Paul R. Raffoul

Intentional Prescription Nonadherence (Noncompliance) by the Elderly

Prescription drugs are not always taken as directed. When there is a discrepancy between the use of a drug and the prescription directions, the drug‐taking behavior is considered “nonadherent.” To determine the extent of prescription nonadherence by old persons and the reasons for nonadherence, an in‐home survey was made of 111 elderly subjects who were taking prescription drugs. Drug‐taking behavior was compared with the behavior implied by the prescription instructions, and reasons for the differences were sought. Of the study sample, 43 per cent showed such differences in use of one or more prescription drugs. The chief type of discrepancy was underuse (90 per cent of nonadherence). No difference was observed in most of the psychosocial variables studied between those who took drugs as directed and those who did not. Hypertensive subjects did not differ from those without hypertension. A large proportion of nonadherence (73 per cent) was intentional. Intentional nonadherence was more likely to occur in subjects who used two or more pharmacies and two or more physicians. Traditional efforts aimed at reducing the incidence of forgetting to take medicines would not seem to be helpful in cases of intentional nonadherence.

Designing Student Work Groups for Increased Learning: An Empirical Investigation

Abstract Although instructors traditionally have used student group projects as an educational tool, little guidance is available to faculty on how to establish groups to maximize student learning. The study reported in this article examined 97 graduate students to identify relevant antecedent, structural, and process variables that would affect student group learning. The findings indicate that method of group selection, initial preference to be in a group, and level of interpersonal conflict are significantly associated with learning. The authors present implications for faculty interested in helping students learn to work in task groups, to learn from each other, and to learn about the course content.

Privatization and the Rise and Fall of the Public Mental Health Safety Net

When not neglecting or jailing them, American states have attempted in various methods and degrees to provide care for persons with mental illnesses. Throughout our history the states have developed policies providing a safety net of basic clinical services for those persons with severe and persistent mental illness who could not purchase (or whose families could not provide) needed care. Our level of commitment has varied dramatically depending on political and economic factors. The nature of the safety net has been shaped by the level of treatment technology avail-

DRUG USE AMONG OLDER PEOPLE: AN INTERDISCIPLINARY CURRICULUM PARADIGM

The results of a pilot study demonstrated the need for more content about drug use among the older population for health care professionals. The authors share their experiences in developing, teaching, and evaluating an interdisciplinary graduate course on the use and misuse of prescription and proprietary drugs. The course content, which includes a topical outline, bibliography, and a model for interdisciplinary group education, is provided to assist educators in the development of similar curricula for students and practitioners in the health care professions.

Book Review: THE INSIDER'S GUIDE TO MENTAL HEALTH RESOURCES ONLINE, John M. Grohol, Psy.D. New York: Guilford Press, 1997. 275 pp.

Few would deny the impact that managed care and other financial reforms have had on the American health care system. The changes are especially dramatic in the mental health field, as community mental health clinics nationwide experience decreases in revenue and employees, along with simultaneous increases in caseloads and severity of patients’ illnesses. Doctors Lazarus and Sharfstein have assembled a wide ranging and knowledgeable set of contributers to discuss these changes and strategies to confront them. Born from a 1994 joint meeting of the APA’s Managed Care and Ethics Committees, this book provides both theoretical and practical approaches to this increasing crisis in mental health delivery. The first of the book’s four sections addresses the history of how medical care has been reimbursed over the past 30–40 years. It traces the roots of managed care in economic, political, and social terms, explaining how each sphere influenced the development of our current system. It also explores the positive and negative effects of these roots. The book moves quickly into a second and more lengthy section discussing psychiatrists’ roles in managed care systems. Separate chapters address the clinical and administrative changes that have come with managed care systems. The authors provide practical advice on what roles are appropriate, and which should be avoided (e.g., how to safely and effectively provide medication management for a patient receiving therapy from a nonpsychiatric clinician). An additional chapter discusses the problems faced by private practitioners, and presents data suggesting that fee for service systems provide better care and produce better patient satisfaction than managed care systems. The third section discusses how managed care has changed the context in which psychiatry is now practiced. The first chapter in this section discusses how academic psychiatry and psychiatric training have changed, and makes suggestions for overcoming obstacles created by managed care (e.g., how to make resident delivered services reimbursable). The section then expands to an interesting discussion on the philosophical and ethical changes in psychiatrists’ roles, including informed consent/confidentiality issues, financial issues, and the conceptualization of quality of care. The book’s fourth section comes full circle, revisiting the history and transformation of American psychiatry by managed care in greater detail, and points to the origins of the previous sections’ issues. In addition, it discusses the changes from a business/organizational perspective, providing further insight into how the current system of care developed. In short, New Roles for Psychiatrists in Organized Systems of Care provides a concise overview of the forces that created our current climate of health care delivery, the problems it has created, and possible solutions to them. As may be expected from a book written and published by physicians, its underlying tone suggests the importance