Mental Health Administration Research Articles

Selective serotonin reuptake inhibitors for children and adolescents.

The controlled studies of selective serotonin reuptake inhibitors (SSRIs) in pediatric psychopharmacology research lag behind the controlled studies of SSRIs in adults. As a result, widespread use of SSRIs in the treatment of child and adolescent psychiatric disorders is in stark contrast to the paucity of research data. Recent changes in the research climate (including support from the National Institute of Mental Health, the Food and Drug Administration, and industry) have encouraged well-designed SSRI studies in pediatric psychopharmacology, and will ultimately provide needed information to guide treatment. This paper reviews the best available data from pediatric SSRI trials, including 10 double-blind placebo-controlled trials, and two abstracts of open-label continuation studies of SSRIs associated with large pediatric efficacy studies. Adverse events (AEs) of SSRIs in children and adolescents are discussed in reference to available pediatric studies. Recent pharmacokinetic studies of SSRIs in children and adolescents are reviewed. Future SSRI research strategies are also discussed.

Comparing provider perceptions of access and utilization management in full-risk and no-risk Medicaid programs for adults with serious mental illness.

This article compares provider perceptions of access to services and utilization management (UM) procedures in two Medicaid programs in the same state: a full-risk capitated managed care (MC) program and a no-risk, fee-for-service (FFS) program. Survey data were obtained from 198 mental health clinicians and administrators. The only difference found between respondents in the FFS and MC sites was that outpatient providers in the MC site reported significantly lower levels of access to high-intensity services than did providers in the FFS site (p < .001). Respondents in the two sites reported similar attitudes toward UM procedures, including a strong preference for internal over external UM procedures. These findings support the conclusion that through diffusion of UM procedures, all care in the Medicaid program for persons with a serious mental illness is managed, regardless of risk arrangement. Implications for mental health services and further research are discussed.

Confronting misconduct in science in the 1980s and 1990s: what has and has not been accomplished?

In 1985, after nearly a decade of inconclusive professional response to public concern about misconduct in research, Congress passed legislation requiring action. Subsequent to this legislation, federal agencies and research universities adopted policies for responding to allegations of misconduct in research. Conferences, sessions at professional meetings, and special publications were organized. New educational initiatives were begun, many in response to a 1989 National Institutes of Health/ Alcohol, Drug Abuse, and Mental Health Administration requirement to include ethics instruction in training grants. Notwithstanding a few key unresolved issues, such as the lack of a uniform federal definition of misconduct in research, the years since 1985 have witnessed a marked change in the professional response to misconduct in research. This paper evaluates the change since 1985 from the perspective of three key goals: 1) confronting misconduct, 2) promoting integrity and 3) ensuring integrity. While significant progress has been made in achieving the first two goals, the third remains largely unaddressed. The latter is due to the fact that researchers have not been interested in studying the integrity of their own profession. It is therefore suggested that studies are needed of routine or normal research practices and their impact on integrity for use in making decisions about research conduct policy.

Action Research: From mental hospital reform in Saskatchewan to community building in California.

Abstract. Action Research was used at the Saskatchewan Hospital, Weyburn in the 1950s. The research influenced the hospital and the field of psychology. At the heart of the approach was intense collaboration between the researcher and hospital staff who were the end users of the information. Action Research is contrasted with two other models, the Academic and the Applied. Two applications of action research at Weyburn are described, followed by subsequent usage in California with consumer cooperatives and an organization for families of mental health clients. Collaboration with lay individuals changes the research process and requires trade-offs between rigour and relevance.The Saskatchewan Hospital, Weyburn provided my first opportunity to engage in action research (AR), an approach also known as action science (Argyris, Putnam, & Smith, 1985), participatory action research (Whyte, 1991) and praxis research (Honadle, 1996). There are similarities between AR and Schon's (1983) model of reflective practice, in which a person simultaneously engages in research and practice using theory as a framework while fully respecting the discrete nature of each case. AR emphasizes the practical use and dissemination of research products and builds utilization strategies into the overall research design (Ketterer, Price, & Politser, 1980). My usage can be traced back to Lewin's (1946) conception of AR as requiring the active involvement of the potential users of the information throughout the research. This is not business as usual for the researcher but a different kind of business. According to Parlee (1983), Psychological knowledge would be dramatically changed if it were consistently developed through interaction with its 'subjects' and its intended audiences instead of being developed with professional colleagues in mind and 'given away' (p. 1). AR tends to be value-driven rather than value-neutral and has several related objectives: to improve the lives of the participants (a good test of the success of AR is whether the participants are better off after the research than they were before); to advance knowledge; and to improve the practice of AR through a critical examination of the collaborative process (Sanford, 1970).Prior to coming to the Saskatchewan Hospital, I followed the conventional academic model of research. It took many years before I realized the epistemological breakthroughs made at Weyburn, not so much in content but in approach. I became aware of the assumptions underlying the academic model and how these differed from a collaborative approach. Table 1 shows three research models, the Academic, the Applied, and Action Research, as ideal types. There are hybrids and variants of each model, omitted here in the interests of parsimony.Let us travel back in time over 40 years to Saskatchewan Hospital, Weyburn. In 1957 this was one of the most intellectually exciting places in the mental health landscape. The provincial CCF (now NDP) government encouraged experimentation with new social programs. Cutting edge work was undertaken in community mental health, architectural psychology, psychedelic drugs, operant conditioning, and hospital administration. Psychologists were part of the intellectual ferment and the research done at Weyburn influenced both the hospital and the field of psychology. Ayllon's behaviour modification ward sparked interest in applied behavioural analysis in institutional settings (Ayllon & Michael, 1959) which stimulated the creation of new journals and organizations. The focus on the behavioural effects of architecture gave impetus to a new specialty of environmental psychology.With a vigorous commitment to the value of research-based knowledge, this large Kirkbride-style mental hospital, probably the largest single building between Winnipeg and Vancouver, came very close to being what Campbell (1969) called an experimenting society and Hutchins (1968) described as a questioning community. …

Managed care and medication compliance: implications for chronic depression.

An emerging trend within managed care, "disease management" (DM), will affect consumers and providers of mental health services, clinicians, and mental health administrators. Central to DM programs is the idea that particular diseases, especially chronic illnesses (including depression), can be "carved out" and managed. Pharmaceutical benefit management (PBM) firms may specialize in managing prescription benefits for employers and other managed care organizations by using DM programs. However, given what is known from the theoretical and empirical literature on adherence to medication for chronic illnesses such as depression, it is questionable whether the techniques that are used by PBMs will be effective in managing illnesses that require a multifaceted approach to care. Because the management of antidepressants may have an impact on members of vulnerable populations (e.g., the elderly), more research is required on the approaches used by PBMs and on the cost and quality of the services provided.

Consumers as mental health providers: first-person accounts of benefits and limitations.

Community support programs are increasingly establishing paid service positions designated exclusively for consumers. Project WINS (Work Incentives and Needs Study), a hybrid case management-vocational program for individuals with severe mental illness, used consumers as peer support specialists (PSSs) to supplement professional roles. Semistructured interviews were conducted with PSSs about 12 months after their employment ended. They identified substantial personal benefits specific to consumer-designated roles (e.g., a "safe" employment setting with accommodations) and general benefits from employment. Problems described were just as numerous, encompassing attitudes toward assigned peers and costs to their own well-being. Critical commentary addressed program operations (structure, supervision, and training needs) and problems in the mental health system. The authors discuss the changed sense of self that service provider roles can create for consumers and suggest that mental health administrators provide anticipatory socialization for this service innovation throughout their agencies and ongoing supports for consumers in their new roles.

Women's mental health services: a public health perspective

In this volume, authorities from around the United States and from a variety of perspectives analyze and discuss key topics in women's mental health, including empowerment, substance abuse, severe mental illness and interpersonal violence. Issues examined in the first part focus on service delivery - for example, the organizational structure of service delivery, gender and racial service disparities, and challenges women face as mental health administrators. Contributors to Part Two explore special issues and populations, including women who have survived trauma such as sexual abuse, and women with mental disorders who are in prison.

Managing Care, Not Dollars: The Continuum of Mental Health Services

Back to table of contents Previous article Next article Book Forum: ECONOMIC ISSUESFull AccessManaging Care, Not Dollars: The Continuum of Mental Health ServicesHarold J. Bursztajn, M.D., Harold J. BursztajnSearch for more papers by this author, M.D., Cambridge, Mass.Published Online:1 Jul 1998https://doi.org/10.1176/ajp.155.7.985AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail According to the authors, “Overall, this book.is a guide to setting up and using the emerging continuum of care” (p. 7). The book is well organized, in five sections prefaced by an overview entitled “Managing Care, Not Dollars.” This overview clearly sets out the authors' goals, values, and approach to managing mental health care. In the five sections that follow, the authors deliver as promised. Although not a “why” book, Managing Care, Not Dollars is a wonderful “how to” book.Section 1, Components of the Continuum, covers a range of services from office-based to acute inpatient treatment. Section 2 consists of five chapters, each focused on an at-risk population, including children and the elderly. Section 3 contains six chapters highlighting planning, administrative, educational, and research issues. This most helpful section may well become “must” reading for psychiatrists in administrative positions. It is also a useful entrée into one of the most progressive elements in the evolution of health care, which is conceptually separate from the coincidental advent of managed health care: the emergence of evidence-based medicine to support clinical decision making under conditions of uncertainty. As others have emphasized, the emergence of evidence-based medicine may be the most beneficial and lasting of the current changes, irrespective of the eventual organizational structure of the health care economy.Section 4, Public Policy Issues and the Continuum, consists of two chapters focusing on the role of the public sector, the community, the family, and consumer services. Section 5 is a well-written tour de force conclusion recognizing that, today, “Clinical innovators must continue to learn how to do more with less” (p. 361). Still, the more conflictual “why” issues raised by the organizational practices of managed mental health care need to be explored eventually.At a time when many employers offer only one health care benefit package, many patients are de facto captive. Among the issues this volume does not address, 50 years after the promulgation of the Nuremberg Code, is whether informed consent as a process is applicable to innovative, experimental managed mental health care programs that are now doing “more with less.” At the same time, more remains to be said about such pernicious managed care practices as physician profiles. Such profiles often penalize physicians for hospitalizing patients, or even for requesting approval to hospitalize patients when such approval is subsequently denied. There thus exist de facto physician gag clauses, which not only substantially control clinical judgment and practice but also compromise meaningful informed consent as a process. Under these conditions, it is not surprising that physicians whose practice survival is at stake will tend to err more on the side of not recommending hospitalization, or of failing to explore and address the expected initial patient resistance to hospitalization, under the pretext of respecting the uninformed “choice” of a gravely impaired patient. Anyone wanting to reflect seriously on these issues will be grateful to the authors for courageously providing a factual database of managed-mental-health-care-driven program innovations for experimental alternatives to hospitalization.I see this volume as a springboard for a much-needed analysis of the clinical, ethical, and legal implications of economics-driven mental health care program experiments. Given the data offered, the present volume will no doubt become required reading for public policy programs and mental health administration courses as well as for programs in mental health, ethics, and the law that are ready to proceed to the requisite next level of analysis. The present volume can also be enthusiastically recommended to residents in training interested in each of these areas, as well as to the relevant training faculty and program administrators.by Robert K. Schreter, M.D., Steven S. Sharfstein, M.D., M.P.A., and Carol A. Schreter, M.S.W., Ph.D. Washington, D.C., American Psychiatric Press, 1997, 361 pp., $55.00. FiguresReferencesCited byDetailsCited byNone Volume 155Issue 7 July 1998Pages 985-985 Metrics PDF download History Published online 1 July 1998 Published in print 1 July 1998

Impact of the Child and Adolescent Service System Program in California

Results of an evaluation of the Child and Adolescent Service System Program (CASSP) in California are reported in this article. Interviews were conducted with human services agency staff ( n = 60) and parents of children with serious emotional disturbance (SED; n = 67) regarding changes over the previous 4 years in their local children's service systems. Despite administrative obstacles and significant funding limitations, results indicate that CASSP had a modest, positive impact in the state of California. Specifically, CASSP increased interagency collaboration in human services planning and delivery and positively affected family participation in all aspects of services. CASSP inspired county mental health administrators to be leaders in the effort to establish culturally competent systems of care for children with SED. County agency administrators reported more significant positive changes than did parents of children with SED. Both groups of subjects indicated that many children with SED are not identified by service systems, and the needs of children with SED in the state of California are not adequately addressed.

Oklahoma City: disaster challenges mental health and medical administrators.

Mental health and medical administrators responded to the Oklahoma City bombing with cooperative and overlapping efforts to meet community needs in the wake of terrorism. The major agencies assisted in the immediate rescue response, organized crisis hotlines, prepared mental health professionals to counsel bereaved families and victims, organized debriefing of rescuers, assessed mental health needs of local school children, planned for longer term treatment, and coordinated research efforts to learn from the disaster. Implications to mental health administrators responding to significant acts of terrorism are discussed.

Mental Health Services: A Public Health Perspective

Back to table of contents Previous article Next article Book ReviewsFull AccessMental Health Services: A Public Health PerspectivePhyllis Solomon, Ph.D.Phyllis SolomonSearch for more papers by this author, Ph.D.Published Online:1 Apr 2006https://doi.org/10.1176/ps.49.1.118AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This edited volume represents the first attempt to provide an integrated text of the critical elements and issues of mental health policy, management, and service delivery within a public health framework. This approach requires the integration of knowledge derived from mental health epidemiology, treatment, and service system research.The editors are well suited to this challenge. Both are from Florida Mental Health Institute, a multidisciplinary research and training institute whose efforts are focused on the public mental health system. Dr. Levin is trained in public health and is noted for his writings on mental health administration and policy. Mr. Petrila is trained as a lawyer and known for his critical assessments of the impact of legislation and regulation on service delivery. The first, and strongest, of the volume's four sections covers core mental health service delivery issues including organization, legislation and regulations, economics, financial management, quality improvement, consumer and family advocacy, evaluation, and multicultural perspectives. All the contributors to this section are nationally recognized experts on their respective topics.The chapters in this section generally are good comprehensive overviews of the substantive issues covered, such as the chapters on mental health services by Elpers and Levin, on economics of mental health by Frank and McGuire, and on the impact of consumer and family advocacy on service delivery by Lefley. However, for readers well versed in mental health service delivery issues, they offer little new information. The chapters on evaluation written by Orwin and Goldman and on the impact of disability law on mental health policy and services by Petrila and Levin are strikingly innovative and do provide new insights.The following three sections are devoted to three specialized populations—children and adolescents, the elderly, and adults with substance abuse problems—with each containing three chapters on the relevant epidemiological, treatment, and policy issues. These sections are uneven in quality and comprehensiveness. For example, the chapter on epidemiology of psychiatric disorders among the elderly is too detailed, and the reader becomes impatient. On the other hand, the treatment chapters in these three sections provide rather limited coverage; in addition, they have an extremely clinical orientation, not well balanced with a service perspective. The selection of these three populations results in the omission of relevant treatment, service, and policy issues related to adults with severe mental illness, such as those who are homeless, those who are in jails and prisons, and those who need psychiatric rehabilitation.This book suffers from the typical problems of edited volumes, variable quality and redundancy of information. Given the book's significant gaps, it falls somewhat short of being a comprehensive introduction to mental health services from a public health perspective. However, many practice disciplines, such as social work, nursing, and psychiatry, need a single source that offers an overview of mental health services and related policy issues. With the use of some supplemental material, this book can serve as such an introduction, for there is no text that currently competes with it.Dr. Solomon is professor in the School of Social Work at the University of Pennsylvania in Philadelphia.Dr. Solomon is professor in the School of Social Work at the University of Pennsylvania in Philadelphia.edited by Bruce Lubotsky Levin, Dr.P.H., John Petrila, J.D., LL.M. ; New York, Oxford University Press, 1996, 430 pages, $49.95 FiguresReferencesCited byDetailsCited ByNone Volume 49Issue 1 January 1998Pages 118-118 Metrics History Published online 1 April 2006 Published in print 1 January 1998

The Transformation of China's Mental Health Services

Different powerful groups within a society characterize social deviance in different ways, so the types of social deviance considered 'mental disorders' are a reflection of the relative influence of different institutions in the community at a particular point in time. In most Western countries the influence of the medical establishment and the high profile of psychiatry within medicine result in a strong tendency to medicalize many forms of social deviance, to label them as mental disorders, and to develop corresponding treatment facilities. However, based on my observations during a dozen years as a practising psychiatrist in China, the medical institutions there are relatively weak — medical care only accounts for 3.2 per cent of GNP — and psychiatry has a very low status within medicine. The influence of medical and psychiatric institutions on the understanding and management of socially deviant behaviours is correspondingly small and the range of available mental health services is quite limited.

Onset of Peptic Ulcer and Its Relation to Work‐Related Factors and Life Events: A Prospective Study

Onset of Peptic Ulcer and its Relation to Work‐Related Factors and Life Events: A Prospective Study: Atsuko Sugisawa, et al. Department of Mental Health Administration Studies, National Institute of Mental Health, National Center of Neurology and Psychiatry—Although peptic ulcer (PU) is counted as one of the various work‐related diseases, little is known about the risk factors other than health habits. The authors used data from the Japan Workers Stress and Health Survey—an 18‐month follow‐up study—to ascertain whether psychosocial factors play any role in the development of PU in the working population. The subjects were 9,204 men, working at various occupations and firms, aged 30 through 59 years, who had no prior history of PU at baseline. People with extremely severe life event stress had an increased risk of PU compared with those who had no such experience. An increased risk was found when the frequency of late night work was 10‐12 times a month compared with none. Five items related to perceived work overload—too much responsibility, poor relations with superior, understaffing, excess of evening/holiday business meetings, and physically too tiring —were each positively associated with PU. Life event stress, frequency of late night work, and perceived work overload were all independently associated with the onset of PU after controlling for age and smoking. These results provide evidence that psychosocial factors play an important role in the development of PU.

Residency training in Massachusetts: a new approach to state-university collaboration.

Traditional state-university collaborations, known as public-academic liaisons (PALs), have resulted in improved quality of service and enhanced residency training. Recent national trends for treating persons with serious mental illness, including moving services from institutional settings to community-based care and emphasizing the use of rehabilitative approaches as well as changes in the health care delivery system itself, have led to preliminary rethinking of some discrete aspects of more traditional approaches. Rather than discrete changes, Massachusetts has responded to these emerging trends with a new and comprehensive initiative that emphasizes one set of statewide standards in these emerging content areas for all residency training programs. Consistent with new practices in health care delivery, this new initiative was fielded through a process of competitive bidding rather than through traditional allocation of service positions. The development, implementation, and initial outcomes of this new approach are presented and implications for mental health administrators are discussed.

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports.

The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.

Client and site characteristics as barriers to service use by homeless persons with serious mental illness.

Clients entering the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless mentally ill persons in 18 U.S. communities identified barriers to service use. The most frequent barrier was not knowing where to go for a service (encountered by 32.4 percent of the 1,828 clients). It was followed by not being able to afford it (29.5 percent); experiencing too much confusion, hassle, or waiting to obtain it (27.1 percent); and having been previously denied the service (16.5 percent). Differences in the program site (that is, the 18 communities) explained two to three times more of the variance in encountering barriers use than did individual client characteristics.

Why are African Americans under‐represented in medical research studies? Impediments to participation

Objectives. In accordance with the NIH Revitalization Act of 1993, the National Institutes of Health and the Alcohol, Drug and Mental Health Administration require grant applicants and cooperative agreement participants to include minorities in human subject research. In an environment characterized by diminishing research dollars, this mandate has increased the pressure on investigators to determine factors that impede minority participation and to develop strategies to overcome these impediments. Methods. An extensive review of the literature was conducted to identify the factors possibly responsible for the low participation levels of African Americans in medical research studies and to highlight areas for further research. The items examined included the historical relationship between African Americans and medical researchers and the attitudes, perceptions and beliefs of potential participants and researchers as they relate to the low representation of African Americans in medical research. Results. The factors identified as possible impediments to African American participation included distrust of the medical/scientific community, poor access to primary medical care, the failure of researchers to recruit African Americans actively, the alienation of minority health professionals, lack of knowledge about clinical trials, language and cultural barriers. Conclusions. Well‐designed, relevant, ethical research in conjunction with an appreciation of the many barriers to participation are paramount to increasing African American presence in clinical research.

The legislative structuring of insanity acquittee policies.

Using Missouri's insanity acquittee system as a case study, this analysis explores the extent to which legislation can structure the implementation of mental health policy. It found that Missouri's insanity acquittee legislation substantially structured policy implementation toward its primary goal of public safety. It did so (a) by including actors from both the criminal justice and mental health systems in the insanity acquittee release process, (b) by specifying procedures and criteria for the commitment and release of insanity acquittees, and (c) by requiring monthly monitoring of insanity acquittees released into the community and funding the staff positions to conduct the monitoring. The ability of legislation to structure policy implementation highlights the need for active involvement by mental health policy makers in the legislative process to shape policy goals and to structure implementation to support the interests of the mental health community. Without this involvement, implementation options available to mental health administrators may be severely limited.

Leadership crisis in psychiatric services: a change theory perspective.

In 1990, after twenty years of service, the psychiatrist who had been Director of Psychiatric Services at Alpha Hospital decided to take an early retirement. What followed was a dramatic leadership struggle, which peaked with the resignation (in the summer of 1992) of most of the hospital's psychiatrists. In the years since, there has been a great deal of healing. The psychiatrists are all back at work. Joint leadership of the services is established under the direction of a (psychiatrist) Clinical Director and a (non-psychiatrist) Administrative Director. Management of the programs and services has been reorganized to a much more efficient and effective system. And feelings among the key players are more trusting and collaborative. This paper will explore how this crisis may be understood in terms of change theory. It will also outline the process utilized to resolve the crisis, and will draw implications for other mental health administrators who, in these times of rapid and dramatic change, will undoubtedly confront similar challenges.

Treatment-Resistant Schizophrenia - The Role of Clozapine

SummaryTreatment-resistant schizophrenia is the object of intense interest because of recent developments in its treatment and aetiology. The actual definition of treatment-resistant schizophrenia is, however, still controversial. It should reflect the legitimate and varied needs and perspectives of people with schizophrenia, their family members, mental health care givers, mental health administrators, public health officials, and those who fund the direct and indirect costs of treating schizophrenia.The most common definition of treatment-resistant schizophrenia denotes patients with schizophrenia who, despite at least two adequate trials of classical neuroleptic drugs, have persistent moderate to severe positive, or disorganisation, or negative symptoms together with poor social and work function over a prolonged period of time. This definition reflects the viewpoint of people with this illness, their family members, and mental health care givers. Approximately 30% (range 10–45%) of schizophrenic patients meet these criteria. while this definition is adequate for many purposes, it should be realised that the remaining 70% of schizophrenic patients, whose positive symptoms respond adequately to neuroleptic treatment, may also have clinically significant negative symptoms, poor social and work function, clinically significant cognitive dysfunction, poor quality of life relative to the normal population, and constitute a significant burden to family and society. The lifetime suicide rate in both treatment-resistant and responsive schizophrenic patients is 9–13%, indicating that conventional definitions of neuroleptic response do not convey lower risk of suicide.However, before defining a patient as treatment resistant, it is important to consider whether the patient has received an inadequate duration of treatment, and/or too low, or possibly too high, doses of neuroleptic drugs. Using these stringent criteria, treatment resistance may be present at the time of initial diagnosis and treatment, but if not present initially, it will usually develop subsequently - sometimes not until after multiple acute exacerbations over a period of years.During the first months and years after the diagnosis of schizophrenia has been made, clinicians should be especially alert in identifying a patient as treatment resistant in order to diminish the severe social disability and suicidality which may ensue if it is not recognised and correctly treated. Once present, treatment resistance is usually permanent. However, some treatment-resistant patients may again become responsive to treatment or undergo spontaneous remission of positive symptoms in later life.The treatment of patients with schizophrenia who are treatment resistant is generally much more expensive that that of neuroleptic-responsive patients because their symptomatology and disturbed behaviour leads to more frequent and longer duration hospitalisations.Patients with treatment-resistant schizophrenia may manifest one or more of the classical subtypes of schizophrenia which may differ biologically in terms of neurochemisty and structural brain abnormalities, e.g. ventricular enlargement. They usually have poorer premorbid function, an earlier age at onset of positive symptoms, are more likely to be male than female, and may have various quantitative types of cortical or ventricular abnormalities evident with computer tomography or magnetic resonance imaging scans. There are no established qualitative differences in cognitive dysfunction between the two groups of patients with schizophrenia, but cognitive impairment is more severe in treatment-resistant patients.Treatment-resistant schizophrenia does not usually respond to increased dosages of neuroleptic drugs, switching to other types of neuroleptics, or adding adjunctive agents such as benzodiazepines, anti depressants, anticonvulsants or lithium carbonate. Clozapine has been shown to be more effective than classical neuroleptic drugs in decreasing psychopathology, improving some aspects of cognition, improving quality of life, decreasing hospitalisation, and decreasing suicide attempts and completions. About 20% of the responders to clozapine have a nearly complete remission of positive symptoms and about 40% are able to work or complete school. However, many of the patients who respond better to clozapine than to classical neuroleptic drugs still have residual psychopathology. Further study is needed on whether it is possible to augment the response to clozapine with auxiliary treatments such as classical neuroleptics, antidepressants and anticonvulsants.