Concordance of multiple assessments of the outcome of schizophrenia. On defining the dependent variable in outcome studies.

Concordance of multiple assessments of the outcome of schizophrenia are examined from (1) concordance of three different assessments of mental status, and (2) concordance of four different dimensions of outcome. Findings are related to the methodological issue of defining the dependent variable in outcome studies. When the assessment instruments were compared, discordance in overall assessment happened because each instrument taps varying aspects of symptomatology, suggesting that outcome is somewhat instrument-related. Although adjustment in mental status is correlated with social adjustment and role performance, a patient's status at follow-up bears little relationship to rate of rehospitalization or to consumer satisfaction with treatment. A differential impact of the same predictor variables on four dimensions of outcome underscores the discordance in multiple assessments. Since treatment outcome is multifaceted and multidertermined, multiple assessments must continue as vital procedures.

The concept of prevention in psychiatry: a reexamination.

We examine current concepts of prevention and offer a new approach. Prevention has different meanings and functions in the four major task areas of psychiatry: (1) medical tasks, (2) rehabilitative tasks, (3) social control tasks, and (4) humanistic tasks. Constructs of primary and secondary prevention are most useful in the medical task area. However, efforts at primary prevention of mental illness can have only limited effectiveness when we know so little about etiology. Secondary prevention is central to the medical caring tasks, where early diagnosis and treatment may lead to successful outcome. Tertiary prevention of disease and primary prevention of developmental defect are the work of the rehabilitative task area. The application of models of prevention in the social control and humanistic task areas has led to serious confusion.

The impact of national health insurance on the tasks and practice of psychiatry.

Psychiatry, like all professions, is strongly affected by changes in societal expectations and economic forces. Changes in professional priorities and patterns of patient care will undoubtedly be brought about by national health insurance. Two major types of national health insurance have been proposed: comprehensive health insurance and catastrophic insurance. We do not anticipate major impact on psychiatric tasks from some form of catastrophic insurance. Comprehensive health insurance would shape and change psychiatric practice. An examination of psychiatric tasks provides a framework for anticipating alterations in practice. We identify four major task areas in psychiatry: (1) medical tasks, (2) reparative tasks, (3) social control tasks, and (4) humanistic tasks. These tasks would be differentially influenced. Psychiatry's medical tasks will be stressed, while funding for many reparative tasks may be limited. The care of the severely ill patient may be fragmented because of problems in integrating medical and rehabilitative services.

Treatment of secondary depression in schizophrenia. A double-blind, placebo-controlled trial of amitriptyline added to perphenazine.

The combination of antidepressants and neuroleptics has been widely recommended and commonly used clinically for the schizophrenic patient who becomes depressed. However, the value of the combination for these patients has not been clearly demonstrated. This report presents results of a double-blind, randomized, placebo-controlled clinical trial designed to evaluate the combination of perphenazine and amitriptyline hydrochloride with that of perphenazine alone in the treatment of 35 ambulatory chronic schizophrenic patients in whom depressive symptoms developed. Results showed that the addition of amitriptyline to perphenazine, when compared with perphenazine alone, was more effective in reducing symptoms of depression after four months of treatment, but less effective in reducing thought disorder. The study concludes that the value of adding an antidepressant to the usual neuroleptic in the treatment of secondary depression in schizophrenia should be reviewed.

Medical practice in organized settings. Redefining medical autonomy.

Physicians are perplexed by the ongoing erosion of their individual professional autonomy. While the economic forces underlying such change have received much attention, the evolution of new organizational forms that modify and often diminish medical autonomy is less well understood. The practice of medicine is becoming more organized and more hierarchical. We emphasize the importance of organized medical groups, including the medical staff organization, as structures for appropriate peer monitoring, and for counterbalancing the burgeoning influence of governance and administrative constraints on practice. There is an ongoing tension within organizations between management, governance, and physicians. Over time one or another of these groups achieves some measure of dominance, but good management requires a balance of power. The role of the medical staff, which is poorly represented in some health care institutions and under threat in others, is considered. In general, we find that medical work is becoming more hierarchical, and that physician "leaders" do not substitute for collegial processes.

Characterization of schizophrenic patients who commit suicide.

Twenty schizophrenic patients who committed suicide were compared with a randomly selected group and a sex-matched group of nonsuicidal schizophrenic patients and with a group of nonschizophrenic patients who committed suicide. The schizophrenic patients who committed suicide were more often men, and tended to be young, never married, non-Protestant, and white. They failed to communicate their suicidal intent directly, used highly lethal suicide methods, and tended not to have undergone stressful life events associated with their suicides. A thorough, case-by-case clinical assessment of potential suicidal ideation is essential with schizophrenic patients.

Conceptual and methodological issues in the comparison of inpatient psychiatric facilities.

The authors compared the length of stay of acute admission patients at a mental health center and a nearby state hospital. The two facilities had significantly different length of stay distributions; the mean was not an adequate index to describe these patterns. Despite careful matching, patients at the state hospital were more disabled. Different patient characteristics were associated with length of stay at the two facilities, and these were also characteristics on which the patient populations differed at admission. The authors conclude that comparisons of hospitals, for example, on mean or median length of stay can be misleading unless the different functions, policies, and constraints of the facilities are taken into account.

Economics of practice and inpatient care.

The nature and structure of inpatient psychiatric services are rapidly evolving. This article identifies and explores how these changes are being influenced by four interrelated areas: rapid growth in general and private hospital psychiatric practice; increased connections of public, private, and voluntary sectors of care; the emergence and quick acceptance of capitated and managed care programs; and dramatic change and growth in the insurance industry. These four interrelated areas further the development of a two-tier system in psychiatry: one for those with insurance, and one of the poor and the severely disabled. The changes in these four areas have also led to greater demand for increased economic competition among services, and new alliances and innovations in the delivery of treatment. This article discusses how the four areas have combined to support a two-tier system and how they are likely to affect the future evolution of general and private hospital inpatient psychiatric practice.

Emergency physicians' ratings of alcoholism treaters.

The purpose of this study is to identify treaters whom emergency physicians perceive to offer effective treatment of alcoholism. A random sample of 2,500 emergency physicians received a questionnaire comparing attitudes toward Alcoholics Anonymous (AA) and professional alcoholism treaters. Physician agreement on the efficacy of alcoholism treaters was greatest for AA (87%), moderate for mental health professionals (including psychiatrists and psychologists, 55%) and least for physicians and surgeons (excluding psychiatrists, 23%; chi-square = 1,024, p = .000000005, df = 2). Physician education about other alcoholism treaters may be necessary if all types of treatment are to be considered for the emergency room patient.

A framework for the analysis of theoretical and therapeutic approaches to schizophrenia.

IN previous work we have begun to articulate a conception of psychiatry as a profession and to show how this conception may be useful in examining specific controversial issues such as national health insurance and the concept of prevention in psychiatry (Astrachan, Levinson, and Adler 1976; Adler, Levinson, and Astrachan 1978). We define a profession not in terms of its varied theories or forms of practice, but in terms of the major tasks it must perform and the perspectives it takes regarding these tasks. Historically, psychiatry has been committed to four major tasks. These interconnected tasks have been sanctioned by society, and all must be addressed if psychiatry is to retain its credibility and legitimacy. In practice, the tasks frequently are intertwined, yet they are conceptually distinct. In the present paper, we use this conception of psychiatry as a framework for the analysis of the many approaches that have been taken to the understanding and treatment of schizophrenia. Each task is defined in terms of a problematic condition to be controlled or eliminated: illness, defect, deviance, impeded growth. The rationale for work on each task is given by a corresponding theoretical perspective. There is marked disagreement, and often bitter controversy, about the validity of different theories, the value of different treatments, and even the legitimacy of various approaches. Let it be clear, then, that our goal is not to evaluate specific concepts and techniques, nor to argue that one task or perspective is more legitimate than any other. Our goal, rather, is to clarify the nature of the disagreement and to present a comprehensive framework within which different approaches to schizophrenia can be understood and compared and then reconnected in practice.