Organization Of Psychiatric Services Research Articles

La parentalité des mères psychotiques et sa prise en charge en psychiatrie vue par les professionnels de santé

ObjectivesParenthood of mothers with a psychotic disorder has become a growing social reality that requires specific care. This study was carried out to shed light on an understudied topic that raises a number of ethical questions. The purpose of this study was to explore the point of view of healthcare professionals working in psychiatry services about parenthood of psychotic mothers and what they are offered in terms of support and care. MethodsSixteen health professionals working in psychiatry services responded to a semi-directive interview. They were recruited on a voluntary basis. Anonymity was ensured and all professionals gave their written informed consent to participate in the study. Interview's content was transcribed verbatim then examined through a qualitative thematic analysis. ResultsThe interviews highlighted contrasting representations of these mothers’ parenthood. Whilst the weaknesses and difficulties in parenting and education were predominantly mentioned, mothers’ resources and skills were hardly acknowledged. Although attachment to the child was one of the few resources noticed, the professionals named 25 items relating to parenting problems. The main ones related to the impact on the child of the symptoms of the maternal mental disorder, and to difficulties in coping with daily tasks. A lack of empathy was also observed in these mothers. The parent's difficulties appeared to be more significant depending on the child's developmental stage. Family support was described as essential in helping these mothers with parenting. However, parenting issues seem to be very seldom taken into account by adult psychiatric services, as most health professionals believe these questions do not fall within their field of activity. A lack of training and information on this issue is seen as one of the main barriers regarding this topic. Besides, the organization of psychiatric services in France, with its child and adult sectors, appears to be a barrier to a joint work of child psychiatry and adult psychiatry. However, for these professionals, psychiatry in general remained the place where the issue of parenthood should be addressed. Children of psychotic mothers were perceived as suffering from the parent's difficulties, yet reporting situations where the children were in danger remained an unusual practice in adult psychiatry. This was considered as belonging to the realm of other institutions, or of child psychiatry. Lack of knowledge about existing procedures and partners appeared to limit assessments of situations of concern that should be reported. These results invite to discuss on models of support, for instance based on empowerment and recovery approaches. These models build on the strengths and resources of people who are seen as stakeholders in their own care journey. Given the impact of parenting on the mental health of these mothers, implementing recovery programs that focus on sexuality and parenthood could be effective. Providing health professionals with information might raise their awareness of their role in taking charge of the patients in a comprehensive perspective that includes parenthood issues. Professionals’ practices seemed to be more focused on the patient and his symptoms rather than on all aspects of their personal life (family, children, work). Finally, some ethical issues are discussed. Parenthood of psychotic mothers deserves a global approach, including work in partnership. Although the law lays down the principle of shared secrecy, some professionals still remain reserved about sharing relevant information, given the medical confidentiality principle. These issues also appear to be an argument for refusing to report a child as requiring a child protection intervention. ConclusionAlthough its limitations, in particular the low number of professionals who agreed to participate, this study sheds new light on a scarcely studied issue that deserves more attention given the increasing number of patients with children who are cared in psychiatric services.

Interventi sul caso Giulio

A commentary on Pietro Pellegrini’s paper For the future of the Italian Law no. 180/1978 on psychiatric reform (Psicoterapia e Scienze Umane, 2018, 52, 1: 115-119). Some key aspects of Pietro Pellegrini’s paper are critically examined. It is argued that some of Pellegrini’s comments risk of turning any discussion on the Italian Law no. 180/1978 into an ethical debate on citizenship rights, preventing to see the actual consequences of this Law on the treatment of mental health disorders and the organization of psychiatric services. The actual ethical nature of certain positions is questioned, it is argued that it must be confronted with the suspicion of ideology, on the one hand, and with the need of scientific research and training of mental health professionals, on the other.

Quality management and economic downturn. Post-modern topics of community psychiatry

IntroductionThe reduction of the budget allocated to community psychiatry is part of financial needs in times of economic crisis. However, the community psychiatry is based on human resources rather than on technological devices and the economic downturn affects the quality of care in a field where the social and relational capital developed by mental health workers is fundamental. Some authors such as Serge Latouche propose to stem the economic decline with the concept of “degrowth”, a constructive idea but difficult to apply.ObjectiveWe would like to analyze whether the economic downturn has consequences only for the organization of psychiatric services or even for people with severe mental disorders. Another issue concerns the possibility that economic downturn increases the social exclusion of vulnerable people.ResultsPeople who live on social welfare or disability pension remain on the margins of society but also those supported by families feel increasingly marginalized with respect to the future.ConclusionsThe provision of mental health services may not meet the implicit and explicit wishes in the demand for health by citizens and society. It's therefore necessary to review the quality management within community psychiatry.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Corrosive oesophageal injuries: a preventable menace

IntroductionPotentially catastrophic presentations and lifelong complications resulting from corrosive ingestions in humans is one of the most challenging situations encountered in clinical medical practice. This study reviewed pattern, mechanisms and associated socio-medical challenges with ingestion of corrosive agents as seen in a tertiary health institution in South-western Nigeria.MethodsA retrospective review of all patients that were managed for corrosive ingestion at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria, over a seven year period.ResultsA total of 28 patients M:F: 1.6:1. There were 7 children and 21 adults. Majority (78.6%) of the patients ingested alkaline substances. Accidental ingestion occurred in 28.6% while 71.4% resulted from deliberate self harm especially among adults (66.7%). Almost two thirds (64.3%) of the patients presented after 48hrs of ingestion. Patients who presented early were managed conservatively. Most patients (64.3%) who presented late had nutritional and fluid rehabilitation. Two patients died from oesophageal perforation and resulting septicaemia. Psychiatric evaluation revealed that seven adults (25%) had psychotic illness while (42.9%) of the patients developed oesophageal strictures. Short segment strictures were managed with oesophageal dilatation with good outcome while long and multiple segment strictures were referred to cardiothoracic surgeons for management.ConclusionCorrosive oesophageal injuries remain a prevalent and preventable condition in the developing countries. Preventive strategies should include regulation and packaging of corrosive substances, organization of psychiatric services, and education of the population on corrosive ingestion.

Regional variation in antipsychotic polypharmacy for schizophrenia

Population: The prevalence of APP in 2004 in different municipalities in Denmark was determined using records from the Danish National Board of Health and the Danish Medicines Agency. The number of outpatients with an ICD-10 (International Statistical Classifi cation of Diseases and Related Health Problems 10th Revision) diagnosis of schizophrenia spectrum disorder who were treated with more than one antipsychotic (as defi ned by the fi lling of prescriptions for more than one antipsychotic within 30 days during 2004) were compared with the total number of antipsychotic-treated patients with schizophrenia spectrum disorder to determine the APP fraction. Two municipalities with a mean APP fraction above the national average of 48.5% and two with a mean APP below this average were selected. The regions had comparable need for mental health services (as determined by socioeconomic predictors) and similar organisation of psychiatric services. The nurses and physicians in one of the main psychiatric departments and outpatient clinics in each region served as the target population. Setting: Four municipalities in Denmark selected from all 98 municipalities; two with lower APP prescribing than the national average (Frederiksberg and Odense) and two with higher (Esbjerg and Viborg). Assessment: Questionnaires were distributed to all physicians and nurses in the psychiatric departments and outpatients clinics in the selected municipalities. Additional data were collected from administrative records about the treatment setting in each department such as the number of beds, research activity, number of academic staff, availability of a treatment guideline, how up to date this was and what initiatives were in place to encourage adherence to it. These variables were compared between the municipalities with below average polypharmacy prescribing and those with above average. Categorical variables were compared using χ 2 tests and continuous variables using Wilcoxon tests. A correction for multiple testing was applied, and OR with 98% CI calculated for questions that were signifi cantly different between above and below average APP fraction regions. Outcomes: Nurse and physician knowledge and attitudes regarding APP and guideline use; treatment setting variables including availability of guidelines. METHODS Design: Cross-sectional study. MAIN RESULTS The difference in APP fractions across the regions was not related to differences in disease severity. This was determined by adjusting for disease severity as measured using patient Global Assessment of Functioning scores and substance abuse data. Of 347 participants, 309 (89%) returned their questionnaires. This included 78 physicians and 230 nurses responded across the four municipalities. None of the nurses was authorised to prescribe medication. Compared with high APP areas, physicians in low APP areas had improved knowledge of treatment guidelines (87% vs 65%, p=0.02); believed guidelines were more important than personal experience (13% vs 38%, p=0.01); were offered local education sessions more frequently (76% vs 9%, p<0.0001) and were more engaged in recent scientifi c activity (41% vs 13%, p=0.01). Compared with high APP areas, nurses in low APP areas had improved knowledge of treatment guidelines (74% vs 58%, p=0.01); were less likely to think that polypharmacy increased antipsychotic effect (19% vs 38%, p=0.001); were less likely to have education offered at least once monthly (34% vs 50%, p=0.01); perceived they had suffi cient time for each patient (57% vs 37%, p=0.003) and were less likely to believe their workload was too high (26% vs 44%, p=0.01).

Psychiatric diagnoses during institutionalization: an investigation of 1334 psychiatric patients hospitalized in an Italian asylum during the 20th Century

Interest in the history of psychiatry continues to grow, with an increasing emphasis on topics of current interest such as the history of nosology and the interplay between psychiatry and society. The present study was designed to investigate diagnoses and sociodemographic characteristics of patients during the course of the last century in a sample of Italian psychiatric inpatients. The study also throws light on changes in the practice of explaining and classifying mental disorders. This was a chart analysis of clinical records of 1334 patients hospitalized at "Santa Maria della Pietà" in Rome from 1920 to 1980. We chose every tenth year and the month of May because, on average, there was a reasonable number of admissions compared with the peak of admissions in August and an almost lack of admissions in January. There were relevant differences in diagnostic nomenclature and course of illnesses from 1920 to 1980 in Italy. Schizophrenia was first diagnosed in 1930 and 1940 and then rapidly declined; melancholia was first diagnosed in 1930 but rapidly decreased, whereas dysthymia appeared later in 1960. Dysthymia, manic, and depressive disorders rapidly appeared since 1980. In the "other disorders" group category, there were three peaks in frequency--one in 1930, another in 1940, and the most frequent in 1980. The consistency in diagnosis and the organization of psychiatric services in the last century were quite poor. Improving psychiatric services and quality of care remain a relevant challenge for physicians.

Hospital Variability in Emergency Department Length of Stay for Adult Patients Receiving Psychiatric Consultation: A Prospective Study

We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

Socio-economic status and geographies of psychiatric inpatient service use. Places, provision, power and wellbeing

This editorial briefly summarises some aspects of research on socio-economic status and use of mental health services that have particular relevance for the theme of this issue of Epidemiologia e Psichiatria Sociale. This discussion takes a view from the perspective of health geography, which examines how the relationships between individuals and their social and physical environment result in variations in health and health care use. Three particular issues are considered here. First, the geographical distribution and organisation of psychiatric services may interact with social and economic factors in ways that are important for service use. Second, increasingly sophisticated ecological modelling strategies have elucidated the associations between socio-economic factors and service use at the population level. Third, more intensive, qualitative research complements these statistical analyses and encouraged reflection on the socio-economic processes, within psychiatric care settings, as well as in wider society, which influence service use.

Are readmission rates influenced by how psychiatric services are organized?

A transition is taking place in the organization of psychiatric services. The length of stay in hospitals is reduced and partly replaced by treatment and care in the community. The readmission rate is proposed as one indicator to analyse the effectiveness of this transition. A comprehensive literature review was conducted to ascertain whether readmission rates differ with different service systems. The search yielded 77 articles, of which 28 were selected on the basis of aims and objectives of the articles. The results show that approximately 50% of all patients admitted to psychiatric hospitals are previously admitted patients. Longer length of stay, appropriate discharge planning, and follow-up visits after discharge predicted fewer readmissions, whereas the quantity and quality of community care did not seem to have any impact on readmission rates. On the basis of the analysis of the literature review it is concluded that readmission rates are not a suitable indicator of quality of care in psychiatric hospitals. Readmission rates may, however, be an important tool in the planning of mental health services.

S1. Organization of psychiatric services

S1. Organization of psychiatric services

The Laboratory Revolution in Medicine ed. by Andrew Cunningham, Perry Williams

924 Book Reviews TECHNOLOGY AND CULTURE Roger Cooter’s essay on the development of specialty clinics during the interwar period devoted to the treatment of fractures is a sophisticated assessment of an innovation that was organizational rather than technical. The effort by British orthopedists to create a specialized institutional setting did not rely on any new medical practice. Instead, these physicians sought to create a need for fracture clinics by mobilizing support from disparate social groups: industry (both labor and management), insurance companies, the military, and provincial hospitals. Cooter highlights how the development of frac­ ture clinics was contingent on the intersection of specific social, economic, and intellectual circumstances. Perhaps the most original essay is David Cantor’s “Cortisone and the Politics of Drama, 1949-55.” The discovery that cortisone appar­ ently cured patients with crippling arthritis received extraordinary popular and professional attention. British rheumatologists used this to strengthen their status within the National Health Service. They soon grew wary, however, of the spectacle surrounding the introduc­ tion of cortisone. Cantor perceptively analyzes the bases of this discomfort, discussing both the philosophical roots of modern scien­ tific medicine and the problem of alternative medicine and its use of the dramatic. The remaining articles concern the reception of antisepsis, tuber­ culosis sanatoria, diphtheria antitoxin, oxygen therapy, and obstetric X-rays, and the organization of psychiatric services after World War II. They remain squarely focused on the social, cultural, and eco­ nomic forces that influence medical innovations. Ironically, it is the technical that receives the least attention in the book. Indeed, my principal criticism of this fine collection is that greater technical detail could have reinforced the presentation. One of the great strengths of history of technology is its ability to make a case for social construction by demonstrating how seemingly arcane technical decisions are actually shaped. This collection of essays begins this process, but much remains to be done before we have a clear understanding of the historical roots of our modern reliance on medical technology. Steven C. Martin Dr. Martin is an assistant professor in the Departments of Epidemiology and Social Medicine and Medicine at the Albert Einstein College of Medicine. He is working on a history of chiropractic. The Laboratory Revolution in Medicine. Edited by Andrew Cunningham and Perry Williams. New York: Cambridge University Press, 1992. Pp. xi + 347; illustrations, notes, index. $69.95. “Modern medicine is based on the laboratory.” So claim the first few words of this book. This collection is derived from a conference held TECHNOLOGY AND CULTURE Book Reviews 925 at the Wellcome Unit for the History of Medicine at the University of Cambridge. Following a useful introduction, the eight primary essays cover a wide range of perspectives on the history of the medical laboratory. Mainly focused on 19th- and 20th-century laboratories in Western Europe and the United States, the collection will be of interest to historians of technology both for its attention to the mechanical artifacts used within the laboratory and for its elucidation of the social space within which those artifacts were applied. The essays cover a wide range of topics. Paul Weindling compares the architectural layout of the Pasteur Institute and Robert Koch’s Institute for Infectious Diseases. Andrew Cunningham examines the role of the laboratory in constructing the disease now known as plague. Timothy Lenoir considers how laboratories for experimental physiology were institutionalized in mid-19th-century Germany and characterizes the primary change as a shift in the definitions of the kinds of knowledge that were valued, particularly physiology. Richard Kremer addresses the process by which entrepreneurs were able to create physiological laboratories in Prussia from 1836 to 1846. Other essays address resistance to laboratory-generated information. John Harley Warner considers how knowledge about the laboratory was different in the United States from that in Europe and traces the gradual process by which laboratory-generated knowledge became accepted in the late 19th century. Michael Osborne looks at a mid-19th-century French surgeon’s ideas about bacteriology and disease causation. Stewart Richards explores the use of animals in English laboratories and the objection to such use by the antivivisec­ tion movement. Wai Chen suggests that the Inoculation Unit at St...

Medical Innovations in Historical Perspective ed. by John V. Pickstone

Book Reviews Medical Innovations in Historical Perspective. Edited by John V. Pickstone . New York: St. Martin’s Press, 1992. Pp. xv + 288; notes, index. $49.95. Surprisingly, the history of medical technology remains largely uncharted. Despite the centrality of technology to modern medicine, and the expansion of research by historians of both medicine and technology, there is a paucity of scholarship investigating medical technology. Recently, however, there has been a gradual increase in such scholarship, and this collection of essays stands as a valuable contribution to this important, yet underdeveloped, held. Ten essays cover a wide range of medical innovations that were introduced between 1860 and 1960, all in England with one American exception. The extremely useful introduction emphasizes that an inter­ disciplinary approach is essential to investigating medical innovation effectively. The essays employ a theoretical framework influenced by economic history, diffusion theory, policy analysis, medical history, and history of technology, and they are explicitly intended to lend “sup­ port . . . [to] the new history of technology.” Each stresses “that techno­ logical change has not been ‘inevitable’: the origins of innovations need to be explained, in part, by social process” (p. 13). This emphasis on the social construction of knowledge and practice fits comfortably into current trends in both the history of medicine and history of technology. This historiographic approach unifies an otherwise disparate series of case studies. Several especially strong essays are noteworthy. Michael Worboys’s examination of the relationship between vaccine therapy and laboratory medicine in Edwardian Britain reminds us of the importance of studying “failed” innovations. Vaccine therapy is also noteworthy because historians have asserted that its emergence played a central role in the ascendancy of laboratory medicine. Worboys carefully examines data from British clinical laboratories to document that vaccine therapy actually played a minor role in their development. He rightly emphasizes that it was diagnostic, rather than therapeutic, laboratory studies that fueled the growth of the clinical laboratory. The importance of vaccine therapy rested on the encroachment of laboratory medicine into the realm of therapeutics, thereby creating tension between clinicians and researchers. Worboys carefully documents the importance of this social tension in determining the fate of vaccine therapy. Permission to reprint a review from this section may be obtained only from the reviewer. 923 924 Book Reviews TECHNOLOGY AND CULTURE Roger Cooter’s essay on the development of specialty clinics during the interwar period devoted to the treatment of fractures is a sophisticated assessment of an innovation that was organizational rather than technical. The effort by British orthopedists to create a specialized institutional setting did not rely on any new medical practice. Instead, these physicians sought to create a need for fracture clinics by mobilizing support from disparate social groups: industry (both labor and management), insurance companies, the military, and provincial hospitals. Cooter highlights how the development of frac­ ture clinics was contingent on the intersection of specific social, economic, and intellectual circumstances. Perhaps the most original essay is David Cantor’s “Cortisone and the Politics of Drama, 1949-55.” The discovery that cortisone appar­ ently cured patients with crippling arthritis received extraordinary popular and professional attention. British rheumatologists used this to strengthen their status within the National Health Service. They soon grew wary, however, of the spectacle surrounding the introduc­ tion of cortisone. Cantor perceptively analyzes the bases of this discomfort, discussing both the philosophical roots of modern scien­ tific medicine and the problem of alternative medicine and its use of the dramatic. The remaining articles concern the reception of antisepsis, tuber­ culosis sanatoria, diphtheria antitoxin, oxygen therapy, and obstetric X-rays, and the organization of psychiatric services after World War II. They remain squarely focused on the social, cultural, and eco­ nomic forces that influence medical innovations. Ironically, it is the technical that receives the least attention in the book. Indeed, my principal criticism of this fine collection is that greater technical detail could have reinforced the presentation. One of the great strengths of history of technology is its ability to make a case for social construction by demonstrating how seemingly arcane technical decisions are actually shaped. This collection of essays begins this process, but much remains to be done before we have a clear...

Inquiries at Lakeside and Aradale Hospitals: lessons and advances?

The release of reports of inquiries into two related psychiatric hospitals (Lakeside and Aradale) in Victoria occurred in 1991. These inquiries identified deficiencies in patient care standards and organisational dynamics. Knowledge of institutional dysfunction was available from similar Australian and overseas inquiries but nonetheless this knowledge had not prevented organisational inertia and decline in these two psychiatric hospitals. This paper examines the possible contribution of a failed medical hegemony model to organisational dysfunction and discusses organisational life-cycles. It reaches the conclusions that politically motivated inquiries do not achieve long term positive outcomes and that there is a need for academic research into the organisation of psychiatric services and staff productivity and morale.

Psychiatry for Undergraduates

The reading matter one would recommend to medical undergraduate students clearly depends upon one's own view of the purposes and aims of teaching this group of students in departments of psychiatry. Aims may not be limited to psychiatry itself, and some teachers see the development of interviewing skills, self-awareness, and personal development as being at least as important as the teaching of more technical aspects of medicine such as the psychological aspects of physical disorders, recognition of psychiatric syndromes, psychiatric treatments, the use of the Mental Health Acts, and the organization of psychiatric services and their relation with other medical services.

Textbook of Clinical Psychiatry: An Interpersonal Approach

This textbook reflects the theory of Harry Stack Sullivan that faulty interpersonal relationships cause functional psychiatric disorders. Therefore, the author singles out the interpersonal approach as the most important mode of psychotherapy. The 28 chapters of the book are arranged in eight parts. The first contains the theory of the interpersonal approach, the history of psychiatry, and definitions of the commonly used psychiatric terms. In the second part the author thoroughly covers the interviewing techniques and other methods of psychiatric examination. The subsequent four sections include descriptions of psychiatric disorders, attributed to faulty relationships with significant persons; psychiatric disorders caused by organic brain disease; mental deficiency; and problems of emotional adjustment from childhood through old age. Finally, the last two parts describe treatment, organization of psychiatric services, and legal psychiatry. His rich personal clinical experience enables the author to provide a thoughtful and comprehensive coverage of modern clinical psychiatry. This

The community mental health program and the longer-stay patient.

THE ORGANIZATION of psychiatric services in the United States is presently undergoing a dramatic reappraisal and change. The federal government has taken a strong position, backed by financial support, in favor of comprehensive services in community centers. This new emphasis has been accompanied by declarations of the obsolescence of the state mental hospitals.^1-4The hope has been expressed that the community center can obviate the need for the mental hospital. However, the problem of the chronic hospitalized patient has not been faced squarely by the planners. Although presently few programs in the United States exactly follow the lines of the proposed centers, the development in 1961 of the Fort Logan Mental Health Center was coincident with the changed views about mental health services. While Fort Logan is by no means a model comprehensive community mental health center in the terms set forth by current legislation and

Organization of Psychiatric Service in a Naval Hospital

Organization of Psychiatric Service in a Naval Hospital