Creating community agency placements for undergraduate medical education: a program description.

UNLABELLED: PROGRAM OBJECTIVE: To provide first- and second-year medical students with stimulating learning experiences in the community. SETTING: Three hundred placements representing a broad array of urban community agencies providing both general and specialized health care services. PARTICIPANTS: All first- and second-year medical students at the University of Toronto (n = 354). Other participants include staff of community agencies and tutors from the Faculty of Medicine and from the community. PROGRAM: The Health, illness and the Community course is mandatory and consists of 3 components. The first, in the first semester of first year, emphasizes the provision of health care in the community for individuals and populations. The second, in the second semester of first year, introduces a health promotion paradigm. The third component, throughout second year, allows students to engage in an in-depth study of the interconnection between a health problem and a social issue in a community agency setting. OUTCOMES: Students have expressed high levels of satisfaction with the community agency placements. The feedback from agencies has also been enthusiastic. Patients in the home care program have reported that visits by medical students are a positive experience. CONCLUSION: It is possible to recruit and maintain large numbers of urban community agencies as learning sites for medical students. It is hoped that this approach will help to produce socially responsive medical practitioners.

The role of research in systems reform.

Knowledge concerning the care of people with severe and persistent mental illness has grown dramatically, but that knowledge is seldom translated into improvements in care. The authors describe their involvement in three service delivery projects in Ontario and discuss how, by assuming multiple roles, they were able to ensure that planning and policy development were informed by current knowledge. In addition to being an investigator, such roles may include being an administrator, planner, consultant and advocate. The redevelopment of Whitby Psychiatric Hospital resulted in an innovative plan for a comprehensive, integrated service delivery system based upon community support services research. Implementation of the Graham Report in Ontario provided an array of district mental health plans which incorporate current knowledge with regard to service delivery. Ontario's mental health reform strategy represents a close connection between public policy and scientific information. The authors recommend that researchers be prepared to assume multiple roles in the service delivery field so as to reduce the gap between science and practice.

The cost of schizophrenia.

In 1988, the management of mental illness in the United States cost an estimated $129.3 billion which comprises direct costs (hospital/institution costs, health care provider fees, prescription drugs), indirect costs (reduced/lost productivity due to morbidity or mortality) and other costs including productivity of family caregivers. The largest mental health care expenditure is for schizophrenia due to the high prevalence of this illness, early age of onset, and pattern of chronicity. This paper reviews three aspects of the care of schizophrenia that have an impact on cost: 1. prevention of relapse; 2. provision of community care; and 3. use of new antipsychotic medications. Better compliance, community-based care incorporating clinical case management and improved treatments can be expected to lower costs while improving the quality of life and social functioning of patients.

The hostel outreach program: assertive case management for homeless mentally ill persons.

OBJECTIVE: This study measured the impact of an assertive case management program for psychiatrically disabled homeless persons in metropolitan Toronto. It was hypothesized that the program would improve residential stability, reduce psychiatric symptoms, improve social functioning, improve social networks, and increase use of appropriate services. METHOD: For 59 clients admitted to the program, assessments for the nine-month period before program entry were completed and were repeated nine months later. The Brief Psychiatric Rating Scale and a version of the Scale for Level of Functioning were the main measures of outcome. RESULTS: At follow-up significant improvements in residential stability and reductions in psychopathology were demonstrated. Improvements in social functioning and increases in social network size were significant. Although no baseline data about service use were collected, clients used basic support services during their first nine months in the program. CONCLUSIONS: The success of the program demonstrates that a difficult-to-treat patient population can be helped in a humane fashion if trained personnel are available.

Psychotherapy of schizophrenia revisited.

Erroneous beliefs and questionable scientific evidence have led over the past two decades to a loss of enthusiasm about psychotherapy with schizophrenic patients. Recent information from course and outcome studies and from new approaches to understanding schizophrenia provides a basis for renewed optimism. Improvements in psychotherapeutic technique have the potential to enhance effectiveness. This paper brings together important new findings about schizophrenia and discusses new approaches to psychotherapy with schizophrenic patients.

A psychiatric intensive care unit in a psychiatric hospital.

This paper describes the operation of a psychiatric intensive care unit in a provincial psychiatric hospital. Its introduction led to a decrease in staff and patient accidents, a decrease in constant observation and seclusion hours, and a decrease in the number of nursing hours lost to injuries at work. It had no effect on nursing absenteeism. The ICU was well liked by nursing staff who preferred to work in its more consistent and controlled environment. In addition, it was also felt that the ward environment in other parts of the hospital became more therapeutic. We therefore conclude that psychiatric ICU's are useful additions to psychiatric settings with important cost and patient care implications.

Components of care for patients with schizophrenia.

To assist in the planning of mental health services for Metropolitan Toronto, the Mental Health Care Committee of the Metropolitan Toronto District Health Council convened a Task Force on Mental Health Epidemiology to help determine the need for services for patients suffering from schizophrenia. As part of its work, the Task Force described components of care which comprise a comprehensive treatment model. Underlying this approach was the recognition that many efficient, effective interventions for the treatment of schizophrenia have been developed and evaluated, but few attempts have been made to apply these various interventions in a systematic, comprehensive manner. This report presents an inventory of state-of-the-art approaches to dealing with schizophrenia which should be of interest both to practicing clinicians and health care planners.

What difference does case management make?

The outcomes of 82 patients in a rehabilitation-oriented case management program six months and two years after they were discharged from an inpatient setting to join the program were compared with those of 82 matched control patients who had been discharged from the same inpatient settings before the case management program was established. At the two-year follow-up, the patients in the case management program were significantly more likely than the control patients to have better occupational functioning, to live in a residence requiring more independence than they did at the six-month follow-up, and to be less socially isolated; in contrast, at the six-month follow-up only their occupational functioning was better than the control group's. The two groups did not differ in number of hospitalizations at either follow-up. The authors believe the study supplies much-needed documentation of the effectiveness of rehabilitation-oriented case management.

Impact of a case manager program on psychiatric aftercare.

Shifting the locus of aftercare planning from hospital to community can enhance continuity of care. The authors compared chronically mentally ill patients assessed and managed by community-based practitioners trained in psychiatric rehabilitation with patients whose discharge planning was arranged by inpatient staff members. They found significant differences between the two groups in aftercare needs identified, aftercare referrals made, and use of aftercare services. The authors conclude that this approach to psychiatric aftercare is superior to more traditional models if practitioners are carefully trained.

Psychodynamic aspects of occupational stress.

Freud described work as that which attaches the individual most firmly to reality. Many patients present to psychiatrists with disturbances in the capacity to work. This paper reviews common psychodynamic constellations in such patients in the belief that depth psychological approaches should complement recent person-environment fit considerations. Work inhibitions may arise from repressed aggression and/or sexuality displaced onto occupational tasks. Fear of success may be rooted in both oedipal and pre-oedipal conflicts. Work compulsion may evince attempts to appease a harsh super-ego. Chronic job dissatisfaction often arises from maladaptive attempts to regulate self-esteem. More importantly however, these disturbances frequently arise from interacting dynamic factors which must be carefully attended to by clinicians.

A community-based psychogeriatric service.

The elderly are most susceptible to mental illness, and they receive inadequate mental health services. The authors developed a community-based program to meet the needs of the psychiatrically impaired elderly by providing a multiplicity of indirect services to community caregivers. A psychiatrist and two clinical specialists in psychiatric nursing provide consultation, education, collaboration, and coordination to individuals and agencies dealing directly with elderly clients in the community. Evaluation of data show a high degree of consultee satisfaction, few recommendations for institutional care, satisfactory client outcomes, and a significant impact achieved by a formal educational program for community practitioners.

Problems in psychotherapy with women who leave their families.

This paper discusses difficulties in therapy with a woman who wished to leave her family. Problems were directly related to the act of separation and functioned as resistances to the exploration of intrapsychic conflicts. Therapist reactions are compared to responses in audiences of Henrik Ibsen's play "A Doll's House."

Psychodynamics and aging.

Freud felt that by age 50 the mental processes had lost so much elasticity as to make psychological treatment inadvisable. Subsequent workers have been less pessimistic about the potential for conflict resolution in old age. This paper presents three case vignettes to explore psychodynamic aspects of the aging process. Issues discussed include inevitable losses, grief reactions, difficulties with restitution, structural alterations, redistribution of libido and the use of regression rather than repression as a mechanism of defense. Patients such as these are often diagnosed as depressed or demented and treated with psychotropic drugs. Interpersonal psychotherapeutic approaches can be much more effective.

Psychiatric aftercare: identified needs versus referral patterns.

Although psychiatric aftercare has received increased attention, little is known about patients' needs for community resources or about predischarge referral patterns. The authors interviewed hospital staff about needs and referrals for each of 747 patients about to be discharged. Nearly all patients had needs in the medical/therapeutic area and most received referrals. In three other nonmedical aftercare areas needs were identified for a much lower percentage of patients, and identified need was two to three times greater than referrals made. The authors discuss the implications of these findings for the provision of aftercare services.

An aftercare program for problem patients.

The high readmission rates of discharged psychiatric patients have forced mental health professionals to play closer attention to aftercare planning. A program was developed at a psychiatric hospital in Ontario in 1977 to deal with "problem patients"--those who were deemed difficult to place in the community by the referral person or department. The program was characterized by shared institutional-community staffing, systematic aftercare assessment and planning, a crisis intervention approach to discharge, the use of a transitional staff member with patients, and the development of close relationships with community agencies. Study data show that the program was effective in limiting the number of readmissions during its first two years to 20 per cent.