Medication treatment for the severely and persistently mentally ill: the Texas Medication Algorithm Project.

This article provides an overview of the issues involved in developing, using, and evaluating specific medication guidelines for patients with psychiatric disorders. The potential advantages and disadvantages, as well as the essential elements in the structure of algorithms, are illustrated by experience to date with the Texas Medication Algorithm Project, a public-academic collaboration. Phase 1 entailed assembling research findings on the efficacy of medications for schizophrenic, bipolar, and major depressive disorders. This knowledge was evaluated for its quality and relevance, integrated with expert clinical judgment as well as input by practicing clinicians, family advocates, and patients. Phase 1 (the design and development of the algorithms) was followed by a feasibility test (Phase 2). Phase 3 is an ongoing evaluation comparing the clinical and economic effects of using specific medication guidelines (algorithms) versus treatment as usual in public sector patients with severe and persistent mental illnesses.

Texas Medication Algorithm Project: definitions, rationale, and methods to develop medication algorithms.

BACKGROUND: The Texas Medication Algorithm Project (TMAP), a public-academic collaborative effort, is a 3-phase project to develop, implement, and evaluate medication treatment algorithms for public sector patients with schizophrenia, major depressive disorders, or bipolar disorders. DISCUSSION: This paper, the first in a series describing the activities of the TMAP, focuses on the various definitions and reasons why guidelines have gained popularity. Also discussed are their strengths, the limitations of the various methods used to develop them, and potential barriers to their implementation.

Consensus guidelines in the treatment of major depressive disorder.

The number of available antidepressant medications has increased dramatically in the last 10 years. Furthermore, no single medication is a panacea for all depressed patients-a fact underscored by randomized, controlled trial evidence showing that when one medication fails, an alternative may succeed. Thus, a key issue in the treatment of depression is how to optimally orchestrate available medication options to maximally benefit the greatest number of patients most rapidly. One approach is the use of consensus guidelines or medication algorithms. This paper discusses the rationale for and critical issues in the development of medication algorithms, and the timely use of symptom measures to ensure proper implementation. Once developed, guidelines must be appropriately implemented by clinicians, adhered to by patients, and supported by administrators. These three stakeholder groups often need education, incentives, and ongoing support to implement such guidelines. Whether guidelines actually improve outcome is largely uninvestigated, although a recent study of depressed patients in primary care found that using guidelines did improve outcome but at an increased treatment cost. The clinical and economic impact of guideline-driven treatment for the severe and persistently depressed deserves study.

Developing clinical work processes in a state psychiatric hospital: a case study.

The Texas Department of Mental Health and Mental Retardation applied the continuous quality improvement (CQI) concept of work process to the delivery of clinical services in each of its eight state psychiatric hospitals. Two different clinical processes were involved: (1) individualized psychiatric treatment and (2) medical treatment. The processes were then benchmarked against national leaders in the delivery of public psychiatric hospital services. This case study demonstrates the applicability of the work process concept to a clinical environment where it can function as a management tool that can significantly improve the quality and efficiency of services provided to individual patients.

Total quality management strategies in mental health systems.

This paper introduces the concept of total quality management (TQM) to top managers of mental health systems. While TQM is a philosophy of management at the cutting edge of U.S. business, it has only recently entered the vocabulary of health care managers. To our knowledge, TQM has yet to be systematically applied to the state mental health service delivery system. After introducing some key concepts and techniques, we develop two extensive examples of how TQM can be integrated into the already existing management structure of the psychiatric hospital.

Effect of increased space on the social behavior of institutionalized profoundly retarded male adults.

The social behavior of a group of institutionalized profoundly mentally retarded male adults was observed under conditions of increased space. The findings demonstrated that an increase in space of 29 percent significantly reduced the frequency of aggressive acts occurring within the group. Also observed was the effect of increased space on the residents' mobility and nonaggressive interactions. Results were discussed in relation to the residents' need for space.

Stability of territorial and aggressive behavior in profoundly mentally retarded institutionalized male adults.

Previous research has documented that institutionalized profoundly retarded male adults are territorial and aggresive. The present study represents a follow-up on the same group of males. Results demonstrated that the behavior initially observed remained highly stable across the 19 months since the previous study.

Eye gaze and dominance hierarchy in profoundly mentally retarded males.

Previous research on gaze aversion has suggested that avoiders are communicating subordinance in the social interaction. A study on aggression in profoundly mentally retarded persons provided the objective measure required to determine the relationship between duration of eye gaze and ranked position in a social group's dominance hierarchy. Results indicated that submissive individuals maintained significantly longer eye contact as contrasted with dominant individuals. Implications of the findings were discussed.

Identifying profoundly mentally retarded subtypes as a means of institutional grouping.

While the profoundly mentally retarded social group is behaviorally heterogeneous, this knowledge appears to be of more theoretical than practical interest. The behavioral identification of functional profoundly retarded subtypes derived from ethological analysis may supply the structure necessary to utilize this behavioral variability. Institutional groupings based on dominant and subordinate subtypes may prove to be efficacious in increasing programming efficiency. A study of profoundly retarded persons' territoriality was discussed as it relates to new grouping procedures based on behaviorally identified subtypes. Implications with respect to the control of aggression, stereotypic activity, and behavior modification for functional subtypes were discussed.