The well-being of chronic mental patients.

The concept, "quality of life" (QOL), offers a broad perspective for assessing the needs and outcomes of chronic mental patients. In this survey of Los Angeles board-and-care homes, 278 randomly selected, mentally disabled residents evaluated their QOL in structured interviews based on a general QOL model. Life areas studied included living situation, family, social relations, leisure, work, safety, finances, and health. The model performed as well among these residents as among the general population, explaining 48% to 58% of the variance in global well-being. Adding patients' subjective QOL evaluations doubled the explanatory power of a model based only on personal characteristics and objective life conditions. Global well-being was most consistently associated with personal safety, social relations, finances, leisure, and health care variables. The study identifies methodological and service issues in need of further examination.

A randomized trial of assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses. METHODS: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations. RESULTS: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status. CONCLUSIONS: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.

First-admission psychiatric ward milieu: treatment process and outcome.

A two-year, prospective study of 123 first-admission patients examined the impact of different inpatient treatment decision-making styles on patient outcome on a therapeutic community ward and a medically oriented psychiatric ward. Ward philosophy, programmatic and administrative structure, and ward atmosphere defined the ward milieus. Data on length of stay and the use of various therapeutic modalities provided comparisons of treatment process. Standardized ratings of psychopathologic condition and levels of function, readmissions, and illness attitudes were used to assess two-year outcomes. The major finding was the absence of outcome differences despite longer lengths of stay on the therapeutic community ward. Hence, differences in ward decision-making style may not influence outcome, but may affect the process of care among diagnostically heterogeneous, first-admission patients treated in a university setting.

Biases in the laboratory diagnosis of depression in medical practice.

Several studies, conducted in psychiatric settings, have reported that the dexamethasone suppression test (ST) is useful in the diagnosis of endogenous depression. To determine whether the test has clinical utility in internal medicine practice, data were reviewed and reanalyzed from all studies that evaluated the dexamethasone ST in the diagnosis of depression. In these 11 studies, the mean positive predictive value reported for the test was 84%, reflecting high prevalence of disease (50%), sensitivity (43%), and specificity (92%) in those specialized populations studied. When estimates of the prevalence and severity of conditions associated with depressed mood seen in internal medicine were used, the sensitivity dropped to 30%, and the specificity to 85%. Assuming a prevalence of 20%, a figure based on available epidemiologic data, the predictive value for a positive test would be 33%, too low to have value in most clinical settings. Data from studies currently available do not support the use of dexamethasone ST in internal medicine practice. More generally, before any test is adopted in a general medical setting, it should be studied in that setting, or available data should be reanalyzed to correct for biases affecting prevalence, sensitivity, and specificity that may inflate the test's value.

Crimes against discharged mental patients in board-and-care homes.

A survey of 278 persons discharged from mental hospitals who were living in board-and-care homes showed that one-third of them had been victims of crime during the preceding year. In a comparison of nonvictims, victims of theft, and victims of violence, it was found that victims of violence were younger, were more active socially, reported more psychopathology and less satisfaction with their lives, and engaged in more criminal behaviors themselves than the other groups. Both victim groups used emergency mental health services more than nonvictims did during the preceding year. Strategies for future research and interventions are discussed.

Remission of substance use disorder among psychiatric inpatients with mental illness.

OBJECTIVE: The authors assessed the nature and stability of remission of substance use disorder among persons with severe mental illness at index hospitalization and at 1-year follow-up. METHOD: Consecutively admitted inpatients with severe mental illness completed the Structured Clinical Interview for DSM-III-R, Quality of Life Interview, and Addiction Severity Index at admission and 1 year later. Of the 268 patients, 70 were classified as past substance abusers in remission at baseline. Baseline characteristics and 1-year outcomes of this group were compared with those of the 109 current substance abusers and the 89 patients who were not substance abusers. RESULTS: The past abusers were significantly more likely to be women, and they consistently differed significantly from the current abusers in variables involving frequency of drug and alcohol use at baseline. During the follow-up period, the patients with current abuse at baseline were significantly more likely to have recurrences of substance use disorders and to use substance abuse services, and they had significantly more months of alcohol use and alcohol use to excess during follow-up than did the past abusers. CONCLUSIONS: Baseline and follow-up assessments suggested that a substantial proportion of severely mentally ill patients with past substance use disorders are in stable remission.

Chronic mental patients: the quality of life issue.

Quality of life issues must be addressed more vigorously in the care of chronic mental patients. In a survey of 30 large board-and-care homes in Los Angeles, 278 mentally disabled residents described their life conditions and satisfaction in eight areas: living situation, family relations, social relations, leisure activities, work, finances, safety, and health. Residents were less satisfied than the general population in most life areas, especially finances, unemployment, safety, and family and social relations (p less than .001). Of particular concern was the finding that 34% had been recent victims of crime. The results underscore the need for better social programs for these patients.

Developing an outcomes-oriented approach for the treatment of schizophrenia.

The recent introduction of new antipsychotic medications has renewed hope and expectations that outcomes for persons with schizophrenia will improve and that more attention will be given to maximizing recovery rather than mere maintenance treatment. This article provides a framework for conceptualizing the complex range of outcomes relevant to long-term treatment of psychosis and provides some examples of the relationship of treatments to this outcomes framework. This framework can be used in developing better treatment programs.

Evaluating outcomes of treatments for persons with psychotic disorders.

Advances in the neurosciences, concerns about cost containment, and a growing consumer advocacy movement are creating new hopes and challenges for the development of more effective and cost-effective treatments for persons with psychotic disorders. Using the development of new antipsychotic agents for the treatment of schizophrenia as a prototype, this article examines the assessment of outcomes of treatments for these patients. Psychotic disorders exert a broad range of negative effects on patients' lives. This requires a broad view of outcomes to assess the relative effectiveness of alternative pharmacotherapies. The outcomes of interest cover the clinical, rehabilitative, humanitarian, and public welfare domains. Most of our knowledge about the efficacy of antipsychotic agents focuses on improvements in and prevention of positive symptoms of schizophrenia. However, better antipsychotic medications must show advantages above and beyond symptom suppression. We need to know not only whether alternative medications offer advantages in these other dimensions of outcome, but also how they interact with psychosocial treatments to enhance outcomes, how effective they are with patients in usual practices settings, and how cost-effective they are relative to other treatments. A research agenda for evaluating these impacts must include longer term outcome studies that evaluate the wider range of outcomes of interest to practitioners, patients, families, and payers.

Quality of care in mental health: the case of schizophrenia.

Scientific evidence supporting the efficacy of a range of treatments for persons with schizophrenia set the stage for the recent development of evidence-based quality-of-care indicators for this disorder. On the heels of these quality indicators, research has found that treatment services for many persons with schizophrenia are inadequate. Because most of these patients receive their care under public auspices (Medicaid, Medicare, and Veterans Affairs), public health policy can exert considerable influence to address these quality-of-care problems. Publicly funded managed care could promote evidence-based care. It also could coordinate specialty and primary care to improve early detection and general medical care for persons with schizophrenia.

Measuring quality of life in a reformed health system.

"Quality of life" encompasses functional status, access to resources and opportunities, and sense of well-being. It offers a useful perspective on the value of health care, especially for chronically disabling conditions, including chronic mental illness. At least three major quality-of-life outcome assessment frameworks are available: general quality of life, health-related quality of life, and disease-specific quality of life. Choice of a framework must be driven by the intent of the services. For persons with chronic, disabling conditions, a general quality-of-life perspective is most appropriate, one that accounts not only for direct health outcomes but also for the potential social and economic effects of medical disability.

Vocational rehabilitation in schizophrenia.

Schizophrenia exacts a heavy toll on a person's capacity to work, and a variety of vocational rehabilitation interventions have been developed over the past few decades to enhance the vocational capacities of persons with this disorder. The research literature on outcomes of vocational rehabilitation during the era of deinstitutionalization for persons with schizophrenia is reviewed. Most vocational rehabilitation programs have a positive influence on work-related activities, but most have failed to show substantial and enduring impacts on independent, competitive employment. Recent advances in supported employment suggest that vocational rehabilitation offers greater promise than do transitional and sheltered employment approaches. Vocational rehabilitation intervention may also exert positive influences on such clinical outcomes as medication compliance, symptom reduction, and relapse.

Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations.

Beginning in 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientific evidence. These Treatment Recommendations, presented here in final form for the first time, are based on exhaustive reviews of the treatment outcomes literature (previously published in Schizophrenia Bulletin, Vol. 21, No. 4, 1995) and focus on those treatments for which there is substantial evidence of efficacy. The recommendations address antipsychotic agents, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, and assertive community treatment/intensive case management. Support for each recommendation is referenced to the previous PORT literature reviews, and the recommendations are rated according to the level of supporting evidence. The PORT Treatment Recommendations provide a basis for moving toward "evidence-based" practice for schizophrenia and identify both the strengths and limitations in our current knowledge base.

Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey.

To examine the conformance of current patterns of usual care for persons with schizophrenia to the Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations, the PORT surveyed a stratified random sample of 719 persons diagnosed with schizophrenia in two States. The types of treatment settings surveyed included acute inpatient programs and continuing outpatient programs in urban and rural locales. Using data from medical record reviews and patient interviews, the PORT assessed the conformance of current care with 12 of the Treatment Recommendations. The rates at which patients' treatment conformed to the recommendations were modest at best, generally below 50 percent. Conformance rates were higher for pharmacological than for psychosocial treatments and in rural areas than in urban ones. Rates of Treatment Recommendation conformance for minority patients were lower than those for Caucasians, and patterns of care varied between the two States. The findings indicate that current usual treatment practices likely fall substantially short of what would be recommended based on the best evidence on treatment efficacy. This disparity underscores the need for greater efforts to ensure that treatment research results are translated into practice.

Family interventions for schizophrenia.

This article reviews the existing evidence for the efficacy and effectiveness of psychoeducational family interventions in the treatment of persons with schizophrenia. There is substantial evidence that psychoeducational family interventions reduce the rate of patient relapse. There is suggestive, though not conclusive, evidence that these interventions improve patient functioning and family well-being. Interventions with multifamily groups that include the patient may be of superior benefit for subgroups of patients. More research is necessary to determine the critical ingredients of family interventions, to expand the groups of patients included in these studies, and to evaluate a broader range of outcomes.

Conventional antipsychotic medications for schizophrenia.

This article reviews the existing evidence for the efficacy and effectiveness of conventional antipsychotic medications in the treatment of schizophrenia. Among the issues reviewed are their efficacy for acute symptom episodes and for long-term maintenance therapy, differential efficacy among medications, the gap between research-based efficacy rates and effectiveness rates in practice, dosing strategies, and the treatment of first-episode cases. Evidence for efficacy is overwhelming for reduction of positive symptoms but quite limited for other outcomes. Effectiveness in practice may be substantially less than efficacy in clinical trials, perhaps owing to patient heterogeneity, prescribing practices, and noncompliance. First-episode patients should be treated with antipsychotic medication, but perhaps at lower dosages, with consideration of a gradual decrease or discontinuation at 6 months to 1 year.

Schizophrenia: treatment outcomes research--editors' introduction.

Considerable research over the past few decades on the nature and treatment of schizophrenia has yielded important advances to improve the outcomes of this disorder. Recent action plans, including the "Decade of the Brain," the National Institute of Mental Health (NIMH) A National Plan for Schizophrenia Research, and NIMH's report, Caring for People With Severe Mental Disorders: A National Plan of Research to Improve Services, promise major new advances over the next several years. As research advances, it is critical to ensure that patients in everyday practice receive the most effective treatments being developed. This issue of the Schizophrenia Bulletin reviews the research on outcomes of treatments for schizophrenia and lays out an agenda for available research knowledge to be translated into practice and for future research to improve outcomes.

Treatment outcomes in schizophrenia: implications for practice, policy, and research.

Outcomes research on treatments for schizophrenia has identified a number of efficacious interventions. The degree to which such scientific knowledge influences the care delivered in everyday practice depends on a large number of patient, practitioner, service system, and other social factors. The current atmosphere for change in the health care delivery system poses both risks and opportunities to improve care for persons with this disorder. Scientific knowledge about treatment outcomes must inform this rapid evolution of practice, policy, and research to ensure that effective treatments are preserved and available for all who need them and that new treatments continue to be developed, evaluated, and disseminated.

Influence of psychoactive substance use on the reliability of psychiatric diagnosis.

The interrater reliability of diagnoses made on the basis of a structured interview for psychiatric patients with and without psychoactive substance use disorders (PSUDs) was examined. Forty-seven pairs of ratings by 9 different clinical interviewers were used. Results supported 3 major findings: (a) The interrater reliability for non-PSUD psychiatric diagnoses is quite high when a subject has no diagnosable PSUD; it is lower, though still substantial, when a PSUD is present. (b) Interviewers are not aware of this and are just as certain of the accuracy of their diagnoses when a PSUD is present as when one is not. (c) Interrater reliability is moderate to substantial as to the judgment of whether, when a non-PSUD diagnosis is present, it is caused by the use of psychoactive substances. The implications of these findings for the appropriate selection of treatments for dually diagnosed patients are discussed.

Public health policy, community services, and outcomes for patients with schizophrenia.

Amidst the specter of managed care, individual mental health services are struggling to redefine their niche, consolidate with partners and provide a realistic continuum of care for persons with serious and persistent mental illness. Because of the chronicity of schizophrenia, its economic and social ramifications, the disparity in health insurance for these patients and limited resources, the development of community services has often proceeded in a fragmentary manner. Several states have well coordinated community programs with integration between private and public services. The Assertive Community Treatment (ACT) model has proved successful, although this is costly to maintain. Services that synergize optimum pharmacologic and psychosocial treatments can achieve favorable patient outcome, as evaluated across clinical, rehabilitative, humanitarian, and public welfare domains.