Psychiatric Contact Research Articles

‘Elderly graduates’ and a hospital closure programme: the experience of the Camberwell Resettlement Team

The closure of Britain's large psychiatric hospitals, long foreseen, is now rapidly becoming a reality. Surprisingly little is known about the process and outcome of the relocation of long-stay hospital residents. One area of particular concern is the fate of ‘elderly graduate’ patients, who are by convention defined as long-stay patients aged over 65 years who came into continuous psychiatric contact before the age of 65. (More cynically they might be defined as those elderly patients whom our colleagues specialising in the psychiatry of the elderly choose not to take over). This paper documents the experience of a specialist resettlement team working within a declining mental hospital attempting to place ‘elderly graduate’ hospital residents into community provision.

Day Care in an Inner City

The socio-demographic and clinical characteristics of patients attending psychiatric day care in an inner-urban catchment area were assessed using structured techniques. The overall prevalence of the use of day care was high (164 per 100,000 total population), and 86% of attenders were in prolonged psychiatric contact. Of those in prolonged contact, the clinical and social morbidity of 68 attenders at National Health Service day hospitals was strikingly similar to that of 42 attenders at other units. Users of a 'community mental health centre' and two work centres were less disabled than attenders at other day units. Implications of these results for the organisation of day services and training of staff are discussed.

Care of Chronic Neurotic Out-patients by Community Psychiatric Nurses

Ninety-nine neurotic patients from a controlled trial of CPN v. psychiatric out-patient aftercare were followed up seven years later. Of the 92 survivors, 76 were successfully interviewed. Few differences were found between the groups. Chronic mild symptoms and moderate social disability persisted, and tended to worsen a little. Treatment patterns persisted for one to two years beyond the original study; the CPN group had more CPN contacts, fewer psychiatric out-patient contacts and less psychiatric care. Thereafter, more out-patients were discharged from psychiatric care and care patterns for the two groups became similar. Out-patients attended more non-psychiatric out-patient clinics than the CPN group, but it is possible that this reflected pre-existing differences. About a third of patients remained in contact with the psychiatric service during follow-up.

Psychiatric Problems in Obese Children Followed up for 10 Years-Reply

To the Editor.— The report by Epstein et al, 1 Ten-Year Follow-up of Behavioral, Family-Based Treatment for Obese Children, notes long-term positive results with that mode of treatment applied to 76 selected patients: obese children with intact families, no history of psychiatric contact, at least one obese parent, and one parent willing to attend treatment meetings. Noted by the authors, but otherwise overlooked in the discussion of the outcome of this study, were the psychopathological effects that occurred among these 76 supposedly psychologically healthy children. Near the beginning of the study, one of the 76 children was dropped because of unreported psychiatric problems. During the second 5 years, six of the 67 children who were still eligible for the study developed significant psychiatric problems that required hospitalization and long-term medication use. Three children had manic-depressive illness, two had major depression with suicide attempts, and one developed an eating disorder. Finally,

A Profile of Mentally Ill Offenders and their Adjustment in the Community

The research focuses on a little-studied group of mentally disordered offenders: inmates requiring psychiatric hospitalization during imprisonment. Information is provided on the pre-prison and prison histories of all male mentally ill offenders (MIOs) released during a 13-month period (N = 150) and followed for 18 months in the community. Results indicate that MIOs displayed a marginal existence prior to their incarceration, with the vast majority having had a prior criminal and/or psychiatric contact. Problems in both domains continued upon release into the community. By followup's end, 48% required at least one psychiatric commitment, and 64% experienced at least one rearrest. Multiple regression indicated that recidivism among MIOs was associated with standard criminological variables: age and prior criminal record. These findings are then compared with research on other mentally disordered offender groups.

Daylight saving time in psychiatric illness

It has been reported that the change in photoperiod induced by the occurrence of daylight saving time has an effect on psychiatric presentation. We therefore investigated the impact of daylight saving time in three conditions: (1) parasuicide presentations; (2) psychiatric outpatient contacts and inpatient admissions; (3) registered suicides. Results indicate that neither the change in photoperiod nor the effect of a small change in circadian rhythm associated with daylight saving time has an effect on ‘cases’ in any of the three conditions.

Violent Death and Mental Illness

The names of 412 residents of the catchment population of a district general hospital unit who died potentially self-inflicted deaths in the eight years 1974-81 were identified. They were classified as suicide (245), accidental death (126), and undetermined (41). In each group, over half had a lifetime history of psychiatric treatment and over a third were psychiatric patients at the time of their death. The relative risk of a violent death for those who died within a year of their last psychiatric contact was 27 times greater than that of residents with no recent psychiatric contact. The relative risk was highest for those aged 35-44 and lowest for those of 75 years and over.

Suicide among Chinese schizophrenics in Hong Kong.

A descriptive study of suicides in 74 Chinese schizophrenic out-patients (43 male) is presented. The mean age at death was 31.3 years. The mean duration of illness was 8.5 years and 50 of the 74 died within ten years of onset of illness. Only five lived alone; 35 were openly employed and 20 were married at the time of death. Twenty had a history of depression, and 27 had attempted suicide previously. More females had been depressed or had attempted suicide than males. Over half were last admitted for reasons other than schizophrenic symptoms alone and ten died within one month of discharge. Eight of 71 patients followed up expressed suicidal ideas at the last psychiatric contact, but only 15 were symptomatic. Jumping was the commonest method used. Analytical studies are needed to identify risk factors in Chinese schizophrenics.

Eating disorders in a general practice population. Prevalence, characteristics and follow-up at 12 to 18 months.

Attenders to four South London group general practices were screened using the Eating Attitudes Test (EAT), after which all high scorers and a random selection of low scorers were approached for interview. General practitioners (GPs) were given details on a random half of high-scoring patients with the aim of assessing intervention for revealed and hidden psychopathology. Twelve to 18 months later all high scorers on the EAT were followed up by post to measure change in behaviour and attitudes. Practice records were examined to determine the doctor's knowledge of the patient and any intervention that had occurred. It was found that 1.1% of women had bulimia nervosa and 2.8% a partial-syndrome eating disorder. No cases of anorexia nervosa were found. Cases of bulimia nervosa and partial syndromes were similar in being: mainly female, of higher social class, in the normal weight range but with considerable weight fluctuation in the past, more likely to have had a history of menstrual irregularity, and frequently psychologically troubled with more past psychiatric contact. Over the follow-up period there was some change along a spectrum of normal dieting to the full syndrome, although only one subject with bulimia nervosa recovered significantly. Although the GPs were unaware of the eating pathology and their intervention was minimal, most had documented their patients' psychological distress.

The Long-Term Outcome of Maudsley Depressives

Eighty-nine consecutive admissions with primary depressive illness were prospectively ascertained and diagnosed in 1965-66 by R. E. Kendell, who also allocated each a position on a neurotic-psychotic continuum on the basis of previous discriminant function analysis. In 1983-84, 94% of the survivors were personally interviewed by a psychiatrist blind to index admission data. Operational outcome criteria were employed and longitudinal data were established for 98% of the series. Mortality risk was doubled overall, and increased sevenfold for women under 40 years at index admission. Less than one-fifth of the survivors had remained well, and over one-third of the series suffered unnatural death or severe chronic distress and handicap. Patients whose index episode marked their first psychiatric contact had a 50% chance of readmission within their lifetime, but those with previous admissions had a 50% chance of readmission within three years. Readmissions occurred even after 12 years of being symptom-free, and conversely patients recovered after as long as 15 years of illness. There was a high incidence of other disorders (schizoaffective disorder, alcoholism, schizophrenia), and only four patients showed pure recurrent unipolar histories. Patients at the psychotic end of the continuum were more likely to be readmitted and to have very poor outcomes.

Social construction or causal ascription: distinguishing suicide from undetermined deaths.

This study reports findings of the first Scottish comparison between suicide and undetermined deaths on a number of sociodemographic and psychiatric variables, and also in relation to the method of death. Logistic regression analysis confirmed that method was the most powerful and significant discriminator (88% of ‘active’ deaths were labelled suicide compared to only 54% of drowning) and also pointed to an interaction between gender and age. The two types of death could not be differentiated by marital status, previous psychiatric contact or social class. Time interval between psychiatric contact and death was not significantly associated with classification of death. The authors conclude that evidence concerning the aetiological significance of prior parasuicide and psychiatric illness in suicide remains valid. The alternative social construction hypothesis, namely that these are criteria used by officials to label an ambiguous death as suicide, finds no support.

Psychiatric residents' sexual contact with educators and patients: results of a national survey.

In a national survey of PGY-4 psychiatric residents, 4.9% of the 548 respondents indicated that they had been sexually involved with psychiatric educators and 0.9% reported that they had been sexually involved with patients. Most residents reported no or minimal instruction in their residency programs about educator-resident and resident-patient sexual contact. The authors compare these results with those from previous surveys of psychologists. They discuss the need for expanding training curricula to include specific education on sexual exploitation.

Countertransference and Inpatient Psychiatry: Theoretical and Clinical Aspects

Few aspects of psychiatric training are more troubling to beginning residents than the emerging awareness of their own countertransferences. This is often viewed with a mixture of disgust and embarassment as a sign of incompetence and lack of professionalism. Conflicting views on the origins of, and appropriate responses to countertransference further add to the difficulty and anxiety of psychiatric training. The frustration and sense of helplessness which often accompany these feelings can lead to disillusionment and various degrees of acting out which ultimately compromise patient care and resident education. Ironically, the feeling of being overwhelmed by countertransference can often occur several months into a psychiatric residency. Once beginning residents have acquired the basic clinical skills needed for acute diagnosis and treatment, subtler issues in patient management arise. The greater degree of psychiatric patient contact and greater difficulty in maintaining professional distance through procedures and lab studies makes this inevitable. It is often not until the outpatient years when residents begin to treat "higher functioning" patients that psychodynamic education is deemed clinically useful. Countertransference, like other psychodynamic topics, may be viewed as "irrelevant" to inpatient psychiatry, which emphasizes biological and behavioral interventions. At all levels of training, however, acquiring a systematic understanding of countertransference may be one of the most anxiolytic and educationally useful advances a resident can make.

Benzodiazepine dependent patients and their psychological treatment

1. 1. 91 patients were referred to a tranquillizer withdrawal clinic. 44 of these entered a withdrawal programme. The characteristics of the patients are described. 2. 2. 72% of patients accepted for benzodiazepine withdrawal had a history of previous psychiatric contact. They also had significantly higher scores on S.T.A.I. than control groups of non-psychotic psychiatric out-patients indicating a considerable psychiatric morbidity prior to withdrawal. 3. 3. 12 patients were treated with psychological group therapy using anxiety management techniques. The outcome of this pilot study showed that 50% of subjects were able to discontinue their benzodiazepines despite previous failures. 4. 4. Patients found learning to cope with symptoms, sharing problems with others and learning to change thoughts the most useful components of the anxiety management package during withdrawal.

Psychosocial coping in young adulthood of male child psychiatric outpatients: implications of early treatment.

The frequencies of new psychiatric diagnoses received during compulsory military service among a group of 534 former child psychiatric patients were studied with regard to the earlier clinic experience. The nature of the former patients' contact with the clinic was the strongest predictor of a subsequent diagnosis. Risk was lowest for those who had received a systematic course of therapy in childhood, and matched that of a control group of conscripts with no history of psychiatric contact.

Evaluation of 294 psychiatric consultations involving in-patients above 70 years of age in somatic departments in a university hospital.

The integrated geropsychiatric service of the Psychiatric Department of the University Hospital in Linköping consists of an observation ward, a day unit and an out-patient unit. One of the main tasks of the last-mentioned unit is to provide geropsychiatric consultations for in-patients in the non-psychiatric departments of the hospital. During the first 2 years from October 1982 to October 1984 300 consultations were performed. The consultations included registration of social, medical and psychiatric data, a psychiatric examination, discussions with the staff and a psychiatric report. Out of the total number of 300 consultations 294 could be evaluated completely. They comprised 247 individuals. The evaluation was performed after the first 2 years by screening the patients' psychiatric records and reports and by computer-analysis of 89 variables covering medical as well as social data. The patients' mean age was 78 years and 52% were treated in the Department of Internal Medicine. Fifty-three percent had had previous psychiatric contacts. Many were suffering from serious somatic diseases and 22% from depressive states. Only 9% showed no signs of psychiatric disorders. Twenty-three percent of the patients were transferred to the geropsychiatric observation ward or day unit and only 3% were recommended to be certified and transferred to a mental hospital. Pertinent findings are discussed in the light of international data on geropsychiatric consultations and liaison psychiatry. The study shows the importance of providing special geropsychiatric consultations for in-patients in somatic departments as a part of an integrated geropsychiatric service.

Suicides among 523 persons in a Swedish county with and without contact with psychiatric care.

Among 523 (350 males, 173 females) suicides in 1977-1984, subjects who had had contact with psychiatric care (PC) (63%) were compared with those who had never had such contact (NPC) (37%). The male:female ratios in the PC and NPC groups were 1.6 and 3.0, respectively. Intoxication with drugs and or alcohol was the main method of suicide among the PC subjects, and hanging and intoxication with carbon monoxide predominated among subjects of the NPC group. High percentages of divorces and widows/widowers were characteristic of both groups. Among men and women of the PC group the age groups in which the highest mean suicide rates per 100,000 were found were 45-54 and 55-64 years respectively. The corresponding age groups in the NPC group were greater than or equal to 75 and greater than or equal to 70 years. In the PC group the number of admissions to psychiatric hospitals was more than three in 55% of the subjects and more than eight in 25%. Seventy-three percent had had psychiatric contact within 6 months before the suicide. About 40% in each group had had depressive syndromes. Somatic disease of relevance to the suicides was found among 10% of the PC subjects and 20% of the NPC. About 1/4 of the subjects in both groups had expressed serious suicidal intent shortly before the suicide. The importance of information and education about suicide problems among personnel and relatives is underlined.

Epidemiology of Puerperal Psychoses

Computer linkage of an obstetric register and a psychiatric case register made it possible to investigate the temporal relationship between childbirth and psychiatric contact in a population of 470 000 people over a 12-year period: 54 087 births resulted in 120 psychiatric admissions within 90 days of parturition [corrected]. The 'relative risk' of admission to a psychiatric hospital with a psychotic illness was extremely high in the first 30 days after childbirth, particularly in primiparae, suggesting that metabolic factors are involved in the genesis of puerperal psychoses. However, being unmarried, having a first baby, Caesarian section and perinatal death were all associated with an increased risk of psychiatric admission or contact, or both, suggesting that psychological stresses also contribute to this high psychiatric morbidity. Women with a history of manic depressive illness, manic or depressive, had a much higher risk of psychiatric admission in the puerperium than those with a history of schizophrenia or depressive neuroses, and the majority of puerperal admissions met Research Diagnostic Criteria for manic or depressive disorder. Probably, therefore, puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia.

A Diagnostic Study of the Criminal Alias

Abstract The author found that 64 (30.9%) of 207 incarcerated male offenders had been officially recognized as having changed their names at some time. The most common ways in which their names were modified included changing the middle name or initial, changing the spelling of one name, or completely changing all three names. These alias users were older property offenders who had more prior arrests, less education, more tattoos, more prior psychiatric contact, and were more often alcoholics than alias nonusers. While these findings are consistent with intentional deception, they also suggest that criminal alias users may have a pathological self concept.

Outcome of patients committed to hospital under the Mental Health (Scotland) Act 1960.

All patients formally detained in a Scottish psychiatric hospital between 1974 and 1979 were identified and their outcome determined 2 1/2-8 1/2 years later. A matched group, detained under Emergency Orders only, were also followed-up. Those formally detained had more previous psychiatric contact: functional psychoses were significantly more common in them. They remained in hospital longer, and required extensive community support when discharged. Those detained under Emergency Orders only, consisted of two sub-groups--one who left the area within two years of admission and could not be traced, and the remainder, who continued to require hospital treatment but for shorter times and with less continuous support. Amongst those detained, lack of insight was a predominant feature, which may create difficulty with regard to informed consent to treatment, given the present Amendments to the Mental Health Acts.