Becoming an administrator: the vicissitudes of middle management in mental health organizations.

Middle management has been a conceptually neglected and operationally abused position in the administrative hierarchy of mental health organizations. The position is viewed as a preparatory exercise for executive responsibility, and frequent changes disrupt service delivery. The author describes the responsibilities, hierarchical role relationships, rewards, and constraints of middle management positions. Health care professionals must actively seek and retain these positions if they wish to maintain their place in directing the work of mental health institutions.

The treatment of depression with ECT in the presence of brain tumor.

Traditionally, the presence of brain tumor has been considered an absolute contraindication to the use of electroconvulsive therapy. In selected cases, however, this procedure may be beneficial and at times even lifesaving. The authors point to the need for an eclectic approach to treatment, given the current state of psychiatric knowledge.

Utilization review of treatment for suicide attempters.

The authors describe an effort to develop criteria for utilization review of treatment for suicide attempters. Explicit criteria proposed by a panel of experts as essential determinants for hospitalization of these patients were compared with actual clinical practice. It was found that according to the experts' criteria (which were operationalized into rating assessments), over half of the outpatient sample should have been hospitalized. After multiple regression analysis was carried out on the criteria, however, four predictors showed that only 20 percent of the outpatients should have been hospitalized. The authors discuss the issues these findings raise about the criteria of the experts, their utility for research, their validity, and their implications for utilization review.

Bupropion in depression: a tri-center placebo-controlled study.

In a double-blind, placebo-controlled, variable-dose study of 59 hospitalized nonpsychotic depressed patients, bupropion was significantly (p less than .05 to less than .001) more effective than placebo on measures of depression, anxiety, and global improvement. Statistically significant drug-placebo differences appeared as early as day 5 of treatment and increased on subsequent assessments. In an evaluation of Baseline X Treatment interactions, bupropion was particularly more effective than placebo in those patients with more severe depression. Placebo and bupropion groups had similar frequencies and severity of side effects. Laboratory data showed minimal differences between the two treatments. The most common adverse experience was mild dry mouth (20% of patients). Compared to placebo, bupropion was found to be effective in the treatment of depression and to have a favorable safety profile.

Clinical services within a general hospital department of psychiatry: conceptual issues and operational guidelines.

This paper presents a checklist of conceptual issues and operational guidelines determining the organization of clinical services within a general hospital department of psychiatry. Issues emphasized include philosophy, target population, definition, structure, location, financing, and cost effectiveness of services, utilizing the experience of a specific department of psychiatry to illustrate their application. As the trend continues for mental health service delivery within a general hospital, recognition of these issues and their application is essential to effective service delivery.

Psychiatric crisis. A comparison of schizophrenic and nonschizophrenic patients.

Thirty-nine patients (23 nonschizophrenic and 16 schizophrenic people), who were hospitalized on a short term, crisis intervention ward, were extensively interviewed to discover whether the crisis precipitants and the crisis experience differed for the two groups. As opposed to the schizophrenic individuals, the nonschizophrenic, "distraught" patients led orderly lives and were more likely to be in problematic developmental life stages (i$, late adolescense) or to be physically ill. For the distraught patients, the precipitating events were clearer and were more likely to involve interpersonal or narcissistic loss (i.e., the end of a romance), overt anger was less likely to be expressed, and parental figures were less likely to be involved. Both the nonschizophrenic and the schizophrenic people were thought to be chronically vulnerable to external stress. A phenomenological description of their psychopathology was included to explain, in part, their vulnerability. Suggestions about treatment approaches were developed.

Clinician attitudes toward the suicide attempter.

The clinical and sociodemographic characteristics and dispositional outcome of 248 suicide attempters were studied in a general hospital emergency room. A mood adjective checklist was completed by evaluating psychiatric residents and three orthogonal factor analytically derived mood clusters were related to sociodemographic, clinical, and dispositional variables. Residents expressed warmth toward patients having low suicide risk and limited overall psychopathology. They felt anxious toward patients with high suicidal risk and significant psychopathology. Angry feelings were reported toward patients with high suicidal risk in the absence of recent precipitating events. Residents reported warmth toward patients admitted to private or mental health center vs. state hospital facilities and tended to devote more time to their clinical assessment of these patients. Feelings of anxiety and anger characterized the responses to state hospital admissions who were only briefly assessed. The findings have implications for the organization of clinical services and the training of mental health professionals. Supervision needs to be directed to the recognition and modification of therapist emotional attitudes as well as to the understanding of patient psychopathology. Clinician feelings can then be effectively utilized to "capture" a high risk, high drop-out population into effective follow-up care.

Hospital, nursing homes become partners in psychiatric care.

Hospital psychiatric staffs can effectively share their expertise with nursing homes. One hospital's psychiatric out-reach program has reduced patient management problems at participating nursing homes, improved patients and staff morale, changed staff attitudes, garnered physician support, and extended services provided by the psychiatric department.