Jeffrey L. Geller

Insight and the clinical outcome of schizophrenic patients.

At the time of discharge from their index hospitalizations, 52 schizopheric patients initially admitted for acute psychotic episodes were assessed on an Insight and Treatment Attitudes Questionnaire. When these patients were followed up 2½ to 3½ years later, adequate information on their clinical courses and outcomes was available in 46 cases. A global assessment of aftercare environment was made in each case, reflecting the degree to which individuals other than the patient were helpfully invested in maintaining the patient in treatment, whether these individuals were in the patients living or treatment situations. Five factual outcome variables were also assessed: a) compliance with treatment 30 days after discharge; b) long-term compliance; c) whether or not patients were readmitted; d) readmissions per year; and e) percent of time spent in the hospital. As expected, aftercare environment was significantly related to outcome (p = .039). The overall relationship between insight and the outcome variables closely approached statistical significance (p = .053). Patients with more insight were significantly less likely to be readmitted over the course of follow-up. There was a trend for patients with more insight to be compliant with treatment 30 days after discharge. No significant interaction between aftercare environment and insight was found, suggesting that insight may influence outcome independently of aftercare environment.

Why must some schizophrenic patients be involuntarily committed? The role of insight

Twenty-four of 52 (46%) schizophrenic patients hospitalized because of acute psychotic episodes associated with preadmission medication noncompliance required involuntary commitment. Committed patients were rated as significantly more severely ill than voluntary patients and were significantly more likely to be transferred to extended treatment facilities after acute care. However, committed patients were significantly less likely than were voluntarily admitted patients to acknowledge that they were psychiatrically ill and in need of treatment, i.e., to demonstrate insight. Although psychopathology diminished significantly in both committed and voluntary patients over the course of hospitalization, only in voluntary patients did insight increase significantly. Over a 21/2 to 31/2 year follow-up, those patients who had been involuntarily committed at the index hospitalization were significantly more likely to require involuntary admissions than were the initially voluntary patients. Inability to see the self as ill seems to be a persistent trait in some schizophrenic patients.

The efficacy of involuntary outpatient treatment in Massachusetts

One means to address some of the unintended consequences of the shift of treatment for individuals with serious mental illness from hospitals to communities has been involuntary outpatient treatment (IOT). Using Massachusetts data, 19 patients with court orders for IOT were matched to all and to best fits on demographic and clinical variables, and then to individuals with the closest fit on utilization before the IOT date. Outcomes indicated the IOT group had significantly fewer admissions and hospital days after the court order. The full impact of IOT requires more study, particularly directed toward IOTs effects on insight and quality of life.

Redefining Self-Help: Policy and Practice

long-time concern in medicine, education, and social reform has been how to motivate the recipients of services to achieve their goals: how to ensure that addicts give up their addictions, how to encourage failing students to do better, and how to promote more rapid recovery among patients. In their book Redefining SelfHelp, Frank Riessman and David Carroll suggest that in self-help, society already has the tools available. The goal now, Riessman and Carroll believe, is to hone the self-help movement to even greaten social advantage. With this aim in mind, they outline the history of self-help and its goals, organization, and benefits. And they delve into the possibilities for greaten use of this approach in a time of limited financial resources. Riessman and Carroll are well equipped to address this topic. Frank Riessman has been a member of various self-help organizations for 40 years, has a Ph.D. in social psychology, writes and lectures widely on selfhelp, and is currently the editor-inchief of Social Policy and director of the National Self-Help Clearinghouse at the City University of New York. David Carroll has written extensively on health-related issues, including a book series for consumers on Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis. The authors’ main premise is that self-help holds tremendous power as a motivaton for both the helper and the “helpee.” They devote a chapter to the Alcoholics Anonymous model in which recovering alcoholics help new members and vice versa. Under the umbrella of AA, helpees have been transformed from needy and dependent receivers of help to motivated,

Mothers with severe mental illness caring for children

This research identifies and describes the Massachusetts population of Department of Mental Health (DMH) case-managed women with severe mental illness who are caretakers of their minor children (N = 314), and compares their demographic and clinical characteristics and service utilization with those of a matched, randomly selected group of DMH case-managed noncaretaking women (N = 328) using the Client Tracking System database. Caretakers were significantly younger, had less formal education, and had higher rates of marriage than did noncaretakers. They are diagnosed more often with major affective disorders and less often with psychotic disorders. Caretakers demonstrate higher levels of functioning and are less likely to have a representative payee. Although caretakers function better, the groups do not differ significantly in their use of DMH services. This is the first systematic, statewide effort to specify the unique characteristics of this substantial group of women with severe mental illness who are caring for their children.

The premature demise of public child and adolescent inpatient psychiatric beds : part I: overview and current conditions

Current trends on the national landscape of available treatment and delivery systems for children and adolescents with serious emotional disturbance indicate a sharp decline in the availability of inpatient psychiatric services. These trends are troubling as six to nine million children and adolescents in the United States suffer from some serious emotional disturbance, and the majority in need of treatment do not receive behavioral health services. The consequences of untreated mental illness in children are grave, and the cost to society of children’s mental health problems is high in both human and fiscal terms. This paper will describe national trends in behavioral health in general and specifically children’s mental health, and will detail the experiences of many states to identify possible problems and pitfalls to downsizing and closing child and adolescent inpatient psychiatric beds.

The Changing Role Of The State Psychiatric Hospital

State hospitals were once the most prominent components of U.S. public mental health systems. But a major focus of mental health policy over the past fifty years has been to close these facilities. These efforts led to a 95 percent reduction in the countrys state hospital population. However, more than 200 state hospitals remain open, serving a declining but challenging patient population. Using national and state-level data, this paper discusses the contemporary public mental hospital, the forces shaping its use, the challenges it faces, and its possible future role in the larger mental health system.

Pathological firesetting in adults

The case of Kleim, summarized in the second volume of the American Journal ofInsanity, highlights America’s early struggles to understand the relationship between psychopathology and firesetting. In this case the psychiatric experts offered their opinions that Kleim suffered from “monomania” or “dementia” or both, and that his acts were the result of insanity. The jury, after only a few hours of deliberation, found Kleim “not guilty owing to insanity.” While 150 years later the language has changed-both psychiatric and legal terminology having evolved-the dilemma is little changed. What is pathological firesetting? How are we to understand the relationships between firesetting and medical, neurologic, or psychiatric disorders that may influence the behavior?

Empirically assessing the impact of mobile crisis capacity on state hospital admissions

The literature on emergency psychiatric services contains numerous claims to the effect that mobile crisis capacity reduced hospitalization by resolving emergencies in the community. To date these claims have not been substantiated by empirical analysis. This study, using 1986 data from Massachusetts, compares first and total admission rates of catchment areas with mobile capacity to those without such services, controlling for differences in community resources and demand for hospitalization. This analysis showed no effect of mobile capacity on admission rates. These findings are not interpreted as evidence of the ineffectiveness of mobile services, but are seen as indicative of the need for further empirical investigation of these services.

The quandaries of enforced community treatment and unenforceable outpatient commitment statutes.

One response to the problems created by deinstitutionalization has been outpatient commitment. Involuntary community treatment presents a series of dilemmas, including those involving the role of enforced treatment in psychiatry, the implementation of informed consent, the application of “least restrictive alternative,” and the ever-widening liability of psychiatrists. While outpatient commitment itself presents conundrums, outpatient commitment which is unenforceable brings the psychiatrist to even further quandaries. Using Pennsylvania as an example, the difficulties posed by unenforceable outpatient commitment are presented. The author concludes that although coerced community treatment may be successful even without legal sanctions, this is not an ethically sound solution.