The course of psychiatric disorder, III: Longitudinal principles

Attitudes toward and patterns of medication use among people with serious mental illness: There's more than meets the eye

BACKGROUND AND AIM

There are growing concerns about the long-term effects of psychiatric medication after a major psychiatric crisis. Recent evidence shows a diverse impact of long-term use on various outcome domains, which may help explain why non-adherence is so common. In the current study we explored the subjective perceptions of factors that impact both attitudes toward and patterns of use of medication among individuals with serious mental illness (SMI).

METHOD

Sixteen individuals with an SMI and a recognized psychiatric disability who had used psychiatric medication for at least 1 year were recruited for the study via mental health clinics and social media. Participants were interviewed using a semi-structured interview based on the narrative approach, focusing on attitudes toward and patterns of use of psychiatric medication. All interviews were transcribed and analyzed using thematic analysis.

RESULTS

Three discrete sequential phases emerged, each characterized by different themes referring to attitudes toward medication and patterns of use: (1) "loss of self" and a high level of medication use; (2) accumulating experiences of using/reducing/stopping medication; and (3) forming more stable attitudes toward medication and developing one's own pattern of use. The transition between phases was dynamic in nature and represents a non-linear process. Complex interactions were generated at different phases between the related themes, which shaped attitudes toward medication and patterns of use.

CONCLUSIONS AND IMPLICATIONS

The current study reveals the complex ongoing process of forming attitudes toward medication and patterns of use. Recognizing and identifying them via a joint reflective dialog with mental health professionals can enhance alliance, shared decision-making, and person-centered recovery-oriented care.

The Person with Schizophrenia as a Person

In the mental health field, the attention given to the subjective side of a person's experience is grossly inadequate. The best way to reflect the subjectivity of a person may be by means of the subjectivity of another. To take account of both subjective experience and objective measures in the course of mental disorders, a new concept is needed. This may be the person's story.

Uncertainty Theory: A Powerful Approach to Understanding Psychiatric Disorder

OBJECTIVE

The tendency over the years in the mental health field has been to cling in circular fashion to one single domain after another, biological, psychological, or social, to explain severe disorder and not even to consider the data from the domain of focus that came before. This report notes that attempts to explore more complex biopsychosocial explanations that integrate the diverse domains have been generally ignored or foundered on the problems posed by the complexities involved and suggests an approach for moving beyond these problems.

METHOD

A case history using two different formats highlights the degree to which the single domain models ignore one or another area of data.

RESULTS

Uncertainty theory is suggested as providing an important basis for exploring the complexities of a biopsychosocial understanding of mental health problems.

CONCLUSIONS

This approach can provide a possible orientation to promote improved research, training, and treatment.

Trajectories of medication attitudes and adherence behavior change in non-adherent bipolar patients

OBJECTIVES

While medication treatment is necessary for the successful management of bipolar disorder (BD), non-adherence rates are up to 60%. Although medication attitudes are believed to be relevant to adherence behavior, few studies have investigated the trajectories of adherence change. This study evaluated attitudinal correlates of adherence conversion in 86 poorly adherent individuals with BD.

METHODS

This secondary analysis pooled data from two uncontrolled prospective trials of customized adherence enhancement (CAE), a psychosocial intervention delivered over 4-6 weeks. Poor adherence was defined as missing at least 20% of prescribed BD medication based on the self-reported Tablets Routine Questionnaire (TRQ). The sample was dichotomized into converters who achieved good adherence (N=44) and non-converters who remained poorly adherent (N=21). Converters vs. non-converters were compared on adherence, attitudes, and symptoms at baseline, 6 weeks and 3 months.

RESULTS

At baseline, converters and non-converters were similar demographically and clinically, but converters were less non-adherent (32% doses missed) than non-converters (59% missed). At 6 weeks, converters had better attitudes than non-converters. At 3 months, converters maintained improvements, but group differences were less pronounced due to some improvement in non-converters. Converters had better adherence at 3 months and trajectories differed for the groups on attitudes. Symptoms gradually improved for both converters and non-converters.

CONCLUSIONS

Over two-thirds of poorly adherent BD patients who received CAE converted to good adherence. Improved medication attitudes may be a driver of improved adherence behavior and ultimately reduce BD symptoms.

Clinicians' perceptions of challenges and strategies of transition from assertive community treatment to less intensive services

The study aimed to identify clinical strategies and challenges around transition from Assertive Community Treatment (ACT) to less intensive services. Six focus groups were conducted with ACT team leaders (n = 49). Themes were grouped under four intervention-focused domains: (1) client/clinical, (2) family and natural supports, (3) ACT staff and team, and (4) public mental health system. Barriers to transition included beliefs that clients and families would not want to terminate services (due to loss of relationships, fear of failure, preference for ACT model), clinical concerns that transition would not be successful (due to limited client skills, relapse without ACT support), systems challenges (clinic waiting lists, transportation barriers, eligibility restrictions, stigma against ACT clients), and staff ambivalence (loss of relationship with client, impact on caseload). Strategies to support transition included building skills for transition, engaging supports, celebrating success, enhanced coordination with new providers, and integrating and structuring transition in ACT routines.

Recovery from serious mental illness: trajectories, characteristics, and the role of mental health care

OBJECTIVE The objective was to identify trajectories of recovery from serious mental illnesses. METHODS A total of 177 members (92 women; 85 men) of a not-for-profit integrated health plan participated in a two-year mixed-methods study of recovery (STARS, the Study of Transitions and Recovery Strategies). Diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis. Data sources included self-reported standardized measures, interviewer ratings, qualitative interviews, and health plan data. Recovery was conceptualized as a latent construct, and factor analyses and factor scores were used to calculate recovery trajectories. Individuals with similar trajectories were identified through cluster analyses. RESULTS Four trajectories were identified-two stable (high and low levels of recovery) and two fluctuating (higher and lower). Few demographic or diagnostic factors differentiated clusters at baseline. Discriminant analyses for trajectories found differences in psychiatric symptoms, physical health, satisfaction with mental health clinicians, resources and strains, satisfaction with medications, and mental health service use. Those with higher scores on recovery factors had fewer psychiatric symptoms, better physical health, greater satisfaction with mental health clinicians, fewer strains and greater resources, less service use, better quality of care, and greater satisfaction with medication. Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications. CONCLUSIONS Having access to good-quality mental health care-defined as including satisfying relationships with clinicians, responsiveness to needs, satisfaction with psychiatric medications, receipt of services at needed levels, support in managing deficits in resources and strains, and care for general medical conditions-may facilitate recovery. Providing such care may improve recovery trajectories.

Dynamic patterns in mood among newly diagnosed patients with major depressive episode or panic disorder and normal controls

OBJECTIVE

The purpose of this pilot study was to compare the dynamic patterns of hourly mood variation among newly diagnosed primary care patients with major depressive disorder or panic disorder with patterns in patients with neither disorder.

METHOD

Five adult patients with major depressive episode, 5 with panic disorder, and 5 with neither disorder were asked to complete hourly self-assessments of anxiety and depression (using 100-mm visual analog scales) for each hour they were awake during a 30-day period. Time series were analyzed using ARIMA (autoregression, integration, moving average) modeling (to assess periodicity), Lyapunov exponents (to assess sensitivity to initial conditions indicative of chaotic patterns), and correlation dimension saturation (to assess whether an attractor is limiting change). The study was conducted from March to June 2003.

RESULTS

Controls displayed circadian rhythms with underlying chaotic variability. Depressed patients did not display circadian rhythm, but did show chaotic dynamics. Panic disorder patients showed circadian rhythms, but 2 of the 4 patients completing the self-assessments displayed nonchaotic underlying patterns.

CONCLUSIONS

Patients with major depressive disorder or panic disorder may differ from controls and from each other in their patterns of mood variability. There is a need for more research on the dynamics of mood among patients with mental disorders.

Subjectivity and severe psychiatric disorders

To have a complete human science in the mental health field it is essential to give adequate attention to both the objective and the subjective data related to people with psychiatric disorders. The tendency in the past has been to ignore or discount one or the other of these data sources. Subjective data are particularly neglected, sometimes considered (only) part of the "art" of medicine since the usual methodologies of the physical sciences in themselves are not adequate to reflect the nature, elusiveness, and complexity of human subjective experience. The complete experience of hallucinated voices, for instance, often includes not only the voices themselves but also terrible anguish and terrifying inability to concentrate. But even such descriptors fall unnecessarily short of reflecting the data of the experience, thus leaving research, theory, and treatment with incomplete information. To represent adequately the subjective data it is essential to recognize that besides the usual discursive knowledge and methods of traditional physical science, a second kind of knowledge and method is required to reflect the depth of human experience. To accomplish this, we must employ approaches to narrative and the arts that are uniquely capable of capturing the nature of these experiences. Only by attending seriously in our research, training, theory, and practice to the unique nature of subjective data is it possible to have a true human science for our field.

The pain and the possibility: the family recovery process

The onset of a mental illness is a traumatic experience for all the members of a family. While the mental illness in their family member may be life long, family members can experience their own recovery from the trauma, just as their family member with a mental illness can experience recovery. This article will describe the family recovery process.

Culture, stress and recovery from schizophrenia: lessons from the field for global mental health

This cultural case study investigates one U.S. psychosocial rehabilitation organization's (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons' "recovery-oriented" initiatives unwittingly mobilized stressful North American discourses of valued citizenship. At times, efforts to "empower" people diagnosed with schizophrenia to become esteemed self-made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia's sensitivity to stress and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to "better" outcomes in the developing world may rely on the availability of locally relevant techniques to address stress.

Schizophrenia and alterations in self-experience: a comparison of 6 perspectives

Contemporary researchers have tended to examine dysfunction among the lives of persons with schizophrenia as a matter of the impact of biological and social forces. While this has greatly advanced the knowledge base, any account of schizophrenia without a full consideration of the illness's first-person dimensions risks missing that schizophrenia is a disorder that interrupts the lives of people who must continue to struggle to find and create security and meaning. While literature from a range of sources has explored self-experience in schizophrenia, one barrier to the creation of a larger synthesis and application of this work is that it remains unclear whether, and to what degree, these differing views of self-experience are comparable with one another. To address this issue, this article reviews 6 different accounts of self-experience, a fundamental, first-person dimension of schizophrenia. The 6 are early psychiatry, existential psychiatry, psychoanalysis, phenomenology, psychosocial rehabilitation, and dialogical psychology. After comparing and contrasting the 6, we conclude that there is a wide-ranging, if general consensus, which suggests that many suffering from schizophrenia experience themselves as diminished relative to their former selves, ie, after onset they experience themselves as less able to engage the world effectively, which intensifies their anxieties in the face of everyday interactions. However, within this broad consensus, significant disagreements exist around issues such as whether these difficulties meaningfully predate the illness, how recovery is possible, and if so, under what conditions. In closing, we suggest a program of research to address these disagreements.

Activity and Social Participation in the Period following a First Episode of Psychosis and Implications for Occupational Therapy

Purpose:

The study advances a conceptual understanding of activity and social participation in the period following the first episode of psychosis.

Method:

A constructivist, grounded theory approach was used. Data were collected from 25 primary participants who had experienced a first episode of psychosis in the previous 5 years; 15 secondary participants, such as family and friends, with knowledge of the activity and social experiences of primary participants, personal records and documents; and six key informants.

Findings:

The first episode of psychosis was highly disruptive and even damaging to activity and social participation. Recovering from this fall-out, to maintain engagement in activities and social participation, included the need to create new plans, adjust to affective disconnection, develop balanced lifestyles, match participation to abilities, learn new skills, and participate under new and constraining social conditions.

Conclusion:

The period following the first episode of psychosis is a time of high risk for disengagement from activity and social participation. Occupational therapists have an important role to play in enabling activity and social engagement. The findings offer examples of how occupational therapy services might address critical tasks for activity and social engagement.

Beyond early intervention: can we adopt alternative narratives like 'Woodshedding' as pathways to recovery in schizophrenia?

AIM

To consider how early intervention in psychosis can support a recovery paradigm.

METHODS

Significant numbers of those developing a first episode of psychosis are on a path to a persisting and potentially life long condition. Constituting the schizophrenia spectrum disorders, such conditions demand the particular qualities and attitudes inherent within recovery-based practice. This paper explores some of these qualities and attitudes by examining the tension between a traditional 'clinical' narrative used by many health providers and a 'human' narrative of users of services and their families.

RESULTS

We draw out key features and constructs of recovery practice as they relate to the EI paradigm. These include: woodshedding, turning points, discontinuous improvement models, therapeutic optimism, gradualism and narratives of story telling. We also highlight the role of family members and other close supporters and believe their potential contribution requires greater consideration.

CONCLUSIONS

The early intervention (EI) paradigm can resonate and indeed offer a stronghold for recovery-based practice where traditional mental health services have sometimes struggled. Conversely, failure of caregivers to provide such an approach in the early phase of illness can cause unnecessary and sometimes disastrous consequences.

Lessons from Jurassic Park: patients as complex adaptive systems

RATIONALE

With realization that non-linearity is generally the rule rather than the exception in nature, viewing patients and families as complex adaptive systems may lead to a better understanding of health and illness. Doctors who successfully practise the 'art' of medicine may recognize non-linear principles at work without having the jargon needed to label them.

METHODS

Complex adaptive systems are systems composed of multiple components that display complexity and adaptation to input. These systems consist of self-organized components, which display complex dynamics, ranging from simple periodicity to chaotic and random patterns showing trends over time.

RESULTS

Understanding the non-linear dynamics of phenomena both internal and external to our patients can (1) improve our definition of 'health'; (2) improve our understanding of patients, disease and the systems in which they converge; (3) be applied to future monitoring systems; and (4) be used to possibly engineer change.

CONCLUSION

Such a non-linear view of the world is quite congruent with the generalist perspective.

[Who is Called "Schizophrenic"?]

Someone is called "schizophrenic" when suffering from a disorder described in 1911, for the first time by a Swiss psychiatrist Eugen Bleuler in a book entitled "Dementia Praecox oder Gruppe der Schizophrenien". In this book, Bleuler proposes a two-faced approach: one centered on the disease, the other on the person. Bleuler's main contribution was to show the importance of the latter in the determinism of clinical pictures and illness course, thus opening the way to more anthropological approaches to the schizophrenic self. Taking these approaches into account, at a time when naturalistic models of the illness are prevailing, is far from being of no consequence, as far as the effectiveness of our therapeutic actions is at issue.

ACT and recovery: integrating evidence-based practice and recovery orientation on assertive community treatment teams

We examine whether Assertive Community Treatment (ACT), a widely implemented and rigorously studied practice, can successfully incorporate a recovery-oriented approach while continuing to retain program fidelity. We briefly review the effectiveness of ACT as an evidence-based practice, with a focus on adaptations to changing populations and contexts. We explore philosophical similarities and differences between ACT and recovery and examine how fidelity standards, a widely used indicator of how ACT teams operate, support or interfere with the adoption of a recovery-oriented practice. Finally, we provide recommendations on how best to incorporate a recovery orientation into existing ACT teams.

Identifying mechanisms of treatment effects and recovery in rehabilitation of schizophrenia: longitudinal analytic methods

The longitudinal dimension of schizophrenia and related severe mental illness is a key component of theoretical models of recovery. However, empirical longitudinal investigations have been underrepresented in the psychopathology of schizophrenia. Similarly, traditional approaches to longitudinal analysis of psychopathological data have had serious limitations. The utilization of modern longitudinal methods is necessary to capture the complexity of biopsychosocial models of treatment and recovery in schizophrenia. The present paper summarizes empirical data from traditional longitudinal research investigating recovery in symptoms, neurocognition, and social functioning. Studies conducted under treatment as usual conditions are compared to psychosocial intervention studies and potential treatment mechanisms of psychosocial interventions are discussed. Investigations of rehabilitation for schizophrenia using the longitudinal analytic strategies of growth curve and time series analysis are demonstrated. The respective advantages and disadvantages of these modern methods are highlighted. Their potential use for future research of treatment effects and recovery in schizophrenia is also discussed.

Attrition bias in longitudinal research involving adolescent psychiatric outpatients

This study investigated whether the degree of difficulty contacting participants at follow-up in a longitudinal study of adolescent psychiatric outpatients is associated with baseline and/or follow-up Axis I and II psychopathology and sociodemographic variables. At baseline, 101 participants 15 to 18 years old were assessed using standardized diagnostic instruments, and 97 were reinterviewed, face-to-face, at 2-year follow-up. A hierarchical tracking strategy and meticulous follow-up contact log were used. More than one quarter of the sample required multiple tracking efforts to be located and interviewed. The presence and number of Axis I and II disorders at 2-year follow-up was significantly associated with follow-up contact difficulty. Baseline psychopathology and sociodemographic variables were not associated with follow-up contact difficulty. The findings indicate that longitudinal studies of adolescent outpatients that compare dropouts with completers utilizing baseline characteristics are likely to underestimate the extent of psychopathology at follow-up.

Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery?

There is a tension between models of 'recovery', which are increasingly important in mental health policy and practice, and systematic models of care delivery based on the notion of 'chronic illness'. A collaborative approach is central to the development of high-quality recovery-oriented mental healthcare.

How evidence-based practices contribute to community integration

Since the groundbreaking work of the Robert Wood Johnson Conference in 1998 identifying six evidence-based practices (EBPs) for people with severe mental illness (SMI), the mental health field has moved in the direction of re-examination and redesign of service systems. Surprisingly, one area that has not been fully explicated is the role that EBPs play in promoting community integration. In this paper, we explain how community integration is a unifying concept providing direction and vision for community mental health for people with SMI. As one crucial aspect of the recovery process, community integration clarifies the link between EBPs and recovery. We propose an alternate view, grounded in the empirical literature, to the assertion by Anthony, Rogers, and Farkas [2003, Community Mental Health Journal, 39, 101-114] that "EBP research has rarely demonstrated a positive impact on recovery related outcomes."

Longitudinal course of bipolar I disorder

The course of bipolar I disorder is characterized by frequently fluctuating levels of manic and depressive symptoms. In the current study, we sought to characterize the month-by- month course of this disorder in 61 patients who were originally enrolled in a clinical trial and were followed for a mean of 23.7 months (SD = 6.1). All patients in the trial received medication management; some received family psychosocial interventions as well. On a monthly basis, we assessed symptom severity using the Modified Hamilton Rating Scale for Depression (MHRSD) and the Bech-Rafaelson Mania Scale (BRMS). Each month, we categorized each participant as fully symptomatic, partially symptomatic, or asymptomatic in terms of both depressed and manic symptoms. We found that the median percent time fully symptomatic was 8%, the median percent time partially symptomatic was 22%, and the median percent time asymptomatic was 59%. Using DSM-IV-TR criteria for defining an acute mood episode, we found that the median length of episode was 1 month, and participants experienced, on average, one episode every 8 months. Estimates concerning percent time fully symptomatic and asymptomatic converge with those reported in other datasets.

The integration of treatment and rehabilitation in psychiatric practice and services: a case study of a community mental health center

After briefly reviewing the relationship of psychosocial rehabilitation to psychiatric practice, the authors recommend a renewed commitment of psychiatrists to bridge and integrate psychiatric treatment with psychosocial rehabilitation in practice and in the organization of services. They use the case example of an urban, community mental health center to illustrate a strategy for achieving greater integration of these two, relatively independent fields of professional practice. The Center's strategy for integration includes (1) center-wide planning, (2) structuring the medical staff office to support the task of integration, (3) establishing a model of practice and principles of care that supports both domains of intervention, (4) educating medical staff about psychosocial rehabilitation, (5) inter-disciplinary team building, including a definition and discussion of professional roles, (6) expanding services research on psychosocial rehabilitation, and (7) advocating in alliance with rehabilitation colleagues for expanded psychosocial rehabilitation services and their integration with treatment. By taking initiative to forward the integration of treatment and rehabilitation, psychiatrists better serve seriously ill patients and more effectively define their own work and roles.

Coping with schizophrenia: patterns in later adulthood

By exploring the subjective experience of older people, this study investigated whether the coping framework developed with younger adults with schizophrenia could be applied to people with schizophrenia over the age of 50 years. Fifteen participants diagnosed with schizophrenia, over the age of 50, were recruited from clubhouses and given a semi-structured interview to identify what, if any, coping strategies were used to manage persistent symptoms. The results indicated that the coping strategies used by this older sample were similar to those reported by earlier studies with younger populations. However, it was reported that the efficacy of the coping strategies had increased as the participants had grown older and accepted their illness. Older adults with schizophrenia are capable of employing strategies to manage their illness and should be considered an important source of knowledge for younger individuals who struggle with the illness and for mental health professionals who work with the chronically mentally ill.

Does U.S. federal policy support employment and recovery for people with psychiatric disabilities?

Evidence suggests that a high percentage of people with a psychiatric disability can recover--find meaningful work, develop positive relationships, and participate fully in their communities. Evidence also suggests that work is an essential component of recovery. However, few people with a serious psychiatric disability are actually employed and most of those who are employed work only part-time at barely minimum wages. To assess the impact of federal programs such as Social Security Disability Insurance, vocational rehabilitation, medical insurance, and psychiatric services upon employment, we conducted a qualitative study of 16 employed and 16 unemployed individuals with psychiatric disabilities. All of our participants had disabilities severe enough to qualify them for Social Security Disability benefits. They told us that current federal policies and practices encouraged employment and integration of only a few participants, in a particular stage of their recovery, and placed significant barriers in the employment path of others.

Progressing from patienthood to personhood across the multidimensional outcomes in schizophrenia and related disorders

The conceptualization of outcome in schizophrenia has been modified since Krapelin's dementia praecox and is now thought to be more heterogeneous and multidimensional. Qualitative research reveals a deeper and more complete understanding of the complex processes involved. This study investigates and describes the subjective experience of the multidimensional outcome of schizophrenia. The findings are based on bimonthly comprehensive assessments conducted over a 1-year period with 43 persons who were hospitalized for schizophrenia and related disorders. Results reveal ongoing person-environment interactions, which constitute the nonlinear progression from "patienthood" to 'personhood" across the multidimensional outcome domains of work, treatment, and social relationship. To facilitate this difficult process, it is essential to simultaneously help consumers develop their strengths and increase society's awareness and commitment to meet their unique needs.

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.

Exploring the longitudinal course of psychotic illness: a case-study approach

OBJECTIVE

Thirty-three patients with a diagnosis of a psychotic disorder (schizophrenia, bipolar disorder, atypical psychosis) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) were studied to qualitatively assess the longitudinal course of the disorder using a case-study approach.

METHODS

Weekly fluctuations in patient symptomatology and overall social and personal functioning using the Global Assessment Scale were assessed following index hospitalization. Patients were followed for 1 year.

RESULTS

The emergent courses showed no relationship to diagnosis but followed 3 general trends: 1) positive incline; 2) fluctuating; and 3) stable. Individual representations of each course were examined closely, and biological and psychosocial factors associated with each were evaluated.

CONCLUSIONS

The results supported the longitudinal patterns and individual interactions of Strauss's Interactive Developmental Model. The clinical course of psychotic disorders may be represented by 3 patterns. Key factors in the interaction between patient and environment that generate important changes in the evolution of each illness were illustrated.

The evolution of mental health services: partial hospitalization as a case example

Controversy exists regarding the current status, merits, and future of partial hospitalization. Originally conceptualized as one of the least restrictive modalities for treating acutely ill or highly impaired individuals in the community, these functions increasingly are being addressed by rehabilitation programs and assertive or intensive outpatient treatments. At the same time, third-party payers, such as managed-care firms, are extending coverage for the partial-hospital modality. We use the current debates about the merits of this modality to identify potential forces that impede and promote the evolution of mental health services. Specifically, we use this case example to illustrate four prevailing myths about the manner in which services evolve.

Defining new frameworks for psychosocial intervention

The personal experiences of individuals with schizophrenia have been neglected in the psychiatric literature. Disappointingly, ideas about the impact of the illness on the experience of "self" have either been devalued or based primarily on the impressions of theorists rarely collaborating with individuals with the illness. Rather than making assumptions about the subjective experience of mental illness, we must enter a meaningful dialogue with our clients so that they can tell us about their situations using their own voices. This study presents life-history interviews with 15 individuals diagnosed with schizophrenia and describes the explanatory models they use to give coherence to their experiences of psychosis. The struggle for control emerges as a central theme with effects on the management of symptoms, self-image, feelings of social competence, and dealing with others' expectations. Respondents speak about the possibility of recovery from illness through engaging in a process of internal and external reorganization. These individuals echo the assertions in the literature generated by consumers and other investigators of subjective experience and advocate for recovery-based models of care including therapeutic discourse with clients.

The long-term course of panic disorder and its predictors

Whereas lifetime prevalence rates of panic disorder--as established in epidemiologic surveys--range between 1.6 and 3.5%, 1-month rates usually amount to much less than one half of the lifetime rates. This finding indicates that a substantial proportion of patients who had panic disorder at some stage in their life must have remitted. In contrast to these results, clinicians tend to regard panic disorder as a chronic condition because, as a rule, they see panic patients only several years after onset of the disorder. A number of small, prospective, long-term studies of such clinical populations indicate that after several years, between 17 and 70% of patients still have panic attacks, and between 36 and 82% have phobic avoidance. In the largest and longest follow-up study published to date, 45% of all patients showed an unremitting--although in a certain proportion waxing and waning--course, 24% followed a pattern of remissions and relapses, whereas 31% went back into a stable remission. The evidence of factors predicting the course of panic disorder in clinical populations suggests that long duration and agoraphobia at baseline--not the severity and frequency of panic attacks--are predictors of an unfavorable course. Additional studies are needed to determine whether personality factors, depression, and other variables are also of predictive relevance. Also, factors working during follow-up, such as positive and negative life events, coping behaviors, and treatment, should be considered in future studies.

Chronically mentally ill individuals re-entering the community after hospitalization

The purpose of this phenomenological study was to increase the understanding of the experiences of chronically mentally ill individuals who are re-entering the community after hospitalization. Ten individuals from an acute care psychiatric hospital who had had two or more admissions within a 12-month period were interviewed, shortly before discharge and subsequently between two and four times while in the community. Three interrelated themes emerged. First, at the time of discharge, the optimism of the participants about returning home was tempered by a realistic recognition of their problems. As time passed, their problems seemed to become their preoccupying focus and optimism faded. Second, for most of the participants, relationships with others, positive, negative or both, played an important role in their return to home and community. Third, participants who experienced more positive social relationships also described individual achievements and community involvement. The re-entry process was not a smooth transition for these individuals.

The active ingredients of effective case management: a research synthesis

As we move to managed care, the nature and role of case management is in flux and undetermined. Based on the outcome research, this paper seeks to identify the common elements of effective case management practice to guide its development under the new financing schema.

Patterns of short-term course in patients treated in a day unit for personality disorders

The objectives of the study were (1) to explore differences in the course for patients treated in a day unit specializing in personality disorders (PDs), and (2) to determine characteristics of patients with different courses and predictors of various courses. K-mean cluster analysis was applied to partition a sample of 128 patients, 101 with various PDs and 27 with axis I disorders only, into four groups representing different courses. The course was defined on the basis of global functioning (Health Sickness Rating Scale [HSRS]) at admission, discharge, and 3-years follow-up evaluation. The four courses were labeled good, fair, late improvement, and poor, demonstrating great variation in the short-term course among patients with PDs. Predictors were studied by means of polychotomous logistic regression using the patients with a fair course as the reference group. The dichotomy no PD/cluster C versus cluster A/B predicted a good versus a fair course. A poor work status the last year before admission and irregular discharge predicted a poor or late improvement course versus a fair course, also when controlling for PD clusters. None of the included variables discriminated between patients with a poor versus late improvement course.

"Full recovery" from schizophrenia in the long term: a ten-year follow-up of eight former schizophrenic patients

The present study reports longitudinal data on individuals who ten years ago were fully recovered from a previously diagnosed schizophrenia. Seven out of ten subjects consented and were reexamined at the present follow-up, and data on an eighth subject was secured elsewhere. A semistructured interview was used to examine psychosocial functioning of the subjects in the follow-up period. Out of the six subjects with a confirmed diagnosis of schizophrenia, only three subjects were still fully recovered; one had a deteriorating course and two had a fluctuating course of illness. The results from the study indicate that recovery from schizophrenia may take the form of time-limited remissions for half of the reexamined subjects when strict criteria for full recovery are used. Protective factors such as willpower, a (partly) intact capacity for object attachment, and a supportive family may be important prerequisites for recovery. Two different courses of schizophrenia are illustrated by cases.

Neuropsychological dysfunction and clinical outcome in psychiatric disorders: a two-year follow-up study

The presence of neuropsychological disturbances in schizophrenia and mood disorders raises the question that cognitive impairments might contribute to poor outcome. This report examines changes in neuropsychological performance from hospitalization to a 2-year follow-up evaluation in relation to psychosocial outcome. Findings indicated that unfavorable clinical outcome is associated with marginal changes in neuropsychological performance, whereas good outcome status is associated with neuropsychological improvement. Neuropsychological improvement may thus require a stable period of favorable psychosocial recovery, in schizophrenia and schizoaffective disorder, as well as major mood disorder syndromes.

Dynamical analysis of schizophrenia courses

In order to assess the working hypothesis that schizophrenia may be viewed as a nonlinear dynamical disease, we examined the long-term psychoticity dynamics of 14 patients. The data consist of daily ratings of psychopathology observed for 200 or more consecutive days in each patient. We implemented nonlinear dynamical analysis methods with a potential of being applicable even to relatively short and noisy time series: two different forecasting approaches combined with surrogate methods that allow statistical testing in each single case. The resulting classification of dynamics gives evidence that eight patients show nonlinear evolutions of symptom courses. Four cases can be modeled linearly, two as random processes. Thus, a larger proportion of the schizophrenic psychoses we studied shows nonlinear time courses. In this way the validity of the concept of dynamical diseases could be supported on statistical grounds in this important area of psychopathology. The nonlinear view-a low-dimensional nonlinear system generating psychotic symptoms--may provide the foundation for a more parsimonious theory of schizophrenia compared to traditional multicausal models. In several of the nonlinear cases we also observed the qualitative "fingerprint" of deterministic chaos: a decay of deterministic features of the course of disorder with time.

Patient dynamics in early stages of vocational rehabilitation: a pilot study

Since little is known of the dynamics of the rehabilitation process, this pilot study aims to explore (1) the work performance and personal and social functioning of patients attending a vocational reintegration program; (2) any significant differences in course between successful and unsuccessful patients; and (3) whether these subgroups differed at entrance assessment. Using the 30-item Nurses' Observation Scale for inpatient Evaluation (NOSIE) and a global work performance scale, the sample (N = 31) showed a significant decrease in work performance and a negative trend in most NOSIE scores, instead of the expected steady progress. The turning point is reached after 9 to 12 weeks. In the entrance assessment, the failure subgroup (n = 11) displayed more negative and general symptoms and fewer social skills. It seemed to be not their initial work performance but their resources to cope with the stress of the program that were insufficient. However, not every downhill trend leads automatically to failure, and some patients still have a chance of later improvement.

An analysis of the subjective experience of schizophrenia

To examine how varieties of the subjective experience of schizophrenia (SES) can be categorized, a self-report questionnaire consisting of 150 items from the SES in Japanese was administered to 237 Japanese schizophrenic inpatients, and the results were analyzed through a multivariate method. The first factor represents loss of focus and adequacy of thoughts, behavior, and interpersonal perception; it resembles negative symptoms and coincides with the basic symptoms of schizophrenia reported by anthropological psychiatrists. The second factor represents automatic and excessive thoughts and affective loading, and overlaps "the tremble" of Conrad and the mental automatism of de Clerambault. Both signify different combinations of experiences from conventional descriptive symptoms, and may represent more suitable ways to describe the SES.