transition from inpatient to outpatient status. The day hospital can also provide a diagnostic setting. Such programs help preserve the patient's position in the family and the community, minimize the ill effects of hospitalization, and lower capital and operating costs of the psychiatric services. Awareness by medical and paramedical services of the value of these programs would increase their utilization. Shifting the emphasis of administrative and fiscal policies from inpatient to part-time hospitalization programs is also required.

Self-care program for inpatients in a mental hospital.

SUMMARY: A self-care program for selected inpatients in a mental hospital has been developed and has been in operation for more than a year. The 12-bed unit operates without any nursing or other professional staff during the night and weekend. Certain factors, including the mental hospital as an organization, tend to hamper the development of this type of program as well as the progress and growth of other programs in psychiatric hospitals. It is suggested that the much needed progress in the mental hospital would be facilitated by an open-systems approach to its organization. Mental hospitals should consider the introduction of self-care programs for selected patients, mainly in view of their therapeutic potential, but also because of the financial savings such programs offer.