Jose M. Santiago

Homeless mentally ill patients in the community: Results of a general hospital emergency room study

Previous inattention to the specific circumstances of homeless mentally ill individuals in general hospital settings is discussed. Homeless mentally ill individuals who presented for emergency psychiatric care in a public general hospital setting exhibited distinctive patterns of service utilization and showed evidence of being a uniquely disabled, rootless, and impoverished subgroup of mentally ill individuals. The characteristics of homeless users of general hospital psychiatric services may provide some important clues to system-wide deficits in community-based care for the members of this population.

The seriously mentally ill: another perspective on treatment resistance.

There is a subpopulation of the seriously mentally ill who remain acute care recidivists, rarely becoming engaged in follow-up treatment. It has been argued that these individuals are system, rather than treatment resisters. The perceptions they have of their problems are often in conflict with staff evaluations, or with what the system has to offer. In the present study, patients who dropped out of residential care against staffs advice were compared to patients who remained in treatment. The results suggest that the greater the difference between the perceptions a patient and therapist have concerning the patients problem, the greater the likelihood of the patient dropping out of treatment.

An introduction to the special issue on systems aspects of chronic mental illness

This issue of the Community Mental Health Journal focuses on the chronically mentally ill (CMI) . The articles address issues ranging from the effects of fiscal retrenchment on services (Surber et al.) to a statewide planning model for providing a con t inuum of residential service settings for the chronically mental ly ill (Shern et al.). One article views the C M I issue from a global perspective and presents a model for comprehensive treatment of schizophrenia and chronic mental illness (Bellack et al.). Two other articles are more specific in nature and look at specific system issues related to the chronic mental illness: homelessness (Roth et al.), and criminalization (Sipes et al.). In addit ion to the stated theme of chronic mental illness, the papers included in the selection of articles share the common focus of a systems orientation. In reviewing and selecting articles for the special issue, we purposefully chose an orientation that did not focus on specific clinical programs. Although such descriptions are definitely valuable, it is our feeling that a priority should be the unders tanding of the more global systems concerns. We reviewed the articles with the philosophy that effective t rea tment of the chronically mentally ill does not occur in a vacuum. Effective t reatment requires both clinical skills of professionals as well as the flexibility and comprehensiveness of a t rea tment system. In our own experience, failures in the t rea tment of the chronically mental ly ill are rarely the result of pure clinical issue. Rather , inadequate t rea tment is often the result of a system that is unresponsive to the needs of the chronically mental ly ill. For example, the best clinicians who sit in the offices of the best communi ty mental health centers provide inadequate services to patients who are unable or unwill ing to keep appointments at those communi ty mental health centers. Similarly, communit ies that do not provide residential services to the acting out chronic patient are in fact denying services to certain patients because of their illness. Hence, the contextual system of care determines the effectiveness of specific interventions. The final article in the series illustrates this point quite vividly from a family member s point of view.