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As indicated by the content of this text, the care of the chronic psychiatric patient in the community consists of two major elements—the psychosocial therapies and the pharmacotherapies, as set in different care sites. The delivery of these therapies occurs within a complex administrative and legal structure, a structure that is designed to insure that patients have access to such care and that the care provided is of optimal quality. The major events that have led to what is now considered standard care for the chronic patient include the development of the major tranquilizers starting in the mid 1950s, deinstitutionalization, which started in the 1960s, changes in the legal status of the chronic patient in the 1970s and the slow development during this period of community care programs which are now becoming mature in form, quality and numbers.

It seems particularly appropriate in a memorial volume for Kurt Goldstein to introduce this essay with a consideration of the importance of the psychopathological for the understanding of normal behavior. Goldstein consistently argued from this point of view. It is especially evident in his two theoretical volumes, both of which make direct reference to pathology in their titles: The Organism: A Holistic Approach to Biology Derived from Pathological Data in Man (16), and his William James Lectures, Human Nature in the Light of Psychopathology (18).

In recent years the introduction of neuroleptic drugs into large overcrowded mental hospitals has been accompanied by a striking improvement in their atmospheres which have become more therapeutic and less custodial (W.H.O., 42). Accordingly it has become possible, often for the first time, to organize effective programmes of rehabilitation for the chronic schizophrenics who still constitute a high proportion of mental hospital populations (Brill and Patton, 7). The new programmes have usually included group nursing, planned activities, and graded incentives for patients to strive to regain their positions in society. This approach has placed emphasis on the patient as an individual, having rights and responsibilities, safe, trustworthy, and, with assistance, often able to help himself and others (W.H.O., 41). Because of these changes in the State Hospital, it is not surprising that the literature has been flooded with enthusiastic reports and wholehearted endorsement of the merits of a variety of neuroleptic agents.

Our findings are that the ataraxic drugs do improve the condition of chronic patients sufficiently to effect leave for 25% as compared with 1%-4% in the past, and that various social factors appear related to leave potential. We are left, nonetheless, with 60% to 75%7 of the chronic patient population on our hands in the 20 to 50 years of age and 2 to 10 years hospitalized group, even after intensive drug treatment. The best planning now stresses the need to strengthen community ties—to build mental health centers and various day, night and other bridging facilities,8 to decentralize hospitals and/or see them as only one posibility in a whole gamut of services and the drugs have made this more than ever possible for the majority of new and acute patients. But when we look at the chronic patient, we are led to ask, "What community ties?" and to suggest that for the chronic patient we have not only to strengthen ties but possibly to build and preserve a whole community—a community so shaped that in it he, t...

The indication of this study is that a common integrated treatment program by means of a team approach in an atmosphere of therapeutic optimism can be a potent factor in the rehabilitation of increasing numbers of the so-called chronic patient. By itself, however, it will be doomed to failure if these initial results cannot be followed by the combined efforts of the hospital and the community in combating the "Rip Van Winkle" effects observed in patients hospitalized for many years.

CINCE the introduction of the partial hospital into the spectrum of psychiatric treatment more than two decades ago, many programs oriented toward traditional inpatient and outpatient treatment have expanded to include partial care. The majority of partial hospital programs serve either as a transition between inpatient and outpatient care or as an alternative to inpatient treatment for selected patients. The use of such programs has been reported for many different types of patients, including the patient in acute crisis,’ the chronic patient,2 the alcoholic,3 the geriatric patient,4 and the emotionally disturbed child.5 We believe that the partial hospital may also be of value in the diagnosis and treatment of several additional groups of patients-namely, those for whom a court has ordered a psychiatric evaluation for either criminal or civil proceedings, nonvoluntary patients who may be committed to inpatient

Three hundred and thirty-eight chronic psychiatric patients were followed up for two years after their discharge. Information was available on all but four patients. During the twenty-four month follow-up period, 11% had died and 25% required readmission. The source of support and living arrangements for the whole group were discussed, and the opinions about the outcome by the informant, psychiatrist, and social worker, were compared, The opinions correlated remarkably well. Characteristics of community care deemed important by the investigators were discussed briefly.

The results of this preliminary study suggest that chronic psychiatric patients upon returning to the community do not pose a burden to physicians. This would appear to apply for at least a two-year period. In the present sample of 211 patients those relatively few exceptions tended to be individuals who developed illnesses requiring either surgical intervention or hospitalization for a major medical condition. One question that arises from the low utilization observed in the present study involves the adequacy of follow-up medical care received by these patients. This area poses problems for future investigation involving clinical work in the field.

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Many families have experienced difficulties, when a relative has been hospitalized for some reason or suffers from a chronic condition, such as the Alzheimer's disease. In case of treatment at home, these patients should be constantly monitored. Nevertheless, around-the-clock monitoring may not always be possible. The reasons may be both economical and social, since families may not afford external help and sometimes patients do not trust outsiders. In this paper, we present an application for the monitoring and the protection of these patients, without the need of constant human helper. The use of a mobile telephone running a custom application and is connected to various biometric sensors will aid to achieve this goal.

A health data monitoring and transmitting system for chronic patient at their home-site was presented. It consists of physiological measurement, patient monitoring and emergency communication and a long-distance transmitting system. It can solve not only several main problems of chronic patient care at the home-site, but also reduce the medical expense and lessen the doctor's burden to a great extent.

Am J Psychiatry 1 40:3, March 1983 385 disbanded; however, it has recommended that HMO psychiatrists be appointed to substantive components of the Association to ensure that health maintenance organization concerns are considered in the development of policies concerning psychiatric residency training, peer review, health care organization and financing, the chronic patient, and research. The Task Force on Psychiatric Emergency Care Issues, Gail Barton, M.D., chairperson, hopes to conclude in 1983 work on its final report, which will be a discussion of the state of the art and a guide to those who administer psychiatric emergency programs. In recent months Dr. Barton has met with representatives of NIMH to provide strong arguments for the support of studies related to emergency mental health care, not only for disaster planning but also for those emergencies seen by the routine emergency care system. The task force continues to be active in training efforts within APA, including sponsorship of courses at the annual meeting and the H&CP Institute. Liaison with the Joint Review Committee to Accredit Emergency Medical Technician-Paramedic Training Programs, the American College of Emergency Physicians, and other groups has resulted in psychiatrically oriented segments of their educational meetings. Some members of the task force are working on the development of questions for the fifth edition of the Psychiattic Knowledge and Skills Self-Assessment Program. For 4 years APA has served as one of several sponsors of the Joint Review Committee to Accredit Emergency Medical TechnicianParamedic Training Programs. This sponsorship has allowed APA to provide psychiatric input into the development of accreditation criteria and then to make recommendations for program content. The Council believes that APA should continue to provide psychiattic input as requested by the Joint Review Committee, but in September the Council concluded that the Joint Review Committee had had several years of experience and time to establish a full accreditation program and therefore recommended termination of APA’s sponsorship and corresponding financial support of the Joint Review Committee. Within the past few years the task force has developed a number of resource materials, has promoted liaison with many agencies and organizations, and has developed or participated in a number of educational presentations on emergency psychiatric care. While many of the specified tasks of the existing component have been completed, the Council recognized the need for continuing attention to emergency psychiatric care and consequently will recommend disbandment of the task force on the completion of its final report and establishment of a component within APA that will focus primarily on educational and liaison activities concerning emergency psychiatry.

57 of 105 cases of idiopathic thrombocytopenic purpura (ITP) were seen during the first two weeks of illness and evaluated for response to therapy and early indicators of chronicity. The high incidence of chronicitv among children over ten years of ape (67%) was sipnificantly different (p less than .01) from the corresponding incidence for children ten years of age and younger (4%). This difference was unrelated to sex, initial platelet count, precipitating factor or therapy. Among the 48 patients ten years of age or younger, early corticosteroid therapy, for considerations believed to represent increased risk, resulted in a significantly greater portion of the treated group (33%) achieving remission before two weeks from, onset than of the untreated groun (5%), (p less than .05). The difference was apparent when time to remission was calculated from the historical onset of symptomatolopy rather than from time of presentation. Incidence of chronicity was not significantly different (p greater than 0.5) between these proups. Of 7 chronic patients who responded to steroids initially and then relapsed, all had some response to a subsequent course. No chronic patient treated with corticosteroids alone had a sustained remission. 8 of 11 (73%) chronic patients had a sustained remission after splenectory.

Uninstitutionalized young adults with chronic mental disorders and social disabilities pose a new challenge in community psychiatry. These attention-seeking, help-rejecting young men and women spend most of their lives in the community and differ markedly from older deinstitutionalized chronic psychiatric patients. Many confound identification by their abuse of drugs and/or alcohol. Most deny their mental illness and make inappropriate use of mental health services available to them. Because of the different problems and aspirations of these patients compared to older chronic patients, treatment programs must be age segregated to address these differences. Young adult chronic patients are best helped via flexible, accessible, nonstigmatizing, team-oriented treatment programs. Some patients require long-term neuroleptic therapy at low maintenance doses. In addition to their role as the primary provider of psychiatric care to these patients, psychiatrists must act as advisors to families and community planners and as political activists to focus additional attention on community-based (rather than state hospital-oriented) programs.

This is a study of a new role in development. Medical professionals involved in long-term comprehensive care of chronically diseased patients have found that the institutionalized professional/acute patient role does not allow them to cope with problems encountered with chronic patients. Behavioral adaptations to these problems are leading to the development of a professional/chronic patient role, which may be divided into three segments: exercising technical competence, teaching, and socializing-each segment less developed than the preceding one.

T HE nursing care of the chronic skin patient is very complicated. Some patients are difficult to manage. They pick at their skin, thereby retarding their recovery, and various methods of restraint have to be employed. Splints may have to be applied to the hands and arms of the patient, if bandaging will not prevent him from picking at his skin. Lotions and ointments are applied to the skin, daily starch baths are given, a special diet is enforced, and extreme cleanliness is maintained. Pemphigus cases, in particular, require a great deal of careful and delicate nursing. The daily potassium permanganate bath and the dressings take up a great deal of time. The affected areas have to be covered carefully with dressings, otherwise flies may have access to these parts.

IN CONSIDERING possible reasons for the chronicity of patients with schizophrenic reactions or other forms of serious mental illnesses, and with particular attention to the difficulties in their being discharged from treatment settings and being maintained in the community, many authors have considered such factors as metabolic dysfunctions, intrapsychic and interpersonal deficits, and/or adverse influences of the patient's milieu, whether it be familial, cultural, vocational, or others. We propose that particular transactions between patients and various elements of their total milieu may contribute to the problem of the intermittent 1 or chronic patient, and that these transactions may be relevant regardless of, and along with, other etiologic considerations. Our intent is to describe several group, intergroup, and system phenomena which may contribute to the understanding of the patient's lack of movement and inability to respond to treatment. At a number of

MANY perplexing issues are raised when a community mental health service attempts rehabilitation of a chronic patient. The complexity of these problems is compounded in this country, where the orientation and training of mental health professionals is not primarily directed toward the chronically mentally ill. 1 The Challenge of the Chronic Patient.—The patients with whom we are concerned in this paper are those presenting problems of chronic and severe mental illness, chronic poor functioning, chronic regression, and chronic dependency. The rehabilitation of these patients requires a philosophy of treatment that is in many ways alien to the usual thinking of many mental health professionals. We have to recognize that we are dealing with borderline, marginal people, both socially and vocationally, for whom life is a constant struggle. Their tendency is to regress when faced with a stressful situation. They are skilled at evoking

To the Editor:— Of late years the students of vital and social statistics have been calling our attention to the remarkable increase in longevity which is having such a profound influence on our way of living. As the length of our days on earth is increased we find ourselves living longer, in health and otherwise, with people who must live longer with us. Youth, being confronted with the problems of age, must share them. Youth too may be stricken by long-term disease, as in the case of rheumatic fever with its complications and sequelae. Against the satisfaction and joy of preventing and curing illness in the earlier years we now have the specter of the degenerative and malignant diseases which are more characteristic of the later years. The "acute" hospital, which has chosen and specialized in emergencies during the earlier years of our lives, can have only one response to

To the Editor:— When an illness is of long duration it is chronic, but when coming to an early crisis it is described as acute. The impact of medical writing on the scribes of Webster's Third "International" has provided some chronic complaint, which promises to be of long duration. This dictionary has legitimized the chronic sufferer as the chronic patient, the patient of long duration, at the same time creating the acute patient, doomed to an early crisis, yet who is neither sharp nor standing at an angle of less than 90°. Doctor: Well, Jones, how are you today? Jones: Chronic. Doctor: Nonsense. You have chronic arthritis. Your arthritis is chronic. Not you. Jones: Wrong, doctor. According to Webster's Third I'm a chronic sufferer, a chronic patient. Accordingly, I'm chronic. Doctor: Pretty sharp today, eh Jones? Jones: Right. I'm acute and chronic. This can go on forever, and a Fourth