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Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64-1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59-2.29), physical (1.50, 95% CI -2.15-5.15) or mental (-3.97, 95% CI -8.13-0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30-1.49), alcohol (0.053 95% -0.017-0.12) or drug (-0.0027, 95% CI -0.0028-0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Background Addressing the needs of frequent users of emergency departments (EDs) is a health system priority in many jurisdictions. This study describes stakeholder perspectives on the implementation of a multi-organizational brief intervention designed to support integration and continuity of care for frequent ED users with mental health and addictions problems, focusing on perceived barriers and facilitators to early implementation in a large urban centre. Methods Coordinating Access to Care from Hospital Emergency Departments (CATCH-ED) is a brief case management intervention bridging hospital, primary and community care for frequent ED users experiencing mental illness and addictions. To examine barriers and facilitators to early implementation of this multi-organizational intervention, between July and October 2012, 47 stakeholders, including direct service providers, managers and administrators participated in 32 semi-structured qualitative interviews and one focus group exploring their experience with the intervention and factors that helped or hindered successful early implementation. Qualitative data were analyzed using thematic analysis. Results Stakeholders valued the intervention and its potential to support continuity of care for this population. Service delivery system factors, including organizational capacity and a history of collaborative relationships across the healthcare continuum, and support system factors, such as training and supervision, emerged as key facilitators of program implementation. Operational challenges included early low program referral rates, management of a multi-organizational initiative, variable adherence to the model among participating organizations, and scant access to specialty psychiatric resources. Factors contributing to these challenges included lack of dedicated staff in the ED and limited local system capacity to support this population, and insufficient training and technical assistance available to participating organizations. Conclusions A multi-organizational brief intervention is an acceptable model to support integration of hospital, primary and community care for frequent ED users. The study highlights the importance of early implementation evaluation to identify potential solutions to implementation barriers that may be applicable to many jurisdictions.

Objective: The current study evaluated the demographic, clinical, and social support and service use predictors of alcohol and drug use disorders among a population of consumers of community mental health programs. Methods: The methodology is a secondary analysis of data collected from two randomized controlled trials that were part of the Community Mental Health Evaluation Initiative completed in Ontario, Canada. Participants included an inner-city population of persons with severe and persistent mental illness who had experienced housing instability. Participants were either randomly selected to receive Assertive Community Treatment or Intensive Case Management (Toronto) or Intensive Case Management or Standard Community Care (Ottawa). Data were collected from consumers at three time points (baseline, 9 months, and 18 months), and prospective and cross-sectional predictors of alcohol use disorders and drug use disorders at 9- and 18-month follow-up were examined. There were 232 participants at baseline,...

Background and Puspose Prior studies have shown a high prevalence of psychotropic medication use among patients residing in long-term care homes (LTCHs). The purpose of this study was to examine psychotropic medication use by LTCH patients in a metropolitan Canadian city referred to outreach teams for psychiatric assessment. Methods A retrospective review of charts from specialized psychogeriatric outreach teams serving a large metropolitan city in Canada was undertaken. Data from 68 charts were reviewed. Data were analyzed using descriptive and correlational statistics. Results Antipsychotic medications were the most frequent drugs prescribed to patients referred for psychogeriatric assessment (55.9%), followed by antidepressants (50.0%), cognitive enhancers (44.1%) and benzodiazepines (29.4%). More than a quarter of patients (26.5%) were on three psychotropic medications. Medications were adjusted in 35.3% of cases mostly resulting in dose increases. Only 5.9% of patients had their medication dose reduced. Conclusions This preliminary exploratory study suggests that patients referred to specialized outreach teams may be a difficult-to-treat population. Further studies are required to establish effective prescribing practices and service delivery models.

The primary objective of this study was to describe a model for specialized psychogeriatric consultation to long-term care homes in a large metropolitan Canadian city and to provide an overview of the diagnostic and demographic data of patients referred for assessment.Forty long-term care homes and 13 geriatric mental health outreach teams were surveyed and provided feedback on the model. A retrospective chart review (N=88) was also conducted to confirm the survey results and to provide an overview of the types of patients being seen.Team data indicated that 96% of the homes they served (N=81) were using their services, that all referrals were appropriate, and that their recommendations were implemented in over 50% of cases. Referred patients tended to be older (41% age 85 or older); were referred mainly for agitation, aggression, or depressed mood (over 90%); and mainly had a mood or cognitive disorder (over 90%).These preliminary data suggest that the implementation of specialized psychogeriatric consultation to long-term care may be beneficial, but future studies are required to clarify its usefulness.

Objective This study explored service user and provider perspectives on barriers and facilitators of continuity of care for frequent users of emergency departments (ED) participating in a brief intensive case management intervention. Method We conducted semistructured interviews with 20 frequent ED users with mental health and addiction challenges participating in a brief intensive case management intervention, eliciting experiences of care and care continuity. We interviewed 13 service providers working with this population. We used thematic analysis to determine shared and unique barriers and facilitators to continuity of care, and we gave priority to themes reported by both service users and providers. Results Within fragmented systems of care, strong working relationships between service users and providers, timely access to coordinated services and seamless transitions to needed supports increased perceived care continuity. Barriers to continuity of care included difficulties engaging this population, short intervention duration and the lack of a single accountable service provider to address health and social needs. Conclusion Although brief intensive case management interventions have the potential to improve continuity of care for frequent ED users, continuity of care, especially for people with complex health and social needs, may be compromised by program and personal characteristics as well as lack of broader system integration.

Background Although a growing number of collaborative mental health care models have been developed, targeting specific populations, few studies have utilized such interventions among homeless populations. This quasi-experimental study compared the outcomes of two shelter-based collaborative mental health care models for men experiencing homelessness and mental illness: (1) an integrated multidisciplinary collaborative care (IMCC) model and (2) a less resource intensive shifted outpatient collaborative care (SOCC) model. Methods In total 142 participants, 70 from IMCC and 72 from SOCC were enrolled and followed for 12 months. Outcome measures included community functioning, residential stability, and health service use. Multivariate regression models were used to compare study arms with respect to change in community functioning, residential stability, and health service use outcomes over time and to identify baseline demographic, clinical or homelessness variables associated with observed changes in these domains. Results We observed improvements in both programs over time on measures of community functioning, residential stability, hospitalizations, emergency department visits and community physician visits, with no significant differences between groups over time on these outcome measures. Conclusions Our findings suggest that shelter-based collaborative mental health care models may be effective for individuals experiencing homelessness and mental illness. Future studies should seek to confirm these findings and examine the cost effectiveness of collaborative care models for this population.

The following study evaluates the complex association between legal involvement and mental illness. It describes a population of consumers of community mental health programs, comparing those with legal involvement to those without legal involvement, on a number of demographic, clinical and social indicators. It is a secondary analysis of data collected in studies making up the Community Mental Health Evaluation Initiative (CMHEI) in the province of Ontario, Canada. Legal involvement was a significant issue among community mental health program consumers; about one in five consumers had at least some contact with the legal system in the preceding nine months. Legally involved consumers were more likely to be in receipt of social assistance and be unstably housed than those legally uninvolved. However, there were no significant differences between legally involved and uninvolved consumers with respect to severity of symptomatology, current medication use or number of hospitalization days in the past 9 months. A predictive model compared the differential impact of clinical and social determinants upon legal involvement. Analyses failed to uncover a significant relationship between severity of psychiatric symptomatology and legal involvement. Significant predictors of legal involvement included gender, race, drug use as well as housing instability, and receipt of social assistance. Legal involvement was attributable to factors other than the severity of mental illness; these results challenge assumptions that the most symptomatically severe consumers are most at risk of legal involvement. Accordingly, the rate of legal involvement in a sample of community mental health program users must be considered in a broad context, with particular emphasis on social disadvantage.

TOC Summary Line: Healthcare workers in hospitals affected by SARS experience increased psychological stress 1–2 years after the outbreak., Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p

Abstract: Fidelity measurement is an evolving field in mental health case management program evaluation. This article presents an exploratory study in which two separate fidelity measures, the Dartmouth Assertive Community Treatment Scale (DACTS) and the Key Component Profiles (KCP), were used to assess structure and process elements of three mental health case management programs. The programs were studied because they all provided services to seriously mentally ill inner city populations and shared a common context for practice. However, one program followed the Assertive Community Treatment (ACT) model, the other two were Intensive Case Management (ICM) programs, and one of the ICM programs formed a significant partnership with a home care agency for service delivery. The extent to which the DACTS and KCP were able to measure the structure and process similarities and differences of the programs is examined. The results provide information for evaluators on the possible strengths and limitations of each fidelity tool in differentiating various elements of the case management models and reinforce the importance of assessing program fidelity from a multi-dimensional perspective.

OBJECTIVES A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses. METHODS A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression. RESULTS Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress. CONCLUSIONS Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear.

Dealing with mental health problems in the inner city presents a major challenge to planners and service providers. Traditional mental health service-oriented interventions often prove ineffective due to the complexity of individuals' needs. This article argues that a population health framework can be used to identify critical risk and protective factors and facilitate more effective, upstream, population-based interventions for mental health problems in the inner city. A community report card is seen as a useful measure of key indicators at any point in time and of changes over time at the community or neighborhood level. A number of issues with regard to report card development are identified and discussed, as is the process of creating a report card, including key domains and the organization of findings.

This study was carried out with three goals: (1) to determine the prevalence of suicidal ideation and suicide attempts among the homeless; (2) to determine what aspects of homelessness predict suicidality, and (3) to determine which aspects remain predictive after controlling for key covariates, such as mental illness. A sample of 330 homeless adults were interviewed. Sixty-one percent of the study sample reported suicidal ideation and 34% had attempted suicide. Fifty-six percent of the men and 78% of the women reported prior suicidal ideation, while 28 percent of the men and 57% of the women had attempted suicide. Childhood homelessness of at least 1 week without family members and periods of homelessness longer than 6 months were found to be associated with suicidal ideation. Psychiatric diagnoses were also associated with suicidality in this sample.

Although most policymakers agree that a fundamental goal of the mental health system is to provide integrated community-based services, there is little empirical evidence with which to plan such a system. Studies in the community mental health literature have not used a standard set of evaluation methods. One way of addressing this gap is through a multisite program evaluation in which multiple sites and programs evaluate the same outcomes using the same instruments and time frame. The proposition of introducing the same study design in different settings and programs is deceptively straightforward. The difficulty is not in the conceptualization but in the implementation. This article examines the factors that act as implementation barriers, how are they magnified in a multisite study design, and how they can be successfully addressed. In discussing the issue of study design, this article considers processes used to address six major types of barriers to conducting collaborative studies identified by Lancaster or Lancaster's six Cs—contribution, communication, compatibility, consensus, credit, and commitment. A case study approach is used to examine implementation of a multisite community mental health evaluation of services and supports (case management, self-help initiatives, crisis interventions) represented by six independent evaluations of 15 community health programs. A principal finding was that one of the main vehicles to a successful multisite project is participation. It is only through participation that Lancaster's six Cs can be addressed. Key factors in large, geographically dispersed, and diverse groups include the use of advisory committees, explicit criteria and opportunities for participation, reliance on all modes of communication, and valuing informal interactions. The article concludes that whereas modern technology has assisted in making complicated research designs feasible, the operationalization of timeless virtues such as mutual respect and trust, flexibility, and commitment make them successful. © 2002 John Wiley & Sons, Inc.

Objectives This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention. Methods We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care. Results Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers. Conclusion Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.

Tertiary care subpopulations are characterized by having more than one significant condition, each of which has been traditionally dealt with by different systems of care. They experience severe and persistent mental illness and one or more of the following: age-related physical or medical conditions, substance use disorders, developmental handicaps, and acquired brain injury. This paper provides estimates of prevalence for each of these subgroups and discusses best practices which have developed in response to their special needs.

A longitudinal study followed 55 homeless and severely mentally ill clients of a hostel outreach program to assess outcomes and their relationship to program elements. Results at 18-month follow-up indicated that, despite chronic histories of transiency and shelter use, housing stability had been achieved, and that initial gains in social functioning and symptom reduction had been increased. Development of a strong working alliance proved a key program element in the findings.

The Pathways Into Homelessness project in Toronto interviewed 300 unaccompanied adult users of homeless shelters to identify characteristics of individuals who are homeless for the first time. The sample reflected the total population of homeless shelter users in terms of age, sex, level of use, and type of shelter. Two fifths of the sample were homeless for the first time. There were more similarities than differences between those who were homeless for the first time and those who had been homeless previously. The prevalence of psychiatric and substance use disorders and the rate of previous hospitalization did not differ between first-time homeless persons and those who had been homeless before. The two groups were distinguished by some childhood experiences related to housing. Both groups had multiple indicators of serious problems, suggesting that the need for intervention is as pressing for persons who are homeless for the first time as it is for the larger population of homeless persons.

Knowledge concerning the care of persons with severe mental illness is seldom translated into improvements in service delivery. Recent developments in the research utilization field suggest that the manipulation of contextual and bureaucratic variables may be the key to enhancing the use of relevant outcome data. The assumption of multiple roles by the researcher as a strategy to influence decisions and produce change is described. Common issues and problems associated with the researcher acting as administrator, planner or consultant are explored.

Social networks are viable foci for therapeutic interventions. A social network therapy program for clients with schizophrenia was developed by a community-based mental health agency. This paper presents four of the most common clinical issues encountered and illustrates each with a case example.

E. Glenn Schellenberg,* Donald Wasylenki,** Christopher D. Webster,*** and Paul Goering**** Common wisdom has it that “trouble with the law” is a serious problem for psychiatric patients. This may be especially so for chronically mentally ill patients, most of whom have a diagnosis of schizophrenia. However, little is known about how often clinicians should expect to encounter this problem, or about the factors involved. In a major review of the literature, Rabkin (1979) divided relevant studies into two groups-those published before 1965 and those published after. The earlier studies showed that arrest rates for patients were lower than rates for the general population (Ashley, 1922; Brill & Malzberg, 1962; Cohen & Free- man, 1945; Pollock, 1938). Studies published between 1965 and 1979 showed arrest rates of patients to be equal to, or greater than, those of the general population (Durbin, Pasewark, & Albers, 1977; Giovanni & Gurel, 1967; Rap- peport & Lassen, 1965, 1966; Sosowski, 1974, 1978; Steadman, Cocozza, & Melick, 1978; Zitrin, Hardesty, & Burdock, 1976). Rabkin (1979) attributed the increase in arrest rates to an increase in the proportion of patients with prior criminal records. It is important to note, however, that thousands of patients were “deinstitutionalized” between 1965 and 1974. The bed capacity of U.S. state hospitals diminished from 550,000 in 1961 to 110,000 by 1975 (Bassack & Gerson, 1978), placing many more patients at risk for arrest. Data concerning schizophrenia and risk for arrest were equivocal. Rabkin concluded that schizophrenics are no more likely to be arrested than are other diagnostic groups, with the exception of violent crime, for which schizophren- ics may have higher rates of arrest. She also concluded that psychiatric pa- tients, in general, are not predisposed to be arrested for some crimes as op- posed to others, with the exception of assaultive behavior, for which they are more likely than other persons to be arrested. No conclusions could be reached concerning the effect of psychiatric hospitalization or treatment on arrest rates. This report examines research conducted since 1980 concerned with arrest

A brief overview of recent policy developments across Canada and a discussion of the common themes and challenges they address demonstrates the scope of activity in this field. The federal level of mental health planning and a summary of recent of policy developments in each province are described. Significant progress has been made in Canada in the development of mental health services since deinstitutionalization. Major challenges remain, however, which are being addressed to varying degrees across the country. The challenges related to the key issues of major mental illness, integration and consumerism are illustrated.

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.

Differences between 24 female and 35 male clients were assessed at entry into an intensive case management program serving homeless shelter residents and again nine months later. Both men and women were socially isolated, with small social networks and severe deficits in social functioning. Histories of homelessness were similar for both genders, and there were no gender differences in psychopathology at baseline or follow-up. At entry into the program women had higher levels of social skills, larger and more supportive networks, and better housing conditions than men, but these differences disappeared after the subjects spent nine months in the program. Inadequate living conditions may have contributed to the more negative initial picture for men. Although there were more similarities than differences between the men and women in this sample, more research on gender differences is needed to design and evaluate programs for homeless mentally ill persons.

Medical schools and departments of psychiatry around the world face challenges in integrating science with clinical teaching. This project was designed to identify attitudes toward the integration of science in clinical teaching and address barriers to collaboration between scientists and clinical teachers.The authors explored the interactions of 20 faculty members (10 scientists and 10 clinical teachers) taking part in a 1-year structured faculty development program, based on a partnership model, designed to encourage collaborative interaction between scientists and clinical teachers. Data were collected before, during, and after the program using participant observations, surveys, participant diaries, and focus groups. Qualitative data were analyzed iteratively using the method of meaning condensation, and further informed with descriptive statistics generated from the pre- and postsurveys.Scientists and clinicians were strikingly unfamiliar with each other's worldviews, work experiences, professional expectations, and approaches to teaching. The partnership model appeared to influence integration at a social level, and led to the identification of departmental structural barriers that aggravate the divide between scientists and clinical teachers. Issues related to the integration of social scientists in particular emerged.Creating a formal program to encourage interaction of scientists and clinical teachers provided a forum for identifying some of the barriers associated with the collaboration of scientists and clinical teachers. Our data point to directions for organizational structures and faculty development that support the integration of scientists from a wide range of disciplines with their clinical faculty colleagues.

This report explores participants' satisfaction with Assertive Community Treatment Programs in Ontario, Canada through a general satisfaction questionnaire that includes three open-ended questions. Open-ended questions are a simple tool for obtaining more detail about areas of satisfaction and dissatisfaction, and responses seem to be less influenced by social desirability than quantitative ratings. Participants particularly used the opportunity of answering open-ended questions to express feelings about their relationships with the team workers.

There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or timeframes, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.

Deinstitutionalization in Canada produced a shift in locus of care from provincial psychiatric hospitals to general hospital psychiatric units. As a result of this approach, a number of key planning issues have emerged that most provinces are attempting to address.

Planning mental health services is a complex task requiring an understanding of background developments and key issues related to mental health services. In Canada, the deinstitutionalization of patients attempted to shift the locus of care from provincial psychiatric hospitals to general hospital psychiatric units. This resulted in the isolation of provincial psychiatric hospitals, general hospital psychiatric units and community mental health programs, with little overall accountability for the services provided — three solitudes. To move toward the creation of responsible, integrated systems a number of issues must be addressed: target population(s); the roles of provincial psychiatric and general hospitals; community support services; continuity of care; co-morbidity; consumerism; and methods of integration. In the development of a comprehensive mental health plan, each issue should be recognized and decisions made which are in keeping with current knowledge. A companion report will survey Canadian initiatives in mental health planning and discuss approaches to many of the issues identified.

The relationship between life events and symptoms during a six month period following discharge was examined for four diagnostic subgroups of psychiatric patients (N = 505). The significant correlation between total life changes and symptoms disappeared when health related items were deleted. These events should be kept analytically distinct to avoid operational confounding. There was a correlation between undesirable life events and symptoms specific to the diagnostic subgroups characterized by depression. Although the correlations between life event scores and symptoms were weak or non-existent, there are strong correlations between social adjustment scores and symptoms. One explanation is that the most potent stressors are the ongoing difficulties rather than major changes which occur. It is suggested that the ongoing difficulties are, in part, a reflection of inadequate coping skills and a lack of social support: factors which may have a direct negative effect on symptoms and increase vulnerability to minor stressors.

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.

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.

In a larger follow-up study of discharged patients, a subgroup of 87 women with non-psychotic disorders had an unexpectedly poor outcome at six months with regard to readmissions, symptoms and social adjustment. The only factor which distinguished those who had been readmitted was lack of social support. Lack of social support was also related to poor symptom and social adjustment outcomes. There were considerable difficulties with social functioning independent of high symptoms. The adequacy of aftercare services is questioned in the light of these findings.

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.

The authors have completed a large descriptive study of the system of psychiatric aftercare in Metropolitan Toronto. This article describes the relevant 6-month and 2-year postdischarge outcome in each of five aftercare components for 505 subjects in a traditional system of service delivery. Provincial hospital, research institute, and general hospital subgroups are compared. For the total group, recidivism and employment rates are similar to those found in previous studies. Symptoms and distress levels are high. Considerable numbers of subjects live in inadequate and unsatisfactory housing. Social isolation, inadequate income, and difficulties with instrumental role functioning are persistent problems with little improvement between 6 months and 2 years postdischarge. Differences among the subgroups vary according to type of outcome and, for the most part, can be explained by differences in the characteristics of the patients served by the three types of inpatient treatment settings. These findings provide additional information about serious deficiencies in discharge planning and aftercare service delivery that is focused primarily upon the treatment of illness. The authors conclude that a more balanced system of aftercare requires a shift in resources to rehabilitation programs in the community.

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.

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.