John A. Talbott

Deinstitutionalization: Avoiding the Disasters of the Past

The reasons for the problems created by deinstitutionalization have only recently become clear; they include a lack of consensus about the movement, no real testing of its philosophic bases, the lack of planning for alternative facilities and services (especially for a population with notable social and cognitive deficits), and the inadequacies of the mental health delivery system in general. Providing care for the chronically ill and preparing for future deinstitutionalization means that the issue must be reconceptualized not as one of where people should be housed but as the need to provide the full range of treatments and services that are available in a total institution. Attitudinal and institutional biases and discriminatory practices must be combated, planning for community facilities and services must be improved, and funding for both institutional and community services must be provided during the phasing down of institutional services. The author proposes a set of ten commandments or basic rules to guide future deinstitutionalization activities.

A study of suicide in state mental hospitals in New York City.

Suicides at five state hospitals for the mentally-ill located in NYC were studied over a 32 month period. The suicide rates at the individual hospitals appeared to be primarily related to the acuteness of inpatient population and secondarily to the socioeconomic-ethnic characteristics of the inpatient population. White young Puerto Rican male, better educated female involuntarily committed, schizophrenic, and affective disordered patients were overrepresented in the suicide group; black patients were underrepresented. From clinical data two profiles of psychiatric inpatients at high risk for suicide were constructed; 1) a male paranoid schizophrenic with previous suicide attempts involuntarily committed due to acute psychosis who hangs himself in his room or bathroom during the first weeks of hospitalization; 2) a chronic undifferentiated schizophrenic often with affective component who has been hospitalized for more than one month and who is considered by staff to be improving, but is having difficulty with discharge planning who commits suicide by jumping while out of the hospital on an authorized pass. Recommendations were made for reducing inpatient suicides.

Textbook of psychiatry.

The Editors proclaim their goal as “...to assemble a textbook that presents, as comprehensively as is possible in a single volume, the clinically relevant topics in psychiatry. . .We have thus endeavored to present a psychiatric text that may be used in a fashion similar to that of several other standard textbooks in other fields such as internal medicine, general surgery, pediatrics, endocrinology, and pharmacology: a text that is not only useful as a standard educational reference for psychiatrists and psychiatry residents, but that is also purchased and used extensively by medical students, residents, and more advanced professionals from other disciplines and specialties”.

Reactions of schizophrenics to life-threatening disease

This contribution reports a study of chronic schizophrenics hospitalized in state hospitals who suffer from serious and life-threatening medical and surgical illnesses. Four primary findings are described and discussed: lack of verbalization of pain and discomfort; bodily self-mutilation; toleration and exhibition of loathsome lesions; and inability or unwillingness to tolerate medical care. Some examples of exceptions to these four findings are also presented. Possible explanations for the findings are discussed in terms of their biological, social, and psychological components, recognizing that no single factor can explain the findings in this complex and varied population. It is concluded that treatment staffs in the hospital or community must be alert to changes in patient state, must utilize compromise methods of care and must anticipate or deduce a patients needs while the patient is physically ill.

The Fate of the Public Psychiatric System

Psychiatry faces a vast array of problems today, including its inability to implement programs for the chronic mentally ill and to apply principles of differential therapeutics, the lack of funds for community services, and the continuing severe fragmentation of the psychiatric delivery nonsystem. Old solutions will not suffice. If the public mental health system is to survive, it must first be defined as comprising all settings, services, and funding for the severely and chronically mentally ill. And it must shift the balance of resources and services from institutional to community-based care. A range of financial and administrative mechanisms, such as various kinds of aggregate funding and a division of responsibility among levels of government, are available to accomplish that shift.

Stopping the revolving door —a study of readmissions to a state hospital

With readmissions comprising 60% of all admissions, this hospital took a hard look at 100 consecutive readmissions.It was judged that 84 might have been prevented, and that almost half of these might have been prevented with minor improvements of existing services necessitating no additional expenditure of money.Five brief case studies illustrate the various types of preventable and non-preventable readmissions.

Professionalism, medical humanism, and clinical bioethics: The new wave-does psychiatry have a role?

In medicine, and especially in medical school education, there is growing interest in and emphasis on professionalism, humanism, and clinical bioethics, as reflected in the Medical School Objectives Project of the American Association of Medical Colleges and the core competencies developed by the American Committee for Graduate Medical Education and the American Board of Medical Specialties. The authors first discuss the reasons for the increasing emphasis on this area. They then discuss specific areas related to professionalism, humanism, and clinical bioethics where psychiatrists are especially well fitted to play a role because of their training and experience. Finally, they suggest ways in which psychiatrists can play a more active role in this new direction in medical care and education.

State-university collaboration in psychiatry: The pew memorial trust program

This contribution summarizes the background leading up to the goals of and the experience gained from a major national initiative to expand and improve collaborative activities between state departments of mental health and university departments of psychiatry through regional conferences, national workshops, ongoing consultations, and awards. It details the problems of the public system and how successful collaborative efforts have improved the situation, cites the role of one such a program (in Maryland), recounts the process of holding a national invitational conference and the subsequent “Call to Action,” and summarizes what the Pew Project is intended to do and how the project is progressing.

Careers in Psychiatry: Options for the Future

Abstract An examination of data on careers in psychiatry. Discusses the trends in psychiatric careers, mental health services, manpower needs, and academic psychiatry.

CMHC's: relationships with academia and the state.

We have surveyed all community mental health centers (CMHCs), state departments of mental health, and university departments of psychiatry in the country to ascertain the status of their relationships with one another. The response rate to a one page questionnaire was 33%.An overwhelming percentage, 88%, of CMHCs have relationships with state hospitals and/or academia. Most often they consist of a service relationship. The control for such relationships is most often shared or there is no one controlling organization.The benefits of such relationships include improved communication, improved access to state hospitals, and improved quality of inpatient and outpatient care. CMHCs who responded to our survey did not think that relationships with the state or academia resulted in improved recruitment of psychiatrists and improved residency training-but state and academic respondentsdid. All, however, agreed that research, long-term care, and recruitment of other staff are minimally improved by collaborative relationships.