Ann B. Goodman

Clinical correlates of readmission in a schizophrenic cohort.

A study of a cohort of 223 schizophrenic patients from a single catchment area followed up for two years after discharge from inpatient status revealed a significant association between the presence of two of 38 clinical problem categories (social withdrawal and drug abuse) and subsequent readmission. In addition, patients without social withdrawal who were readmitted showed a significantly greater use of aftercare services than those not readmitted, while, among those with social withdrawal, male patients were significantly more likely to be readmitted than female patients. Neither prior hospitalization nor the presence of affective symptoms were significantly associated with readmission. Clinical and research implications of these findings are discussed.

A family history study of schizophrenia spectrum disorders suggests new candidate genes in schizophrenia and autism

To limit genetic heterogeneity, this study focused on the widely extended pedigrees of Ashkenazi Jewish schizophrenic and autistic probands, to determine if similar causal mechanisms might obtain for both conditions. At least two previous epidemiological studies have demonstrated increased risk for schizophrenia in Ashkenazi Jews. The hypothesis posed is that increased prevalence of various rare autosomal recessive diseases among the Ashkenazim might contribute to the increased vulnerability to schizophrenia and to autism in this large genetic isolate. Rates of amyotrophic lateral sclerosis (ALS) and bleeding disorders were significantly increased among relatives of schizophrenic and autistic probands, compared to relatives of normal probands. These results suggest new candidate loci in schizophrenia and autism, particularly the chromosome 15q23-24 locus of the hexosaminidase A gene, causing various GM2 gangliosidoses, and the 21q22.1–q22.2 loci of the antioxidant, superoxide dismutase gene, and a cytokine receptor gene.To limit genetic heterogeneity, this study focused on the widely extended pedigrees of Ashkenazi Jewish schizophrenic and autistic probands, to determine if similar causal mechanisms might obtain for both conditions. At least two previous epidemiological studies have demonstrated increased risk for schizophrenia in Ashkenazi Jews. The hypothesis posed is that increased prevalence of various rare autosomal recessive diseases among the Ashkenazim might contribute to the increased vulnerability to schizophrenia and to autism in this large genetic isolate. Rates of amyotrophic lateral sclerosis (ALS) and bleeding disorders were significantly increased among relatives of schizophrenic and autistic probands, compared to relatives of normal probands. These results suggest new candidate loci in schizophrenia and autism, particularly the chromosome 15q23-24 locus of the hexosaminidase A gene, causing various GM2 gangliosidoses, and the 21q22.1–q22.2 loci of the antioxidant, superoxide dismutase gene, and a cytokine receptor gene.

Mental health service needs assessment

A method is presented for identifying populations in need of mental health services in states, counties, and subcounty areas, using social indicators for zip codes within the areas. Three common approaches to needs assessment are presented, and limitations of each approach are discussed. The zip code method highlights homogeneous subareas of both high and low risk within heterogeneous counties. Using the method targets high risk need areas more efficiently.A method is presented for identifying populations in need of mental health services in states, counties, and subcounty areas, using social indicators for zip codes within the areas. Three common approaches to needs assessment are presented, and limitations of each approach are discussed. The zip code method highlights homogeneous subareas of both high and low risk within heterogeneous counties. Using the method targets high risk need areas more efficiently.

CHARACTERIZING THOSE IN MENTAL HEALTH TREATMENT: THE PLANNER'S PERSPECTIVE

A hierarchical classification scheme intended to categorize patients receiving mental health services into groupings useful for planning purposes is presented. A patient in treatment is assigned one of four levels jointly defined by an assessment of the patients current level of disability and expected long-term service requirements. To illustrate the operationalization of the scheme, using data collected as part of a one week survey of patients in treatment in the New York State mental health service system in 1985, patients are classified on long-term residency, probable source of funding for service received in the week (used as a surrogate measure of level of disability) and diagnoses. Several applications of the scheme are given including crossregional comparisons of service systems and examining service use of targeted minority and age subgroups.

Alternatives to drgs: Research issues

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century.In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency.