Psychiatric care and politics Rates of readmission to psychiatric hospitals have increased in the past decade despite what are generally regarded as marked improvements in the quality of care. This is sufficient cause for us to re-examine the effectiveness and scope of current modes of treatment and to assess the value of the therapeutic efforts relevant to the patient's ability to function in his or her social system. Dr. George Voineskos' article in this issue of the Journal (page 247) deals with this problem. It is a timely article because, apart from confirming for Canada what recently has been shown in England and Scandinavia about factors affecting the former patient's adjustment in the community, the subject of readmission rates brings into focus some of the more critical issues of our professional history. I will examine some of these issues and review the importance of understanding relations and interactions of biologic, psychologic and social factors in the work of hospital-based psychiatrists. Medical school training before this decade usually took little account of the importance of the interaction of psyche and soma. Research, however, slowly is changing this situation. Factors that differentiate subgroups with high and low susceptibility to illness have been described by Hinckle and colleagues.1 They include the way in which situations are perceived and the personality of each person. Roghmann and Haggerty2 have linked stress to illness, and Holmes and Rahe3 have associated important events or changes in the person's life with physical illness. Friedman and Rosenman4 have studied the so-called type A and type B personalities and their differential association with cardiovascular disorders. A number of authors have noted that "5% of first contacts with primary care physicians have a primary diagnosis that is psychiatric, while 30% have a problem involving a significant psy-

chiatric component" (C.B. Robinowitz: of the population and 10% of the offunpublished data, 1977). Bain and spring of two persons, one of whom is Spaulding2 have listed the 10 most schizophrenic.12'" The toll of this suffering on the common physical symptoms in order of their frequency in 400 patients seen individual as well as on the national consecutively in a medical outpatient economic welfare is great. Usually the clinic, and have shown that for 4 of patient repeatedly admitted to a mental these symptoms the cause was psychia- hospital has one of these "incapacitattric in nearly 50% of patients. Large ing" illnesses. He may, for example, epidemiologic studies, such as Leigh- hear alien voices or have thoughts and ton's,6 have shown that in a population feelings that are beyond his control. there are subgroups at high risk for ill- At times his sense of helplessness, hopenesses of all types. These groups can be lessness and despair will reach such defined by an analysis of social and de- depths that self-destruction may seem mographic variables. It is clear that the only means of relief. To talk of patients are no less physically ill when "the myth of mental illness" and the the etiologic or sustaining factors re- absolute necessity of consent with refsponsible for their distress are psycho- erence to this group of patients is not social rather than biologic. Indeed, in only specious, but also inhumane. These many instances symptoms are merely persons should have the right to be the end-point of myriad possible etio- treated when their judgement and insight are so severely impaired that they logic pathways. All family practitioners deal with are unable to ascertain that their sympcomplex interactions of psyche and toms differ from the norm, and when soma and usually are successful. How- they are unable to carry out the simple ever, a small number of patients re- activities of daily living or function in quire specialist consultation. The psy- a manner that is not threatening to their chiatrist, as a medical specialist whose health and welfare or that of others. expertise lies in understanding the man- Also, relatives should have the right ner in which biologic, psychologic, so- to expect us to treat, for example, the cial, cultural and environmental factors paranoid patient, without being coerced govern thinking and feeling and how into the undeniably dangerous position they are subsequently expressed in be- of giving permission for treatment to take place. These rights seem forgotten haviour, is trained for this task. The interaction of biopsychosocial by today's self-styled libertarians. Howfactors is also of importance in the ever, their demand that we be accountwork of mental hospital psychiatrists. able for our work is valid. What has These physicians deal mainly with per- psychiatry to offer and how effective sons in our society who have incapa- are our therapeutic endeavours? We can show a reduction in frecitating mental illnesses, many of which of certain specific symptoms quency of The extent a basis.7 have genetic the problem with which the psychia- through the application of specific trists deal is attested to by large epide- pharmacologic regimens - neurolepmiologic studies that have shown that tics, lithium, antidepressants and, to approximately 5% of the population some extent, anxiolytics. However, we are functionally incapacitated by mental have not been able to prove that this illness for long periods, while a much reduction correlates with improved higher percentage are functioning at community adjustment and increased significantly less than optimal capa- self-sufficiency. Estimates of rates of readmission to city.8-10 For example, a schizophrenic facilities range from 20% psychiatric . 1% will affect approximately illness CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118 223

to 60% and are discouraging.14'15 Clinical and research evidence generally has indicated that rehabilitation of psychiatric patients depends on the minimization of psychopathologic symptoms and the maximization of community adjustment.'6 These factors may vary independently.17 Mental status factors at the time of discharge do not appear to have predictive value.'8 Diagnosis, psychopathologic manifestations in hospital, treatment in hospital, and adjustment as perceived by the patient also do not have significant predictive value.'9"0 On the other hand employment and recreational and other leisuretime activities significantly differentiate between those who are repeatedly hospitalized and those who are not." Similarly, physical health, poor working capacity, social isolation, poor housing, emotional problems in the home and hostile attitudes to and from the patients contribute towards poor community tenure.'6""" However, findings on the effects of high expectations of the patient's family are contradicIt is generally recognized that to predict which patients will return to hospital (or those who will require additional assistance and care), and to distinguish them from patients who require different or additional specialized assistance in the community, it will be necessary to develop a practical means for assessing, before discharge, patients who will have the greatest difficulty in community adjustment. A community adjustment rating examination will have to become as routine a part of our repertoire as the mental status examination is at present. Because many of our patients do not have relatives or close friends who can be contacted, or a professional who has observed accurately their everyday functioning, the most valuable scale of predictive validity for future community adjustment would be based on data gleaned solely from the patient. It would, however, be a scale that had been validated concurrently by extensive study of data from professional observers and relatives or close friends of the patient, and would be valid for a reasonably wide range of "chronic" disorders. Various current questionnaires and rating scales used to predict outcome of psychiatric care in terms of community adjustment after discharge have been reviewed.'7"7 None, however meets the stringent methodologic and practical criteria required for general clinical use.'0 Dollars for research in this field are needed. Funding for this and other projects dealing with psychiatry should be commensurate with the degree to 224

which these illnesses adversely affect society. Further research to increase the specificity of biologic and psychologic types of treatment and to delineate subgroups of patients for whom auxiliary psychotherapeutic interventions would be beneficial is needed badly, but is not in itself sufficient. We must also develop a truly integrated system for delivery of such care and assistance in the community. Indeed, systems involving cooperative functioning of education, health and justice, and all federal, provincial and local aspects of community and social services are being established.27-29 In each successful (albeit not objectively evaluated) instance all sectors of the service delivery system, including politicians and business and community representatives, have made a conjoint, voluntary commitment to the creation of a system of service delivery that was accessible to the former patients, flexible with respect to change, accountable to the local community, parsimonious in its use of patient time and available resources, and feasible in that it was planned locally within legislative and financial limits. In each instance continuity of care for the patient, sophisticated communication systems between involved professionals and commitment to objective evaluation were considered of paramount importance. Such systems link agencies in a meaningful network. In keeping with these changes, the modern psychiatric hospital has evolved from being a totally self-sufficient, community-unto-itself "institution", to being an integral part of this system. Preferably the patient asks the hospital for assistance, and while receiving that assistance maintains a strong psychologic bond with one or more persons within the patient's own social system. To the extent that this is true the hospital is not an institution in the negative sense of the term. In the light of these efforts to coordinate care, decrease institutionalization and increase the effectiveness of treatment, the more recent thrust of governments for management by results rather than just by objectives might seem appropriate and commendable. Unfortunately it appears to be coupled with an exponential increase in numbers of administrators, a decrease in physician input and a definition of results in monetary rather than patient care terms. An uncomfortable trend is emerging wherein crucial health decisions appear to be based largely on political needs, administrative expediencies and budgetary constraints without adequate attention to the needs of the client. In conclusion, around the act of readmitting a patient to hospital care

CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118

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exist a plethora of current political, professional and administrative issues. Advances have been made in psychiatry through systematic studies of drug and psychologic types of treatment and studies of the care of patients with respect to their place and needs in society. Governments have used the results of these studies to save money and to take patients out of hospital and keep them out when humane management would have continued to provide some with asylum (M.O. Vincent: unpublished communication, 1977). Now, also for the sake of small, short-term savings, the future care of many patients is being jeopardized. As a profession we are what we do. Decisive action on each of these issues is necessary. The patient's welfare and best interests must be not only a clinical commitment, but also a political one. M.G.G. THOMPSON, MD Chairman, council on education and professional liaison Canadian Psychiatric Association and medical director London Psychiatric Hospital London, Ont.

References 1. HINCKLE LE JR, CHRISTENSON WN, KANE FD, et al: An Investigation of the relation between

life experience, personality characteristics, and general susceptibility to illness. Psychosom Med 20: 278, 1958 2. ROGHMANN U, HAGGERTY RI: Daily stress, illness, and use of health services in young families. Pediatr Res 7: 520, 1973 3. HOLMES TH, RiwE RH: The Social Readjustment Rating Scale. I Psychosom Res 11: 213, 1967 4. FRIEDMAN M, ROSENMAN RH: Type A Be-

5. 6. 7. 8. 9. 10. 11. 12. 13.

haviour and Your Heart, New York, Fawcett World, 1975 BAIN ST, SPAULDING WB: The importance of coding presenting symptoms. Can Med Assoc 1 97: 953, 1967 LEIGHTON AH: My name is Legion: Foundations for a Theory of Man's Response to Culture, New York, Basic, 1959 ROSENTHAL D: Genetic Theory and Abnormal Behaviour, New York, McGraw, 1970 ESSEN-MOLLER E: Tndvidual traits and morbidity in a Swedish rural population. Acta Psychiatr Scand [SupplI 100: 1, 1956 LEIGHTON DC, et al: The Character of Danger, New York, Basic, 1963 SROLE L, et al: Mental Health in the Metropolis: The Midtown Manhattan Study, New York, McGraw, 1962 Gum SB: Psychiatry and medicine: the research gap. Hosp Pract 12: 15, 1977 EISENsERO L: The future of psychiatry. Lancet 2: 1371, 1973 DUNHAM HW: Schizophrenia: the impact of

sociocultural factors. Hosp Pract 12: 73, 1977 14. DAvIs JM, GOSENFELD L, TsAI CC: Main-

tenance antipsychotic drugs do prevent relapse: a reply to Tobias and MacDonald. Psychol Bull 83: 431, 1976 15. TALaorr JA: Stopping the revolving door a study of readmissions to a state hospital. Psychiatr Q 48: 159, 1974 16. CSAPO GK, KAZARIAN SS, LANDMARK J, et al: Expansion, Revalidatlon and Evaluative Use of a Community Adfustment Scale, Pre-publication Draft, A National Health and Welfare

Research and Development Study (in preparation)

17. WISEMANN MM: The assessment of social adjustment: a review of techniques. Arch Gen Psychiatry 32: 357, 1975 18. ROSENBLATr A, MAYER JE: The recidivism of mental patients: a review of past studies. Am I Orthopsychiatry 44: 697, 1974 19. ELLSWORTH RB, FOSTER L, CHILDERS B, et al: Hospital and community adjustment as perceived by psychiatric patients, their families, and staff. I Consult Clmn Psychol 32: 1, October 1968 20. WILLIAMS RA, WALKER RO: Schizophrenics at time of discharge. Arch Gen Psychiatry 4: 87, 1961 21. CHRISTENSEN JK: A 5-year follow-up study of male schizophrenics: evaluation of factors influencing success and failure in the community. Acta Psychiatr Scand 50: 60, 1974 22. CUNNINGHAM MK, BoTuINIK W, DOLSON J, et al: Community placement of released mental patients: a five-year study. Social Work 14: 54, 1969 23. HERRERA EG, LIFsoN BG, HARTMAN E, et al: A 10-year follow-up of 55 hospitalized adolescents. Am I Psychiatry 131: 169, 1974 24. MANNINO FV, SHORE MF: Family structure, aftercare and post-hospital adjustment. Am I Orthopsychiatry 44: 76, 1974 25. VAUGHN CE, LEFF JP: The influence of family and social factors on the course of psychiatric illness: a comparison of schizophrenic and depressed neurotic patients. Br I Psychiatry 129: 125, 1976 26. Idem: The measurement of expressed emotion in the families of psychiatric patients. Br I Soc Clin Psychol 15: 157, 1976 27. SHAW RC: The role of the North York InterAgency Council. Can Welfare 52: 17, 1976 28. DELAHANTY D: Human Services Co-ordination Project Final Report on Services Integration Targets of Opportunity "SITO" Grant. No. 12-P-57654, 1973-6. Louisville, Human Services Co-operation Alliance, 1976 29. THOMPSON MG: A systems approach to delivery of mental health services in North Halton County, Canada. I Am Acad Child Psychiatry 14: 292, 1975

Registries of persons who may be overusing prescribed drugs and of patients who may be considered dangerous Various kinds of registries are becom- aware that some patients "shop" from ing the vogue, possibly because data physician to physician for prescriptions storage and retrieval systems are be- and often obtain large supplies of coming more sophisticated and more drugs, usually of the psychotropic economic. For example, we have child variety. The AMA believes this activity abuse registries and "at-risk" registries can be curtailed if the names of these for infants and children, and the patients are recorded centrally and reWalton committee1 proposed registries ported to practising physicians periodifor cervical cancer screening programs. cally. The alerted physician should be The Alberta Medical Association less likely to be victimized by the drug (AMA) has embraced the use of patient "shopper". Since 1973 the names of registries. Ten years ago it established approximately 300 persons have been and operated a child abuse registry entered in this registry, and 10 to 15 until a similar registry was established names are added each month. No one by the provincial government. In May is included in the registry until the 1973 the board of directors approved case is reported in writing by a physithe recommendation made by its com- cian. About once a month the names mittee on alcoholism and drug abuse of persons who have been added to that the AMA devise a registry of per- the registry since the last publication sons who may be overusing prescribed are circulated to all registered physidrugs. In 1976, after a near-fatal attack cians, who may keep the letters for on an Alberta physician by a patient, future reference. Any physician unthe board agreed that a registry of certain about a patient can approach dangerous patients should be estab- the AMA office to determine whether lished. that patient has been registered preWhy is a registry for persons who viously. may be overusing prescribed drugs How useful is the registry? Recently necessary? Most practising physicians, approximately 25% of practising physiparticulariy those in primary care, are cians in Alberta wrote to the AMA 226 CMA JOURNAL/FEBRUARY 4, 1978/VOL. 118

office stating that they wished to continue receiving mailings from the registry. The registry of patients who may be considered dangerous was established for the protection of physicians because attacks by patients on physicians are reported periodically. Perhaps such attacks are an occupational hazard, but any attack on a physician is one too many as far as the AMA is concerned. This registry operates on the philosophy that dangerous patients may threaten before they attack or they may threaten one physician and, at some time in the future, attack another. When a physician is threatened or attacked by a patient he or she reports the incident, in writing, to the registry. The names received are circulated periodically to all practising physicians. Armed with this information a physician may be in a better position to protect him- or herself from the patients who may be potentially dangerous. In the 1st year of its operation the registry grew to include 21 individuals; about 1 person is added to it each month. Does this registry help? Already one physician

Psychiatric care and politics.

Psychiatric care and politics Rates of readmission to psychiatric hospitals have increased in the past decade despite what are generally regarded as m...
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