Wesley Sowers

Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity.

The financing of mental health care services hasundergone significant change in the past several years,with increasing emphasis on resource management. Thisemphasis has raised concerns among consumers and providers of services that needed resourcesare often withheld. In order to address this issue, theAmerican Association of Community Psychiatrists (AACP)developed an instrument designed to maintain balance between quality care and the wise useof resources. The Level of Care Utilization System forPsychiatric and Addiction Services (LOCUS) evaluatesclients along six dimensions and defines six levels of resource intensity. It also provides amethodology to facilitate rapid and consistent level ofcare recommendations. This paper describes thecircumstances leading to the creation of LOCUS and theprinciples used to guide its development. It thendescribes preliminary reliability and validity testingdesign and outcome. This initial testing indicates thatLOCUS can facilitate consistent placement of clients in psychiatric or addiction services and doesso in a manner which trends in a pattern similar to therecommendations of clinicians who are naive to LOCUSassessment and placement methodology.

A Four Factor Model of Systems-Based Practices in Psychiatry

A Four Factor Model of Systems-BasedPractices in PsychiatryJules M. Ranz, M.D., Michael Weinberg, Ed.D.Melissa R. Arbuckle, M.D., Ph.D., Joanna Fried, M.D.Anthony Carino, M.D., Hunter L. McQuistion, M.D.Glen Davis, M.D., Donovan Wong, M.D.Sosunmolu O. Shoyinka, M.D.Benjamin Brody, M.D., Kamala D. Sethi, M.D.Anna Skiandos, D.O., Wesley Sowers, M.D.David Stern, M.D., Anne Sullivan, M.D.Michael J. Vergare, M.D.

Public Psychiatry Fellowships: A Developing Network of Public-Academic Collaborations

In response to the expanding public behavioral health care system, a network of 15 public-community psychiatry fellowships has developed over the past six years. The fellowship directors meet yearly to sustain and develop fellowships to recruit and retain psychiatrists in the public sector. This column describes five types of public-academic collaborations on which the fellowships are based. The collaborations focus on structural and fiscal arrangements; recruitment and retention; program evaluation, program research, and policy; primary care integration; and career development. These collaborations serve to train psychiatrists who will play a key role in the rapidly evolving health care system.

Level-of-Care Determinations in Psychiatry

&NA; Clinicians often agonize over decisions related to whether their clients should be admitted to or discharged from a program. The nature of this conflict has changed drastically over the past several years, but the problem remains a central issue for those providing care.

Recommendations for Primary Care Provided by Psychiatrists

Recent studies have shown that people with severe mental illness have a dramatically lower life expectancy than the general population. Psychiatrists have not traditionally been very attentive to or involved with physical health issues and there has been growing emphasis on integrated care for physical and mental health and access to primary care for all members of the population. This paper examines the role of psychiatrists in the provision of primary care to the patients they treat. Some recommendations are offered for their involvement in the provision of primary care at three levels of complexity: Level 1—Universal Basic Psychiatric Primary Care; Level 2—Enhanced Psychiatric Primary Care; and Level 3—Fully Integrated Primary Care and Psychiatric Management. Some of the obstacles to the provision of primary care by psychiatrists are considered along with some suggestions for overcoming them.

Transforming Psychiatry: A Curriculum on Recovery-Oriented Care.

The concept of recovery in substance use disorders care is well known in the medical world and psychiatric community. The recovery-oriented approach to mental health care has more recently become prominent. It emphasizes a strong therapeutic relationship between the mental health professional and the person seeking care and focuses on hope, strengths, shared decision-making, and personalized plans for goal achievement. It is based on the notion that all people with psychiatric challenges have abilities and capacities that other treatment approaches have not always recognized [1, 2]. People in recovery have become leaders in the mental health advocacy community and have been on the vanguard of integrating a recovery focus in helping people with mental illness. In 2009, the Substance Abuse and Mental Health Services Administration (SAMHSA) established an initiative on recovery-oriented mental health care as a transformative effort in mental health professional disciplines. The Recovery to Practice initiative involved a 5-year project to develop and implement curricula in six discipline areas, including psychiatric nursing, addiction counseling, psychology, social work, peer support, and psychiatry. An advisory group formed to guide this process was comprised of a diverse group of thought leaders including mental health professionals and people with lived experience of mental illness and substance use. This paper chronicles the development of the RecoveryOriented Care in Psychiatry curriculum and its meaning for the field. But first we take a brief look back at some of the history of the field of psychiatry. The psychoanalytic or psychodynamically oriented practice that dominated the mid-twentieth century has now given way to predominantly biologic approaches with pharmacotherapy at the center of treatment. Starting in the 1950s, a variety of social and economic forces coalesced resulting in deinstitutionalization—an abrupt transition from primarily state hospital care to community-based care. As individuals with mental illness were released from hospitals, they faced daunting challenges due in large part to inadequate funding, lack of community support, and a poorly developed community mental health system. Limited treatment, without related supports and living skills, often resulted in repeated crises, revolving door hospitalizations, incarceration, homelessness, substance use disorders, and increased vulnerability to physical illness [3]. It was during this time that former hospital “patients” took the initiative and began meeting in their communities to provide each other with support and advocate for more control over decisions about their mental health treatment [4]. Advocacy organizations have been persistent in their demands for system change including a larger role in determining the kind of care people with mental illness receive. Over the years since, there has been an expansion of community resources in most areas and the principles and practices of psychiatric rehabilitation gradually developed to meet these demands. Psychiatric rehabilitation helps individuals learn skills for daily living, interpersonal interactions, education, and employment to enhance their ability to live in the community successfully [3]. * Deborah Cohen dcohen@psych.org

Parallel process : Moral failure, addiction and society

Recent legislation restricting disability and other financial benefits for persons with substance related disorders provides the latest chapter in this countrys relationship with mind altering chemicals and its attempts to control their use. Whether seen from the perspective of a substance user or from that of an angry and insecure public, this relationship seems to lead inevitably to self-destructive processes. This paper will examine the historical context of drug control policy in this country and the impact of current policy on vulnerable populations and on society as a whole. Parallels between factors which drive addictive disorders and those that perpetuate ineffective public policy will be considered along with their moral implications.

Psychological and Psychiatric Consequences of Sedatives, Hypnotics, and Anxiolytics

The use of substances to induce sedation has a long history, even when alcohol is not considered. As early as the mid 19th century, production of agents designed for this purpose began with the introduction of bromide. Paraldehyde, chloral hydrate, urethan, and sulfonyl were also introduced prior to the beginning of the 20th century. Barbiturates dominated the early part of this century after their introduction in 1903, and up to 50 compounds in this class were eventually brought to market (Allgulander, 1986; Janicak, Davis, Preskorn, & Ayd, 1993). The benzodiazepines became available in the 1960s and their use and popularity grew steadily over the next 20 years. The benzodiazepines have now largely replaced barbiturates and other sedatives introduced around mid-century, such as methaqualone, meprobamate, ethchlorvynol, and glutethimide, for most therapeutic uses (Rosenbaum & Gelenburg, 1991; Smith & Seymour, 1991; Sternbach, 1993). This has been due largely to their relative safety (high lethal-therapeutic ratio) and an initial perception that they had a lower potential for misuse and physical dependence. It gradually became clear, however, that a dependence syndrome can be produced in some individuals within a short period of time. As these medications have been prescribed more liberally, there has been significant public concern about their level of use and misuse in society (Lader, 1991; Smith & Seymour, 1991).

Reis’s Pieces: Love, Loss, and Schizophrenia

T is the second novel by Karen Winters Schwartz, an activemember of the National Alliance on Mental Illness and a long-time advocate for mental health awareness. In it she tells the story of a man whose life is altered by the late onset of psychotic illness. As the subtitle implies, it recounts the losses that preceded it and those that resulted from it and, yes, an unlikely love story. Reis Welling is a somewhat precocious professor of botany at Cornell University. He has always been a lover of nature and absorbed by his studies, which have allowed him to advance rapidly in the academic world but have also kept him from developing a very broad social life. Through one of his colleagues, he is introduced to and subsequently falls in love with a less brilliant, but more extroverted young woman on the faculty of another department, who shares his love of nature and hiking. So things are looking pretty good for him until he begins to experience psychotic symptoms, which are worsened by the unexpected death of his father, with whom Reis was quite close. Reis’ fiancé does not understand his grief and is unable to endure his changes and begins to separate from him. Following a suicide attempt, Reis is hospitalized, stabilized, and returned to his hometown community, where he struggles to find a new life. He takes a low-level job in a local library and reluctantly ingests the pills his psychiatrist urges upon him. He feels alienated and observes the community clandestinely, often perching in one of the trees of the public park. One day he startles a young woman and her dog when she encounters him in such a position and has a brief, awkward conversation with her before they part. Although this woman is nearly engaged to a man who is successful and handsome, if somewhat preoccupied with himself, she becomes slightly obsessed with Reis and seeks him out at the library where he works. Thus begins a relationship that endures despite various tribulations faced over the next year and for which she abandons her previous partner. Notwithstanding periods of symptomatic relapse, self-doubt, selfpunishment, and suicidal obsessions, the book ends happily. Critics may find fault with the authenticity and plausibility of certain aspects of the plot and the characters, as well as the portrayal of the illness with which Reis is afflicted and the psychiatrist who treats him. They would probably be justified in doing so, but admirers of the book would counter that the author’s underlying objective is a consideration of the stigma, both internal and external, that accompanies psychotic illness and the portrayal of one man who learns to overcome it and reestablish a satisfying and full life. The author portrays the hope of redemption despite overwhelming challenges. Some psychiatrists will enjoy this book, and persons affected by mental illnesses and their family members will likely appreciate it more. Dr. Sowers is director of the Center for Public Service Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh.

Cultural Issues, Recovery-Focused Care in Spotlight at This Year’s IPS

Multiple sessions at next month’s Institute on Psychiatric Services will focus on aspects of recovery, and an OMNA on Tour track will explore trauma-informed care and racial issues in mental health.