Donald Wasylenki

A Review of Arrests Among Psychiatric Patients

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

Social support and post hospital outcome for depressed women.

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.

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 ICUs are useful additions to psychiatric settings with important cost and patient care implications.

Psychiatric aftercare in a metropolitan setting.

In the face of the trend toward brief hospitalization, rising re-admission rates and other indices of poor community adjustment, concern has developed about the adequacy of psychiatric aftercare services. The authors report on a comprehensive study of psychiatric aftercare in a large metropolitan area (population 2.5 million). The study followed prospectively a group of 747 patients, representative of a significant proportion of patients in the care system. The findings document inadequacies in hospital-based discharge planning, unbalanced use of aftercare services and poor patient outcomes six months and two years post-discharge. The study found heavy reliance on medical/therapeutic aftercare services with a relative neglect of housing, vocational/educational, financial and social/recreational services. Despite the large volume of medical/therapeutic service use, the patient group had a high readmission rate, high levels of symptomatology and poor social adjustment on follow-up. The authors suggest that community-based practitioners with specialized training in psychiatric rehabilitation would improve the system of aftercare.

Understanding the Challenges of Integrating Scientists and Clinical Teachers in Psychiatry Education: Findings from an Innovative Faculty Development Program

ObjectiveMedical 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.MethodsThe 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.ResultsScientists 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.ConclusionCreating 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.

A population health framework for inner-city mental health.

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.

Improving continuity of care for frequent users of emergency departments: service user and provider perspectives

OBJECTIVEnThis 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.nnnMETHODnWe 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.nnnRESULTSnWithin 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.nnnCONCLUSIONnAlthough 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.

Promoting the utilization of outcome study results by assuming multiple roles within an organization

Abstract 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.

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.

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention

BackgroundAddressing 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.MethodsCoordinating 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.ResultsStakeholders 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.ConclusionsA 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.