Case management in psychiatry: an analysis of tasks.

OBJECTIVE: The authors analyze the concept of case management from the perspective of the task areas of psychiatry and demonstrate the importance of case management in the organization of psychiatric services. METHOD: The relevant literature was reviewed, and a functional analysis of current practices is provided. RESULTS: Case management is an ambiguous concept without a clear base in a professional discipline, and thus there is ongoing uncertainty about its mission, practice, and training, as well as authority and accountability issues. The activities of the case manager in both the private and the public sectors entail work in the task areas of medical care, rehabilitation, social control, growth and development, and social welfare. In all of these areas, the case manager may function in boundary management and in system enhancement and development as well as provide clinical services. CONCLUSIONS: Case management has considerable potential as a means of organizing and delivering mental health services in a cost-effective manner as long as its purpose, practice, and organizational structures are consistent. Psychiatrists should be involved in the organization of case management services.

Day hospital/crisis respite care versus inpatient care, Part I: Clinical outcomes.

OBJECTIVE: The authors investigated the clinical feasibility and the outcome for patients of a program designed as an alternative to acute hospitalization. METHOD: This was a random-design study comparing a conventional inpatient program for urban, poor, severely ill voluntary patients who usually require hospitalization to an alternative experimental program consisting of a day hospital linked to a crisis residence. Patients were assessed with standardized measures of symptoms, functioning, social adjustment, quality of life, and satisfaction with clinical services upon admission to the study, at discharge from the index admission, and at follow-ups 2, 5, and 10 months after discharge. RESULTS: One hundred ninety-seven patients were enrolled in the 2-year research program and followed for 10 months. Of the voluntary patients who would have been admitted to the hospital, 83% were appropriate for the experimental program. The clinical, functional, social adjustment, quality of life, and satisfaction outcome measures were not statistically different for the patients in the two treatment conditions; however, there was a slightly more positive effect of the experimental program on measures of symptoms, overall functioning, and social functioning. CONCLUSIONS: The experimental condition, a combined day hospital/crisis respite community residence, seems to have had the same treatment effectiveness as acute hospital care for urban, poor, acutely ill voluntary patients with severe mental illness.

Working memory, attention, and communication disturbances in schizophrenia.

The authors hypothesized that schizophrenic communication disturbances reflect specific cognitive deficits in the areas of working memory and attention. They examined the cognitive correlates of communication disturbances, as measured by linguistic reference performance, in schizophrenic (n = 48), bipolar (n = 24), and nonpsychiatric control (n = 23) individuals. Reference performance ratings in the schizophrenic patients were associated with scores on tests of working memory and attention and were not related to performance on concept formation or verbal fluency tests. In contrast, in the bipolar and nonpsychiatric individuals, reference performance was associated with concept formation and verbal fluency test scores but was not related to performance on tests of working memory. Implications with respect to the processes underlying schizophrenic communication disturbances are discussed.

Normative implications of the relationship between reading vocabulary and Boston Naming Test performance.

The 60-item Boston Naming Test (BNT) was published in 1983 with norms described as provisional. One recent finding (Thompson & Heaton, 1989) suggests that verbal intelligence, and the Wechsler Adult Intelligence Scale (WA1S)-Revised Vocabulary subtest, in particular, is strongly correlated with BNT performance, and that education is moderately so. High false-positive rates for naming deficit may conceivably result from the application of the published norms with subjects of lower verbal abilities or limited educational backgrounds. To further explore the relationship of naming to other verbal abilities, analyses were undertaken of the correlations between Level 7-9 Gates-MacGinite Reading Vocabulary Test (G-MRVT) and BNT data from 97 schizophrenic, bipolar, and normal subjects. Reading vocabulary is strongly correlated with BNT performance, and the nature of this relationship is essentially the same across the three diagnostic groups. Application of the published norms would have resulted in a high false-positive rate for naming deficit in all groups among subjects with reading vocabularies equivalent to twelfth grade or less. As a word-recognition based reading exercise, the G-MRVT is likely to provide a brain-compromise-resistant index against which the adequacy of naming performances can be assessed. Accordingly, G-MRVT based BNT performance expectation guidelines are presented for use as a complement to the published norms. Other implications are discussed.

Differences in social environment between inpatient and day hospital-crisis respite settings.

OBJECTIVE: The study compared the social environment of a conventional psychiatric inpatient setting with that of a combined acute day hospital and crisis respite program that functions as an alternative to hospitalization for patients judged appropriate for acute inpatient admission. METHODS: As part of a randomized controlled study comparing the clinical effectiveness and cost-effectiveness of the two settings, the quality of the social environment in the two settings was assessed using the Multiphasic Environmental Assessment Procedure, an empirical measure of established reliability and validity that is based on objective ratings and perceptions of staff members and patients. RESULTS: Compared with the inpatient setting, the day hospital-crisis respite program had higher expectations for patients' functioning, a lower tolerance for deviance, and more flexibility in patients' choice of activities. The day hospital-crisis respite program also had a more attractive physical environment, and respondents rated its social milieu as more cohesive, less conflictual, and more comfortable. This setting also promoted higher levels of patient functioning and activity and more utilization of health services, assistance with daily living skills, and social and recreational resources and encouraged fuller integration of patients in the community. CONCLUSIONS: The social environment of the community-based day hospital-crisis respite program embodied several principles of community support systems, including provision of treatment in a less restrictive setting, avoiding disruption of patients' ongoing involvement in the community, promoting activities in the community, offering patients respect and opportunities for self-determination, and enhancing their dignity.

"It was just realizing ... that life isn't one big horror": a qualitative study of supported socialization.

This report describes the qualitative component of a large-scale study of supported socialization. Paralleling the recent advances made through supported housing, supported employment, and supported education, this approach seeks to increase the involvement of individuals with psychiatric disabilities in naturally occurring social and recreational activities in community settings of their choice. After a review of social relationships and psychiatric disability, we describe the Partnership Project and present findings from a series of qualitative interviews conducted with a subsample of participants. We then discuss the implications of these findings for the community integration of individuals with psychiatric disabilities.

The low turning point. A control mechanism in the course of mental disorder.

Recent research has suggested that persons with severe mental disorders may have psychological control mechanisms that influence the course of their disorders. One mechanism that appears to be particularly significant is the low turning point. Based on data obtained as part of an intensive follow-along study, the low turning point process is described in this report. It is identified as involving three phases: a) an initial rigid focus on one coping mechanism for dealing with stress; b) relinquishing of that focus and decompensation; and c) reorganizing one's life more broadly. The functioning that emerges from this experience often appears to be more adaptive than that existing before its onset. Conceptual implications of this process are discussed.

Outreach workers' experiences in a homeless outreach project: issues of boundaries, ethics and staff safety.

Mental health professionals and researchers have emphasized the importance of conducting outreach to locate homeless persons with mental illness, and of creatively engaging these persons into a therapeutic relationship. These outreach and engagement activities raise challenging issues in the areas of client-staff boundaries, professional ethics, and staff safety. While several issues in each of these three key areas have received attention in the growing literature on homelessness, certain issues within each area remain unexplored. The authors draw from the street experiences of outreach staff in a federally funded homeless outreach project to further explore each of these areas, and suggest that experiences of outreach workers are essential in shaping and redefining work activities in these, and other important areas.

Distinguishing between multiple personality disorder (dissociative identity disorder) and schizophrenia using the Structured Clinical Interview for DSM-IV Dissociative Disorders.

The authors describe the systematic assessment of dissociative symptoms using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) in 50 psychiatric outpatients with a referring DSM-III-R diagnosis of either schizophrenia or schizoaffective disorder (N = 31) and subjects with multiple personality disorder (MPD [DSM-IV name change: dissociative identity disorder]; N = 19). Results indicate that patients with MPD experience significantly higher scores for five specific dissociative symptoms than patients with schizophrenia or schizoaffective disorder. The range, severity, and nature of the five dissociative symptom areas evaluated by the SCID-D distinguish MPD from the occasional occurrence of dissociative symptoms which may be seen in schizophrenia. Systematic assessment of dissociative symptoms using the SCID-D can assist in accurate differential diagnosis of MPD and schizophrenia.

Cognition, negative symptoms, and diagnosis: a comparison of schizophrenic, bipolar, and control samples.

Forty-six schizophrenic, 22 bipolar, and 26 normal control subjects were administered negative and positive symptoms scales and tests of cognitive function. Test performance was related to diagnosis and to positive and negative symptom ratings within the schizophrenic group. Bipolar patients were significantly superior in cognitive status when compared with all schizophrenic patients, but less so when compared only with those who did not have key negative symptoms (affective nonresponsivity and poverty of speech). The schizophrenic patients with negative symptoms displayed severe impairment, performing significantly worse than the control, bipolar, and other schizophrenic subjects. Negative symptoms thus are significantly implicated in the cognitive inferiority of schizophrenic to bipolar patients. Although the data suggest bipolar patients may also have cognitive deficiencies, these findings are inconclusive and require cross-validation.

Normalizing acute care: a day hospital/crisis residence alternative to inpatient hospitalization.

Normalization is the use of culturally valued means to enable people with disabilities to live culturally valued lives. In this article, the authors describe an effort to bring normalization practices to acute psychiatric care. They describe a day hospital/crisis respite diversion program that serves as an alternative to acute inpatient hospitalization and sketch the research project that fostered it. The authors argue that a day hospital/ crisis respite provides effective clinical care comparable to inpatient hospitalization but achieves greater potential for recovery through a normalizing philosophy and practice. An implication of this finding is that such programs based on the principle of normalization may be both cost effective as well as more empowering for patients.

Can digit symbol-verbal fluency comparisons facilitate detection of pseudodementia? A preliminary study.

Depressive psychomotor retardation may impair performance on timed tests. By comparison word association measures of verbal fluency are reportedly unaffected by depression. Comparisons of a brief psychomotor test with a measure of verbal fluency may therefore prove useful when there is a concern that depression may be undermining adaptive functioning, assuming both measures display: (1) broad-spectrum sensitivity to brain impairment, (2) differential vulnerability to depression, and (3) moderate correlation in nondepressed persons. Digit Symbol (DS) and the "FAS" measure of verbal fluency are sensitive to genuine dementia, satisfying the first criterion. We found that depressed schizophrenics performed at significantly lower levels on DS, but not on FAS, than nondepressed schizophrenics. The two groups differed significantly on a discrepancy score derived by subtracting FAS from DS scores; normals obtained discrepancy scores highly similar to those of nondepressed schizophrenics. As the normals had higher DS and FAS scores, this discrepancy-score similarity suggests that this index may have wide application. The third criterion is satisfied by the findings of a 0.64 correlation between DS and FAS scores adjusted for age (DS and FAS) as well as gender and educational attainment (FAS) in nondepressed samples. Implications for further research and clinical applications are discussed.