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Objective: Total monetized and nonmonetized costs and benefits to society of the Monroe-Livingston demonstration project's capitated payment system (CPS) were analyzed., Methods: Total costs and benefits of care for individuals who were prerandomized to an experimental group (of whom about 57 percent were enrolled in the CPS) were compared with those for a control group who received traditional fee-for-service care. Separate two-year results are presented for continuous patients, who were enrolled in a comprehensive CPS plan (N = 201) and for intermittent patients, who were enrolled in a partial plan (N = 155)., Results: All groups showed improvements on many psychosocial measures over the two years. Continuous patients in the experimental group experienced less hospitalization, more case management and transportation services, and higher levels of victimization and were more likely to live in unsupervised settings than continuous patients in the control group. Total annual per patient costs for care of continuous patients ranged from $74,000 to more than $100,000, largely reflecting differences in rates of hospitalization. Experimental subjects in the partial capitation condition differed from the control group in this plan on fewer measures; both groups reported high levels of case management and social support services and relatively lower levels of supervised housing., Conclusions: The CPS resulted in major improvements in the community's services for persons with serious mental illness and reduced the proportion of care provided in the state hospital.

Objective: The Monroe-Livingston demonstration project's capitation payment system (CPS) was evaluated to determine whether capitated funding of mental health care, compared with fee-for-service funding, could reduce hospitalization rates and improve functioning and symptoms for severely and persistently mentally ill adults without increasing the total cost of care., Methods: The experiment was a communitywide prerandomized clinical trial involving 422 patients. Patients who were randomized into the experimental group were eligible for enrollment in a capitated funding program administered by one of five community mental health centers. Those randomized into the control group received standard fee-based services. Follow-up interviews with patients one and two years after enrollment in the study assessed changes in symptoms and functioning. Data files of the membership corporation that coordinated community mental health services for the CPS provided measures of study patients' use of inpatient mental health services., Results: During the two-year follow-up period, patients in the experimental group had significantly fewer hospital inpatient days than patients in the control group, but the two groups had no significant differences in functioning or level of symptoms., Conclusions: The CPS successfully maintained severely ill patients in the community but did not improve their functioning or level of symptoms.

Objective: The authors describe two psychosocially oriented community residential facilities for patients with persistent and severe mental disorders and multiple failures at community tenure, and they report a retrospective study designed to evaluate treatment outcomes of program residents., Methods: The study employed a retrospective single-group repeated-measures design to evaluate 104 patients who completed the one-year follow-up. One-year mean number of admissions to and days in a hospital or crisis center during the two years before program entry were compared with mean admissions and days for the follow-up year; employment status, living status, and Global Assessment of Functioning (GAF) Scale scores at program entry and at one-year follow-up were also compared. Thirteen sociodemographic and clinical variables were individually tested for association with outcome., Results: Hospital and crisis center admissions and days were significantly reduced during the follow-up year. At one-year follow-up, a significantly greater proportion of patients were employed and living independently, and fewer were homeless. GAF scores were significantly higher. No significant correlations between outcome and sociodemographic and clinical variables were found., Conclusions: Despite design limitations of the study, the findings suggest that psychosocial residential treatment models can offer cost-effective and clinically efficacious care to persistently mentally ill patients.

Community mental health centers are becoming increasingly involved in the delivery of services to victims and perpetrators of domestic violence. To help centers plan a domestic violence program and address the risk of liability in treating clients who may be dangerous, the authors suggest principles to guide clinical decisions, standards for service delivery, and standards for staff development. Domestic violence is clearly defined as criminal behavior. In treatment, cessation of violence takes priority over family reunification and resolution of issues between victim and perpetrator. Decisions about accepting a perpetrator in treatment should be made by the treatment provider, even if treatment is mandated by the court. Suggestions for reducing the burden of domestic violence cases on individual clinicians include using treatment teams, establishing guidelines for maximum caseloads, and encouraging mixed caseloads. CMHCs have an important role in a comprehensive approach to domestic violence that includes a wide array of services and careful coordination among agencies that provide them.

Objective: In a previous study of outpatients with chronic mental illness who were treated with neuroleptic medication, the authors found a higher incidence of tardive dyskinesia among blacks than among whites. In this study the authors examined psychosocial, clinical, treatment, and medical correlates of race that might explain this finding., Methods: Extensive baseline data were obtained for 398 outpatients at risk for tardive dyskinesia. Pearson and Mantel-Haenszel chi square analyses were used to determine significant associations between a large number of variables and race., Results and Discussion: Compared with whites, nonwhites were more likely to be younger, less skilled, and unmarried; to report contacts with relatives outside the home; to have a diagnosis of schizophrenia; and to receive higher doses of neuroleptic drugs primarily through depot medications. Nonwhites were less likely to receive nonneuroleptic psychotropics, to wear dentures, and to report social contact with fathers. None of these racial differences explained more than a trivial portion of the association between race and the incidence of tardive dyskinesia., Conclusions: These results suggest the need for studies of differences in diagnostic and prescribing practices for black and white patients and of differences in the action and side effects of neuroleptics.

Clozapine treatment for schizophrenic patients living in the community requires strategies to ensure safe use of the medication and to foster patients' emerging social and living skills. The authors describe a clozapine treatment program in a community mental health center that includes a weekly clozapine support group meeting followed by drawing of blood for monitoring of side effects. Case managers and other program staff remind patients to take clozapine as prescribed and help them comply with hematological monitoring requirements, manage side effects, deal with the emotional aspects of improvement, and benefit from emerging capabilities. About 75 percent of the center's patients who have been offered clozapine have decided to take the medication, and almost all patients in the clozapine treatment program have experienced significant symptom relief and functional development with manageable side effects.

Clinical decision making in the treatment of families of individuals with prolonged mental illness can be affected by countertransference that is stimulated by the context of treatment as well as by the family being treated. For clinicians, psychoeducation, the current intervention of choice for such families, can serve defensive functions that are motivated by counter-transference; a case example illustrates how such defenses led a clinician to avoid deeper therapeutic work. The authors believe that clinicians must strive to understand their motivations for whatever clinical decisions they make; to facilitate this awareness, intensive psychotherapy should be required as an adjunct to training.

Two scales developed in Great Britain, the QOL Profile and the General Satisfaction Questionnaire, were used to examine the relationship between type of case management services and quality of life and satisfaction with treatment of 68 long-term psychiatric patients in Colorado. Factor analysis identified three types of case management activities that tended to occur together: assertive outreach (direct help, out-of-office visits, and monitoring), brokerage (referral to other agencies), and counseling and assessment. Monitoring was the only variable positively associated with quality of life for all patients; brokerage was the only variable negatively associated with acceptability of services. The number of case management contacts was negatively associated with treatment satisfaction.

Improving the quality of life of persons with chronic mental illness is becoming an important treatment goal. In this study, 101 former acute care psychiatric inpatients with serious mental illness who were living in Mississippi communities were interviewed using portions of Lehman's Quality of Life Interview. A particular focus was whether clinical characteristics, such as medication compliance and social skills, that could be changed by interventions were associated with patients' ratings of their quality of life. Self-reports of better quality of life were associated with fewer depressive symptoms, fewer medication side effects, and better family interactions. Results indicate that clinical interventions to improve quality of life in this population should include family psychoeducational programs and better detection, evaluation, and treatment of both depressive symptoms and side effects of medication.

Although persons with chronic mental illness have a high incidence of physical health problems, they are often ill equipped to seek care within complex health care systems and tend to depend on community mental health centers as their only source of regular health care. The authors describe a role for the nurse practitioner in assessing the medical needs of chronic mentally ill outpatients at a community mental health center and in devising strategies to meet those needs. The nurse practitioner's activities include direct physical health screening and treatment, referral for specialized medical services, consultation, research, and staff and patient education.

The family planning needs of chronic mentally ill women outpatients, many of whom do not use contraceptives and are at high risk for unwanted pregnancies, have been rarely addressed. Taking a thorough sexual history is the first step in assessing patients' need for family planning services. Patient education, including instruction about physiological processes and contraceptive methods and assertiveness training, is the most important service component. Offering family planning services in the mental health center has many advantages, including better communication between mental health care providers and family planning specialists about patients' special needs and enhanced opportunities for integrating family planning with other programs such as parenting classes, substance abuse treatment, and services for preventing sexually transmitted diseases.

Each year in the U.S. more than 130,000 children are hospitalized for psychiatric reasons. The decision to hospitalize a child is based on a complex set of factors. In this study, a 12-item checklist of criteria for hospitalization adapted by the authors was tested for its ability to predict hospitalization in a cohort of 389 children between the ages of two and 12 who were evaluated for either inpatient or outpatient treatment. Eighty-seven (22 percent) of the children were subsequently hospitalized. In 95 percent of the cases, the checklist was able to correctly predict whether the patient was hospitalized. A shorter checklist of six items was also able to predict the subsequent form of treatment in 95 percent of the cases. Although such checklists cannot take the place of informed clinical decisions, they can serve as a guide to decision making, especially for inexperienced mental health workers, and as a tool for utilization review when treatment decisions are questioned.

A continuous care team provides ongoing treatment for chronic mentally ill patients at a community mental health center in an inner-city area. The team, which consists of a nurse-social worker, a psychiatrist, four clinicians, and an addictions counselor, uses aggressive outreach and remains in charge of treatment while the patient is hospitalized. Preliminary outcomes for 32 of 39 patients treated during the first 15 months of the program included increased rates of treatment compliance, decreased frequency of crises, and decreased frequency and duration of hospitalization. However, substance abuse continued to be a problem and was negatively correlated with improvement.

Mental health consumers with chronic mental illness were trained for employment as case management aides in a psychiatric rehabilitation project in Denver. The project incorporated cooperative arrangements between the mental health system and vocational rehabilitation and occupational education agencies. The process used to recruit, select, train, and employ the consumer case management aides is described. Eighteen of the 25 trainees who began the training completed the program, and 17 moved on to employment as case management aides. At two-year follow-up, the 15 trainees who were still employed as case management aides had required a total of only two bed-days of psychiatric hospitalization since the training ended.

Some chronic mentally ill populations are at high risk for infection with human immunodeficiency virus. The authors argue that stereotypes of the mentally ill as asexual or neutered have had dangerous consequences, namely the absence of sex education and AIDS prevention as an integral part of treatment. To counter this neglect, the authors developed an AIDS prevention program in a large inner-city mental health center that serves primarily black and Latino patients. Prevention efforts include individual risk assessments and an innovative drop-in group. Central to effective patient education are the distribution of condoms and concrete instruction in their use.

To provide better mental health services for a population that now exceeds 12 million people, in the 1960s Shanghai began to develop a three-level system of services that is considered a model for the country. Services at each of the three levels--municipal, county or district, and grass roots--are described. Nonpsychiatric medical and paramedical personnel play a significant role in the delivery of services at all levels. Education of the public about mental health issues is considered a high priority.

As fiscal resources for mental health programs dwindle, it is becoming increasingly important to preserve non-direct-service priorities such as staff development. The West Virginia Training Resources Center, a collaborative program operated by the West Virginia Department of Health and the West Virginia University department of behavioral medicine and psychiatry, addresses problems of staff training in the state mental health service system. The authors discuss the development of the center and its functions as provider of training programs, sponsor of statewide training conferences, and clearinghouse of information and expertise. They also discuss problems stemming from the increased need for continuing education for paraprofessionals, the use of outside consultants, and the relationship between academia and the health service sector.

A study of four referral procedures involving 400 patients discharged consecutively from a geographically distant state hospital and referred to a community mental health center for aftercare suggests that simple changes in hospital discharge systems can increase compliance of patients and reduce recidivism. The scheduling of a specific follow-up appointment for the patient increased aftercare compliance significantly. Compliance was further increased, and the recidivism rate was cut in half, when the patient was seen by the community mental health aftercare nurse before discharge and was also given a specific follow-up appointment with that nurse.

Although a nursing mother who becomes psychotic and requires hospitalization is traditionally separated from her infant, the authors successfully treated a psychotic mother by hospitalizing both mother and son. Staff members cared for the infant in the hospital nursing station and assisted the mother in understanding and caring for her son through a structured schedule of infant care. The early focus on the mother-child relationship hastened the recovery of the mother to no detriment of the child.

Despite growing interest in ethical matters in psychiatry, little attention has been paid to means of teaching ethics to mental health professionals. In a monthly "ethics rounds" developed in a community mental health center, the co-leaders of the rounds visited one of the center's clinical services during a regularly scheduled staff conference to lead a discussion of a case selected by the staff and the underlying ethical problems. The rounds were attended by personnel at all levels and from a variety of disciplines. A survey of participants showed that the program was generally well received. Two cases selected for discussion at the rounds--one concerned with confidentiality and the other with court-ordered treatment--are presented, along with the discussion that each case stimulated. The advantages and disadvantages of the model are discussed, and suggestions for implementing a similar program are offered.

During the early 1960s partial hospitalization emerged as an important component of community-based psychiatric treatment. Initially partial hospitals offered all types of treatment to all types of patients. To help mental health professionals make informed decisions when matching specific treatments to specific patient characteristics, the authors define three kinds of partial hospitals--intensive care, chronic care, and rehabilitation partial hospitals--and propose selection criteria for referral to each model. Factors to be considered in making differential therapeutic decisions between a specific type of partial hospital program and alternative methods of treatment, such as inpatient treatment, are discussed.

A study of a group of chronic mentally ill patients from an intensive community support program revealed that 53 percent of the subjects had undiagnosed medical problems and 36 percent had known medical problems requiring initiation of or a change in treatment. These high percentages may be explained by the severity of the subjects' psychiatric problems, the questionable quality of their past physical care, and the difficulties chronic patients have in appropriately seeking and using either physical or mental outpatient health care. The author asserts that community support programs must provide continuing assistance with physical health care and offers suggestions for better addressing the problem.

The design environment of mental health facilities can facilitate the human interactions essential to treatment and can help in meeting clients' basic needs for safety and security, for self-esteem, and for the development of interpersonal and social skills. To determine the factors in the design of interior spaces that optimize clients' response to therapy, the author made a study of six Indiana community mental health centers. Drawing on that study and other sources, she presents design recommendations for mental health facilities for such areas as reception and admission areas, corridors and stairwells, therapists' offices, inpatient rooms, and dayrooms. Other discussions cover the relation of color, visual patterning, and light, and the selection of materials and finishes.

Efforts to eliminate the shortage of psychiatrists in rural areas have been relatively unsuccessful due to the special personal and professional problems facing the rural psychiatrist. The rural psychiatrist may feel personally isolated, encountering a somewhat foreign culture and living in uncomfortable proximity to patients and their families. He may feel professionally frustrated, for his physician colleagues are usually conservative and hold dear the medical model of care. He may suffer the typical frustrations of the psychiatrist working out of a community mental health center, and has little opportunity for professional growth. Academic training centers that train psychiatrists in region where they will work can more adequately prepare trainees for rural practice and can offer continuing education courses to professionals already practicing in the area. These centers should collaborate with mental health facilities to define and respond to manpower problems. Finally, opportunities for rural practitioners to make shifts in career emphasis over time should be created.

In Poland primary health settings provide about 71 percent of mental health services, particularly to patients with less serious illnesses, while psychiatry provides specialized mental health care for the chronic mentally ill, the mentally retarded, and patients with alcohol or drug dependence. Poland has a large number of outpatient clinics and an extensive network of sheltered workshops. Most inpatient psychiatric beds are located in mental hospitals; few general hospitals have psychiatric units. Deinstitutionalization has been less extensive in Poland than in many other countries; only about 10 percent of the chronic patients treated in mental hospitals were deinstitutionalized between 1970 and 1981. During that period the proportion of patients hospitalized for a year or more decreased, the number of chronic patients treated in nursing homes increased, and the pattern of hospitalization shifted toward multiple readmissions.

Child abuse, a problem that has plagued societies for centuries, has been largely ignored by psychiatrists, the author asserts. He traces the relatively recent interest in the problem of other medical specialists such as pediatricians and radiologists and maintains that it is time for psychiatrists to become more involved. He explains how problems of confidentiality, the patient's lack of motivation for treatment, and other factors have discouraged many psychiatrists from treating child abusers. He demonstrates ways psychiatrists can treat both the abused child and his family if they are willing to use non-traditional services such as home intervention.