Ernest M. Gruenberg

The Meaning of Cognitive Impairment in the Elderly

In order to determine the meaning of cognitive impairment in community dwelling elderly, 3,481 adults were interviewed in their homes using the Mini‐Mental State Examination. Ninety‐six per cent of the population aged 18–64 scored 23 or higher, whereas 80 per cent of the population 65 and over scored 23 or higher. Individuals with low scores were suffering from a variety of psychiatric disorders including dementia. Thirty‐three per cent of the elderly population scoring in the range of 0–23 had no diagnosable DSM‐III condition. Prevalence of dementia from all causes was 6.1 per cent of the population over age 65. Two per cent of the population over age 65 were diagnosed as having Alzheimers disease

DSM-III compulsive personality disorder: an epidemiological survey

A two-stage probability sample of community subjects was developed with a full psychiatric examination employing DSM-III criteria in conjunction with the Epidemiological Catchment Area (ECA) survey conducted in Baltimore, MD. This report details the observation on those subjects diagnosed with compulsive personality disorder and compulsive personality traits. The results indicate that this condition has a prevalence of 1.7% in a general population. Male, white, married and employed individuals receive this diagnosis most often. Our data suggest a dimensional rather than categorical character for this disorder. The disorder imparts a vulnerability for the development of anxiety disorders.

Brief report on the clinical reappraisal of the Diagnostic Interview Schedule carried out at the Johns Hopkins site of the Epidemiological Catchment Area Program of the NIMH.

A psychiatric examination was conducted on 810 community dwelling subjects previously given a diagnosis derived from the Diagnostic Interview Schedule (DIS). The agreement in allocating subjects to a particular disorder was never high enough to encourage the confident replacement of a psychiatric diagnosis with a DIS diagnosis.

Prevalence of treated and untreated dsm-iii schizophrenia: Results of a two-stage community survey

Psychiatrists, using a standardized clinical method, examined a probability sample of 810 subjects in eastern Baltimore and made diagnoses of mental disorders among those subjects according to DSM-III criteria. The authors estimated that there were 4.6 active cases of schizophrenia per 1000 adult noninstitutionalized population, and 6.4 cases per 1000 population, including both active and remitted cases. Among the 17 active and remitted schizophrenics identified in the survey, one half were not receiving any form of mental health services at the time of the survey; these data yield a prevalence rate of untreated cases of 3.1 per 1000 population. All of the untreated schizophrenics were deemed by the examining psychiatrist to be in need of services.

Abandonment of Responsibility for the Seriously Mentally Ill

The road leading to the demise of state responsibility for the seriously mentally ill and the current crisis of abandonment was paved with all the best intentions. Tragically, policies underlying the pattern of abandonment are based on erroneous interpretations of what patients need and what our current techniques can produce to help them. An index of declining hospital census must not be mistaken for the goal of care.

Interobserver reliability of a “standardized psychiatric examination” (SPE) for case ascertainment (DSM-III)

The authors describe the Standardized Psychiatric Examination (SPE), a new method for conducting psychiatric examinations in both clinical and research settings that preserves the clinical method. The SPE provides a consistent replicable format for eliciting and recording psychiatric history, signs, and symptoms without perturbing the patient-clinician interaction. By means of the SPE, the clinician can formulate diagnoses using DSM-III or ICD-9 criteria and yet generate CATEGO profiles derived from the Present State Examination, 9th edition. Psychiatrists using the SPE demonstrated high interrater reliability in ascertaining individual psychopathological symptoms (Kappa range, 0.55 to 1.0) and in making DSM-III diagnoses (Kappa range, 0.79 to 1.0) among a sample of study subjects (N = 43) drawn from both a psychiatric inpatient population and a large community sample of nonpatients from the Epidemiological Catchment Area (ECA) study. The implications of the SPE for clinical practice and for research are discussed.

The Evaluation of the Plymouth Nuffield Clinic

practice therapies without requiring first a demonstration that they work, and that they are likely to prove useful only so long as the physician believes that they will. It was not psychiatry that called forth either of these rebukes, yet in that field they apply with especial force. For, although psychiatrists have become sensitive to the need for elaborate and contrived clinical trials of somatic treatments, the sweeping changes in psychiatric administration initiated in the last 20 years, the extensive reforming procedures within the mental hospital, and the measures adopted to extend extramural and community care, all remain untested. They have taken root and spread more because of the crusading enthusiasm of their protagonists than because anyone has shown that they work. Why should the innovator1 who has lighted on and developed a new idea-the open door, group therapy, early discharge, home visiting, whatever it might be-desist from expounding its principles? He is convinced that it is effective. It is effective, very often, when pursued with his zeal. To test it would be a work of supererogation. Moreover, it would scarcely be practicable; it would involve setting up criteria by which its success could be assessed; it would in-

The Dutchess County Project

In January 1960 we set up a relatively small, geographically decentralized 550-bed Unit within a 5,000-bed state hospital to serve all degrees and types of mental illnesses in the county. The countys population was approximately 175,000 and is now approximately 200,000. We automatically accepted mentally ill persons into the Unit, with the exception of children under 16 and individuals with open pulmonary tuberculosis. We had to maintain an acute service and an emergency service because this is part and parcel of the New York State system. We hoped to demonstrate the value of a small community-oriented, malleable, clinically autonomous Unit in accomplishing the following-

Preserving Chronic Patients’ Assets for Self Care

The automobile production line increases worker productivity by fragmenting a complex task into very simple elements, each elementary task being performed by one worker in a routine way. This production-line device has proved enormously valuable in manufacturing large numbers of identical products, put together from identical components. Instead of making each worker a highly specialized technical expert, however, it makes him a highly specialized nonexpert —that is, an operator who can learn his simple task in a short time. The workers thus become readily interchangeable and the product correspondingly impersonal. For many tasks, this method of organizing work is efficient and effective. But treating a chronic mentally ill person—preserving his functional assets in accordance with the present state of our knowledge, deciding when he is ready to leave the hospital and deciding when he needs hospitalization once again—is not such a task.

Some Aspects of Patient-Flow in the Dutchess County Unit, 1960-1963

When the evaluation studies of the Dutchess County Unit were being planned, it was the consensus that no hypotheses relating movement of patients to the evaluation of the Unit could be stated. Nevertheless, it was felt that while collection of the data needed for testing the hypotheses relating to the effectiveness of the Unit was the primary function of the research group, it was also of importance to monitor and analyze the characteristics of the flow of patients through the Unit. Initially, no predictions were made concerning indices of Unit activity based on these data, such as the admission rate, discharge rate, and average length of stay. A reporting system was developed by which each major change of status of each patient as he moved on and off the books of the Unit was recorded. For each patient entering the Unit, much of the information on his or her admission form, filled out by the hospital for state use, was recorded. To follow the movement of the patient into and out of the Unit, a transaction record was prepared for each admission, discharge, death, placement on, or return from, convalescent care, family care, leave without consent, and home leave, and transfer to or from another state or state-licensed mental hospital, or the other services of the Hudson River State Hospital. A separate record specifying each transaction and the date on which it occurred was prepared and filed. Thus a sequential record of each patients experience in the Unit was accumulated, beginning with the admission record of