Mark R. Munetz

Barriers to informed consent.

The law of informed consent seeks to actively involve patients in decision making. Most authorities agree that this involvement has not occurred but disagree about why. Some suggest that patients are incapable of understanding medical issues and others that physicians have not explained issues clearly or extensively enough. We observed decision making in several hospital settings and found other significant barriers to patient participation. These barriers include the fact that treatment decisions take place over a long period; there are often many decisions to be made; although patients want information about treatment, they typically believe that decision making is the physicians task; physicians do not understand the rationale for the patients role in decisions; and the medical decision-making process often involves so many people that the patient does not know who is responsible.

The incarceration of individuals with severe mental disorders.

This study examines the extent to which severely mentally disabled (SMD) patients in one county mental health system were incarcerated in the local jail and examines characteristics of a sample (N = 30) of such individuals. We found that in the study year, 7.9% of known SMD patients had at least one incarceration in the county jail. Diagnoses were predominantly in the schizophrenia spectrum with 70% also actively abusing substances at the time of incarceration. The majority of crimes were non-violent and substance abuse related. Half of the sample was judged to be candidates for diversion programs. Our findings are consistent with recent literature confirming that substance abusing SMD individuals are at high risk of incarceration and could benefit from integrated mental health and substance abuse treatment.

Akathisia, pseudoakathisia and tardive dyskinesia: Clinical examples

Abstract Akathisia is a side effect of neuroleptic drugs characterized by a subjective sense of inner restlessness leading to an inability to sit still and a compulsion to move. 1 There has been a great deal of recent literature encouraging clinicians to consider the diagnosis of akathisia. The major emphasis of these reports has been to distinguish akathisia from the anxiety and hyperactivity frequently seen in psychotic patients and thereby to prevent worsening of this extrapyramidal symptom by the addition of increasing doses of neuroleptics. 1–5 In other words, the thrust of the literature has been education to avoid underdiagnosing akathisia. We believe that there may also be a need to avoid overdiagnosing akathisia. Specifically, it is often difficult to distinguish akathisia and tardive dyskinesia. The involuntary, late onset, treatment unresponsive lower extremity involvement of tardive dyskinesia is not always clinically distinct from the subjectively distressful akathisia which is theoretically of early onset, is treatment responsive and has voluntary movements as a secondary phenomenon. A review of the literature on akathisia and tardive dyskinesia suggests several possible important relationships between these disorders. First, there may be a positive association between the occurrence of akathisia and tardive dyskinesia. Second, some akathisia may actually be tardive dyskinesia or some form fruste of tardive dyskinesia which we have called pseudoakathisia. Finally, there may be a progression from true akathisia through pseudoakathisia and finally to clear cut tardive dyskinesia.

Distinguishing akathisia and tardive dyskinesia: a review of the literature.

Akathisia and tardive dyskinesia, both side effects of neuroleptic drugs, should be easily distinguishable. Akathisia is fundamentally a subjective disorder characterized by a desire to be in constant motion resulting in an inability to sit still and a compulsion to move. Tardive dyskinesia is an involuntary movement disorder characterized by repetitive purposeless movements which typically involve the buccolingual masticatory areas but which can include choreoathetoid limb movement. Clinicians, however, are not always able to distinguish akathisia and tardive dyskinesia. The authors review the literature on akathisia and tardive dyskinesia in an attempt to understand the basis for this diagnostic confusion. They suggest six areas of inquiry which may help in distinguishing the two disorders: (1) the nature of the subjective distress, (2) the voluntary or involuntary nature of the movements, (3) the time of onset of the disorder, (4) the location of signs and symptoms, (5) the presence of other extrapyramidal symptoms, and (6) the response to pharmacologic interventions. In addition to diagnostic confusion, the literature review suggests an association between akathisia and tardive dyskinesia. Because this association is poorly understood, three possibilities are suggested: (1) The occurrence of akathisia may predispose to subsequent tardive dyskinesia; (2) Akathisia may evolve into tardive dyskinesia; and/ or (3) There may be a third group of disorders, distinct from akathisia and tardive dyskinesia, which the authors call tardive akathisia. Each of these possibilities are discussed.

Pharmacogenic depression among outpatient schizophrenic patients: a failure to substantiate

Impaired affect in recovering schizophrenic patients has been viewed as either an integral part of the disease, a postpsychotic depression, or, increasingly, as a pharmacogenically determined effect secondary to the use of antipsychotics. Two months following hospital discharge, operationally defined groups of “depressed” and “not depressed” drug-treated and nonrelapsed schizophrenic patients were randomly assigned to chlorpromazine or placebo and followed for 4 months. Among depressed schizophrenic patients, there was no evidence that drug either contributes to the depression or that depressive signs are primarily extrapyramidal symptom phenomena (akinesia). Equal numbers of nondepressed patients on drug and placebo manifested a subsequent postpsychotic depression.

State Mental Health Policy: Statewide Implementation of the Crisis Intervention Team Program: The Ohio Model

This column discusses ways that states can implement community-based best practices statewide, by using the crisis intervention team (CIT) model as an example. Although state mental health authorities may want to use a top-down approach to ensure uniform, high-quality implementation, programs may be more likely to succeed if they arise as bottom-up, grassroots innovations. Programs like CIT are especially challenging to implement because they involve collaboration between complex systems and affect multiple stakeholders. The column describes lessons learned in Ohio in hopes of assisting other states in implementing this and other innovations.

The Effect of Services and Stigma on Quality of Life for Persons With Serious Mental Illnesses

OBJECTIVE This study examined the effects of mental health services and stigma on self-concept and quality of life among individuals with serious and persistent mental illnesses. METHODS A broad array of inpatient and outpatient services, as well as perceptions of stigma, was assessed among 188 individuals who had been diagnosed as having serious mental illnesses. Quality of life and self-concept (that is, self-esteem and mastery) were also assessed at baseline and follow-up (approximately six months). RESULTS Receiving mental health services had an effect on changes in quality of life over time. Specifically, receiving counseling services had a positive influence on quality of life, whereas receiving inpatient services decreased quality of life. Stigma was not significantly associated with changes in quality of life over the study period. Self-esteem and mastery influenced the association between stigma and quality of life but did not influence the relationship between services and quality of life. Finally, although services had little effect on changes in self-concept, perceived stigma significantly reduced both self-esteem and mastery. CONCLUSIONS The extent to which services influenced quality of life was dependent on the type of service examined. Moreover, although the effects of services were more pronounced with respect to quality of life than self-concept, the opposite was true with respect to the effects of stigma. Efforts should be made to increase access to specific types of services, such as counseling, as well as to reduce negative perceptions of stigma that erode self-image among individuals with serious mental illnesses.

High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: an exploratory trial.

Abstract Case managers spend more time with clients with schizophrenia than any other professional group does in most clinical settings in the United States. Cognitive behavioral therapy (CBT) adapted for individuals with persistent psychotic symptoms, referred to as CBT-p, has proven to be a useful intervention when given by expert therapists in randomized clinical trials. It is currently unknown whether techniques derived from CBT-p could be safely and effectively delivered by case managers in community mental health agencies. Thirteen case managers at a community mental health center took part in a 5-day training course and had weekly supervision. In an open trial, 38 clients with schizophrenia had 12 meetings with their case managers during which high-yield cognitive behavioral techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale, which was independently administered at baseline and end of intervention. Secondary outcomes were dimensions of hallucinations and delusions, negative symptoms, depression, anxiety, social functioning, and self-rated recovery. Good and poor clinical outcomes were defined a priori as a 25% improvement or deterioration. t-Tests and Wilcoxon’s signed-ranks tests showed significant improvements in all primary and secondary outcomes by the end of the intervention except for delusions, social functioning, and self-rated recovery. Cohen’s d effect sizes were medium to large for overall symptoms (d = 1.60; 95% confidence interval [CI], −2.29 to 5.07), depression (d = 1.12; 95% CI, −0.35 to 1.73), and negative symptoms (d = 0.87; 95% CI, −0.02 to 1.62). There was a weak effect on dimensions of hallucinations but not delusions. Twenty-three (60.5%) of 38 patients had a good clinical result. One (2.6%) of 38 patients had a poor clinical result. No patients dropped out. This exploratory trial provides evidence supportive of the safety and the benefits of case managers being trained to provide HYCBt-p to their clients with persistent psychosis. The benefits reported here are particularly pertinent to the domains of overall symptom burden, depression, and negative symptoms and implementation of recovery-focused services.

Diversity in Case Management Modalities: The Summit Model

Though ubiquitous in community mental health agencies, case management suffers from a lack of consensus regarding its definition, essential components, and appropriate application. Meaningful comparisons of various case management models await such a consensus. Global assessments of case management must be replaced by empirical studies of specific interventions with respect to the needs of specific populations. The authors describe a highly differentiated and prescriptive system of case management involving the application of more than one model of service delivery. Such a diversified and targeted system offers an opportunity to study the technology of case management in a more meaningful manner.

Crisis Intervention Team (CIT) Programs in Rural Communities: A Focus Group Study

The Crisis Intervention Teams model (CIT) was originally developed as an urban model for police officers responding to calls about persons experiencing a mental illness crisis. Literature suggests that there is reason to believe that there may be unique challenges to adapting this model in rural settings. This study attempts to better understand these unique challenges. Thematic analysis of focus group interviews revealed that there were both external and internal barriers to developing CIT in their respective communities. Some of these barriers were a consequence of working in small communities and working within small police departments. Participants actively overcame these barriers through the realization that CIT was needed in their community, through collaborative efforts across disciplines, and through the involvement of mental health advocacy groups. These results indicate that CIT can be successfully implemented in rural communities.