The role of the psychiatrist: job satisfaction of medical directors and staff psychiatrists

In a previous survey of Columbia University Public Psychiatry Fellowship alumni, medical directors reported experiencing higher job satisfaction compared to staff psychiatrists. To further this inquiry, the authors conducted an expanded survey among the membership of the American Association of Community Psychiatrists (AACP). We mailed a questionnaire to all AACP members. Respondents categorized their positions as staff psychiatrist, program medical director or agency medical director, and rated their overall job satisfaction. The form also included a number of demographic and job characteristic items. Of 479 questionnaires mailed, a total of 286 individuals returned questionnaires (61%-12 forms were undeliverable). As in our previous survey, medical directors experience significantly higher job satisfaction compared to staff psychiatrists. Program and agency medical directors do not differ significantly. In addition, job satisfaction is strongly and negatively correlated with age for staff psychiatrists but not for medical directors. This survey strengthens the previously reported advantage medical directors have over staff psychiatrists regarding job satisfaction. The finding that job satisfaction decreases with increasing age of staff psychiatrists but not medical directors is particularly interesting, suggesting that staff psychiatrist positions may come to be regarded as "dead-end" over time. Psychiatrists are advised to seek promotions to program medical director positions early in their careers, since these positions are far more available, and provide equal job satisfaction, compared to agency medical director positions.

Early sexual initiation and subsequent sex-related risks among urban minority youth: the reach for health study

CONTEXT

Since the 1980s, the age at which U.S. teenagers, especially minority youth, begin having sex has decreased. There is limited information on the relationship between early sexual initiation and subsequent risky sexual behaviors.

METHODS

A sample of 1,287 urban minority adolescents completed three surveys in seventh and eighth grade, and 970 completed a follow-up in 10th grade. Logistic regression was used to test the effects of timing of initiation on 10th-grade sexual behaviors and risks, adjusting for gender, ethnicity and age.

RESULTS

At baseline, 31% of males and 8% of females reported sexual initiation; by the 10th grade, these figures were 66% and 52%, respectively. Recent intercourse among males increased from 20% at baseline to 39% in eighth grade; 54% reported recent sex and 6% had made a partner pregnant by 10th grade. Among females, recent intercourse tripled from baseline to eighth grade (5% to 15%); 42% reported recent sex and 12% had been pregnant by grade 10. Early initiators had an increased likelihood of having had multiple sex partners, been involved in a pregnancy, forced a partner to have sex, had frequent intercourse and had sex while drunk or high. There were significant gender differences for all outcomes except frequency of intercourse and being drunk or high during sex.

CONCLUSIONS

Minority adolescents who initiate sexual activity early engage in behaviors that place them at high risk for negative health outcomes. It is important to involve parents and schools in prevention efforts that address sexual initiation in early adolescence and that target youth who continue to place themselves and their partners at risk.

Time-space sampling in minority communities: results with young Latino men who have sex with men

OBJECTIVES

This study addressed methodological issues influencing the feasibility of time-space sampling in HIV prevention studies targeting hard-to-reach populations of minority young men who have sex with men (MSM).

METHODS

We conducted interviews with 400 men in 32 venues where young Latino MSM congregate in New York City. Response rates and demographic and sexual risk profiles are compared by venue type.

RESULTS

More than 90% of the men approached were screened. Among eligible men, participation rates exceeded 82%. Participation was higher at special events and gay venues compared with nongay venues (P < .05). Young MSM in nongay venues were less likely to self-identify as gay (P < .01) or to report recent anal sex with a male (P < .10). Condom use did not vary by venue type but was lower with women than with men. If surveys had been limited to gay venues, about half of the young MSM surveyed in nongay venues would have been missed.

CONCLUSIONS

Time-space sampling of a relatively "hidden" minority young MSM population can be successful across a range of venues. However, the benefits of greater outreach must be weighed against the costs incurred recruiting participants in nongay venues.

A venue-based method for sampling hard-to-reach populations

Constructing scientifically sound samples of hard-to-reach populations, also known as hidden populations, is a challenge for many research projects. Traditional sample survey methods, such as random sampling from telephone or mailing lists, can yield low numbers of eligible respondents while non-probability sampling introduces unknown biases. The authors describe a venue-based application of time-space sampling (TSS) that addresses the challenges of accessing hard-to-reach populations. The method entails identifying days and times when the target population gathers at specific venues, constructing a sampling frame of venue, day-time units (VDTs), randomly selecting and visiting VDTs (the primary sampling units), and systematically intercepting and collecting information from consenting members of the target population. This allows researchers to construct a sample with known properties, make statistical inference to the larger population of venue visitors, and theorize about the introduction of biases that may limit generalization of results to the target population. The authors describe their use of TSS in the ongoing Community Intervention Trial for Youth (CITY) project to generate a systematic sample of young men who have sex with men. The project is an ongoing community level HIV prevention intervention trial funded by the Centers for Disease Control and Prevention. The TSS method is reproducible and can be adapted to hard-to-reach populations in other situations, environments, and cultures.

The role of the community psychiatrist as medical director: a delineation of job types

To examine the variety of roles filled by psychiatrists functioning as medical directors in community settings, a survey of all members of the American Association of Community Psychiatrists was undertaken. A total of 168 respondents classified themselves as agency medical directors or program medical directors. Medical directors also classified their breadth of supervisory responsibility as including medical staff only, medical and other clinical staff, or all staff (including administrative staff). A classification scheme of six types of medical director positions based on level of operation and breadth of supervisory responsibility was created. This classification helps clarify the medical director's role, providing guidance to psychiatrists and agencies negotiating job descriptions for this position.

The role of the psychiatrist as medical director: a survey of psychiatric administrators

Previous surveys of public and community psychiatrists have demonstrated that medical directors perform a wider variety of tasks, and experience increased job satisfaction, compared to staff psychiatrists. Notwithstanding respondents' belief that clinical collaboration tasks contribute most to job satisfaction, the performance of administrative tasks is most highly correlated with overall job satisfaction. The current survey was undertaken to determine whether these findings could be replicated among hospital-based psychiatrists. Demographic and job characteristic profiles of hospital-based psychiatrists were clearly distinguished from those of community psychiatrists. Despite these differences, task profiles and job satisfaction parameters of hospital-based psychiatrists were comparable to those previously reported for community psychiatrists.

Inconsistencies over time in young adolescents' self-reports of substance use and sexual intercourse

When surveyed twice within a 6-month period, to what extent do young adolescents give inconsistent answers to questions about sexual behavior and substance use (cigarettes, alcohol, marijuana, inhalants, cocaine)? Data were collected from 1,575 urban African American and Hispanic students during fall and spring of 7th grade. For each behavior examined, less than 2% of the sample gave inconsistent answers within a survey and less than 7.5% did so over time. Retraction of baseline answers at follow-up was greater for rarer and more socially undesirable behaviors (e.g., cocaine versus cigarette use). Over-time inconsistencies were associated with lower reading comprehension and an overall reduction in risk behaviors at follow-up.

The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems

OBJECTIVES

The authors examined Americans' opinions about financial and treatment competence of people with mental health problems, potential for harm to self or others, and the use of legal means to force treatment.

METHODS

The 1996 General Social Survey provided interview data with a nationally representative sample (n = 1444). Respondents were given a vignette based on diagnostic criteria for schizophrenia, major depression, alcohol dependence, or drug dependence, or a "control" case.

RESULTS

The specific nature of the problem was the most important factor shaping public reaction. Respondents viewed those with "troubles," alcohol dependence, or depression as able to make treatment decisions. Most reported that persons with alcohol or drug problems or schizophrenia cannot manage money and are likely to be violent toward others. Respondents indicated a willingness to coerce individuals into treatment. Respondent and other case characteristics rarely affected opinions.

CONCLUSIONS

Americans report greater concern with individuals who have drug or alcohol problems than with persons who have other mental health problems. Evaluations of dangerousness and coercion indicate a continuing need for public education.

Public conceptions of mental illness: labels, causes, dangerousness, and social distance

OBJECTIVES

The authors used nationwide survey data to characterize current public conceptions related to recognition of mental illness and perceived causes, dangerousness, and desired social distance.

METHODS

Data were derived from a vignette experiment included in the 1996 General Social Survey. Respondents (n = 1444) were randomly assigned to 1 of 5 vignette conditions. Four vignettes described psychiatric disorders meeting diagnostic criteria, and the fifth depicted a "troubled person" with subclinical problems and worries.

RESULTS

Results indicate that the majority of the public identifies schizophrenia (88%) and major depression (69%) as mental illnesses and that most report multicausal explanations combining stressful circumstances with biologic and genetic factors. Results also show, however, that smaller proportions associate alcohol (49%) or drug (44%) abuse with mental illness and that symptoms of mental illness remain strongly connected with public fears about potential violence and with a desire for limited social interaction.

CONCLUSIONS

While there is reason for optimism in the public's recognition of mental illness and causal attributions, a strong stereotype of dangerousness and desire for social distance persist. These latter conceptions are likely to negatively affect people with mental illness.

The effectiveness of the Reach for Health Community Youth Service learning program in reducing early and unprotected sex among urban middle school students

OBJECTIVES

This study evaluated the effectiveness of a community youth service (CYS) program in reducing sexual risk behaviors among African American and Latino urban young adolescents.

METHODS

A total of 1061 students at 2 urban middle schools were surveyed at baseline and 6-month follow-up. Students at one school were randomly assigned by classroom to receive either the Reach for Health CYS program or the Reach for Health classroom curriculum only. Students at the other school served as controls.

RESULTS

At follow-up. CYS participants reported significantly less recent sexual activity (P < .05) and scored lower on a sexual activity index than those in the control condition (P < .03). The greatest effect was among eighth graders, who received the most intensive service program (P < .03). The benefit of the curriculum-only intervention appeared greatest among students in special education classes.

CONCLUSIONS

Well-organized CYS that couples community involvement with classroom health instruction can have a positive impact on the sexual behaviors of young adolescents at risk for HIV, sexually transmitted diseases, and unintended pregnancy. This study also suggests the importance of including students in special education classes in health education programs.

Violence prevention and young adolescents' participation in community youth service

PURPOSE

To examine whether participation in a school-sponsored community youth service program reduces self-reported violent behaviors among young urban adolescents.

METHODS

A total of 972 seventh- and eighth-grade students at two large, urban, public middle schools were surveyed at baseline and at 6-month follow-up. One school was assigned to interventions and the other served as a control. All students at the intervention school received the Reach for Health classroom curriculum that included a 10-lesson unit focusing on violence prevention. In addition, approximately half the students were randomly assigned by classroom to participate in the Reach for Health Community Youth Service program (CYS). Under the guidance of teachers and community nurses, these students spent several hours each week providing service in local health care agencies. Regression analyses were used to assess the influence of treatment condition on violent behavior outcomes.

RESULTS

Comparing students in the curriculum-only and curriculum-plus-CYS interventions to the control group, there is a statistically significant interaction (p < .03) among grade, CYS participation, and violence at follow-up. Eighth-grade CYS students reported significantly less violence at follow-up than students in the control school, taking into account baseline level of risk behavior, gender, ethnicity, and social desirability (p < .04). There was no significant difference between controls and students in the curriculum-only condition. Comparing students in the CYS intervention to the curriculum-only condition within the intervention school, the grade by intervention interaction again is significant (p < .05). Eighth-grade CYS students-who received the broadest CYS experience-reported less violence at follow-up than their curriculum-only counterparts.

CONCLUSION

When delivered with sufficient intensity, school programs which couple community service with classroom health instruction can have a measurable impact on violent behaviors of a population of young adolescents at high risk for being both the perpetrators and victims of peer violence. Community service programs may be an effective supplement to curricular interventions and a valuable part of multicomponent violence prevention programs.

Psychotic symptoms and violent behaviors: probing the components of "threat/control-override" symptoms

Evidence for an association between mental illness and violence has grown in recent years, leading many to ask why such an association exists. One hypothesis links elevated rates of violence among people with mental illness to a small set of psychotic symptoms--so called threat/control-override (TCO) symptoms. Several studies have supported this hypothesis, but none has examined which of the components, threat or control-override--if either--predominates in explaining violence. To explore this issue we used data from a two-stage epidemiological study (n = 2741) conducted in Israel. Data on TCO symptoms were collected using two methods--fixed-format self-report questions from the first stage and psychiatrists' ratings based on interviews using the Schedule for Affective Disorders and Schizophrenia (SADS) from the second. Results show that both a measure of threat and a measure of control-override are independently associated with violent behaviors. Results also show that neither method--neither fixed-format questions nor psychiatrist rating--predominates in explaining violence. In sum, these results indicate that both the threat and the control-override components of the TCO concept are useful in predicting violent behaviors and that a better measurement of the TCO concept is achieved using a multimethod approach.

Gender differences in the relationship between mental illness and violence: evidence from a community-based epidemiological study in Israel

Although males are generally more likely than females to report violent behaviors, emerging evidence suggests that the gender gap is substantially reduced among individuals with mental illness. This paper investigates whether the associations between gender and self-reported violent behaviors (fighting and weapon use) are moderated by three mental health indicators--treatment status, psychiatric diagnosis, and threat/control-override psychotic symptoms. Data from a two-stage epidemiological study conducted in Israel (weighted N = 2706) are analyzed using descriptive statistics and logistic regression analysis. Results indicate that treatment status and psychiatric diagnosis moderate the association between gender and fighting, but leave open questions both about the moderating role of threat/control-override symptoms and about the implications of mental illness for the gender/weapon use relationship.

The role of the psychiatrist as program medical director

OBJECTIVE

In a recently published survey of alumni of the Columbia University public psychiatry fellowship, respondents who were medical directors reported performing a greater variety of tasks and experiencing higher job satisfaction than those who were staff psychiatrists. Both medical directors and staff psychiatrists believed that job satisfaction was most dependent on clinical collaboration activities. Survey data were reanalyzed to determine whether there was a relationship between the frequency of tasks performed and overall job satisfaction, and whether the tasks that actually predicted overall job satisfaction were the same as those that respondents believed contributed to job satisfaction.

METHODS

The survey was distributed to all public psychiatry fellows and alumni in active practice (N=89), and 72 forms (81 percent) were returned. The survey consisted of 16 self-administered items divided into three categories of job tasks: direct service, clinical collaboration, and administration.

RESULTS AND CONCLUSIONS

Despite respondents' beliefs that clinical collaboration activities contributed most to job satisfaction, performance of administrative tasks was found to best correlate with overall job satisfaction. Furthermore, overall job satisfaction was related to the performance of administrative tasks and not to the job title of medical director alone. Most of the medical directors in the survey had program-level, rather than agency-level, responsibilities. The findings indicate that the role of program medical director can serve as a crucial next step for staff psychiatrists, offering the opportunity to perform administrative tasks, which, according to the results, improves job satisfaction in public-sector positions.

Obtaining written parent permission for school-based health surveys of urban young adolescents

PURPOSE

To document the process and implications of obtaining written parental consent for school-based health surveys of young adolescents.

METHODS

As part of the evaluation of the Reach for Health prevention program, written parental permission was obtained for student participation in school-based health surveys conducted for three cohorts of seventh graders (N = 3253) enrolled in three urban schools serving predominately economically disadvantaged minority adolescents. Students in general, bilingual, and special education classes were eligible to participate. Rates were recorded for the number of forms returned by parents, parental consents and refusals, student consents and refusals, and surveys completed. Procedures for achieving acceptable rates of written parental permission and survey completion included daily communication between research and school staff during the consent form collection period, student and teacher incentives, provision of alternate activities for students without consent, and scheduling of multiple makeup surveys for absentee students.

RESULTS

Survey completion rates met or exceeded preset goals and ranged from a low of 70% for Cohort A to a high of 83% for Cohort C. At least 89% of the parents in each cohort returned forms. Of forms returned, parent refusals ranged from a high of 18% (Cohort A) to a low of 12% (Cohort C).

CONCLUSIONS

Obtaining written permission from parents for young adolescents to participate in school-based health surveys is possible in urban settings and has potential benefits in terms of community awareness and involvement in research and evaluation studies. It does, however, require a substantial commitment of program resources as well as significant planning and data collection prior to actual survey administration.

Perceived burden among caregivers of adults with serious mental illness: comparison of black, Hispanic, and white families

Differences in perceived burden were investigated among black, Hispanic, and white groups of caregivers of adults with serious mental illness. Controlling for sociodemographic characteristics and caregiving-related stressors, black caregivers tended to report less burden than whites, a result not explained by protective mechanisms (social support, religious involvement, illness attributions). No statistically significant differences were found in perceived burden between Hispanic and white caregivers.

Violence and psychiatric disorders: results from an epidemiological study of young adults in Israel

This paper investigates the association between various psychiatric disorders and violent behavior using data from a community-based epidemiological study of young adults in Israel (N = 2678). Self-reports of recent fighting and weapon use were elevated among respondents diagnosed with psychotic or bipolar disorders but not among those diagnosed with non-psychotic depression, generalized anxiety disorder or phobias compared to respondents without these disorders. Violence was measured using the Psychiatric Epidemiology Research Interview; psychiatric disorders were diagnosed using a modified version of the Schedule for Affective Disorders and Schizophrenia. The analyses controlled for lifetime substance abuse, antisocial personality disorder and demographic characteristics, thereby extending support for a causal connection between some types of psychiatric disorders and violence. The association between disorder and violence was stronger among respondents with less education, indicating the potentially important role of social and cultural contexts in moderating the association between mental illness and violence.

Public knowledge, attitudes, and beliefs about homeless people: evidence for compassion fatigue

Media reports suggest that the public is becoming impatient with the homeless--that so-called "compassion fatigue" has gripped the nation. This characterization of public sentiment could have important policy consequences-- restrictive measures can be justified by growing public impatience, and progressive housing policies seem feasible within a hostile climate of opinion. But evidence to support the compassion fatigue notion is anecdotal. We examine the issue by tracking the results of public opinion polls and by reporting detailed evidence from a nationwide random-digit dial telephone survey (N = 1,507) concerning knowledge attitudes and beliefs about homeless people. To be sure, the public sees homelessness as an undesirable social problem and wants something done about it. However, although the homeless are clearly stigmatized, there is little evidence to suggest that the public has lost compassion and is unwilling to support policies to help homeless people.

Lifetime and five-year prevalence of homelessness in the United States: new evidence on an old debate

A 1990 household-based telephone survey of 1,507 people was followed up by surveying a subsample of those interviewed for the initial report. Results showed very high prevalence figures for homelessness, quite close to those found in the earlier survey. Moreover, using explicit and stringent definitions of literal homelessness and doubling up, most periods of homelessness were found to last for more than one month and, particularly with regard to literal homelessness, to involve serious deprivations and violent victimization.

Lifetime and five-year prevalence of homelessness in the United States

OBJECTIVE

Intense debate exists concerning the number of homeless people in the United States. Previous studies, counting currently homeless people, have provided point-prevalence estimates of homelessness but have been criticized on methodological grounds. This study reports lifetime and 5-year prevalence estimates of homelessness using a different methodological approach.

METHODS

Random-digit dialing was used to interview 1507 adults living in households with telephones in the 48 contiguous states in the fall of 1990. Respondents were asked whether they had ever been homeless and if so, where they had slept while homeless.

RESULTS

Lifetime and 5-year prevalence of all types of homelessness combined were 14.0% (26 million people) and 4.6% (8.5 million people), respectively. Lifetime "literal homelessness" (sleeping in shelters, abandoned buildings, bus and train stations, etc.) was 7.4% (13.5 million people). Five-year (1985 through 1990) prevalence of self-reported homelessness among those who had ever been literally homeless was 3.1% (5.7 million people).

CONCLUSIONS

The magnitude of the problem of homelessness is much greater than most previous attempts to enumerate homeless people have led us to believe. This finding requires reconsideration of inferences about the causes of homelessness that were derived from point-prevalence studies of currently homeless people.

Socioeconomic status and psychiatric disorders: the causation-selection issue

Are inverse relations between psychiatric disorders and socioeconomic status due more to social causation (adversity and stress) or social selection (downward mobility of genetically predisposed)? This classical epidemiological issue is tested by focusing on ethnic status in relation to socioeconomic status. Ethnic status cannot be an effect of disorder because it is present at birth whereas socioeconomic status depends on educational and occupational attainment. A birth cohort sample of 4914 young, Israel-born adults of European and North African background was selected from the country's population register, screened, and diagnosed by psychiatrists. Results indicate that social selection may be more important for schizophrenia and that social causation may be more important for depression in women and for antisocial personality and substance use disorders in men.

Characterizing life events as risk factors for depression: the role of fateful loss events

Empirical associations between life events and health are often weak, in part because event exposure measures may group together very different kinds of experiences within a single event category. Attempts to refine the measures (by using respondents' subjective appraisals of event stressfulness or by taking into consideration situational and personal factors that influence the contextual threat of the events) may strengthen the association, but they cloud the clarity of any causal inference by confounding the measure with extraneous variation. Instead, the use of descriptive information about what actually happened before, during, and after each event is recommended to define exposure to potent, fateful life events. In a comparison of 96 patients with major depression and 404 community residents with no apparent depression, the odds that a person would have experienced one or more events meeting criteria for fatefulness and disruptiveness was 2.5 times greater in the depressed group.

Characterizing life events as risk factors for depression: The role of fateful loss events

Empirical associations between life events and health are often weak, in part because event exposure measures may group together very different kinds of experiences within a single event category. Attempts to refine the measures (by using respondents' subjective appraisals of event stressfulness or by taking into consideration situational and personal factors that influence the contextual threat of the events) may strengthen the association, but they cloud the clarity of any causal inference by confounding the measure with extraneous variation. Instead, the use of descriptive information about what actually happened before, during, and after each event is recommended to define exposure to potent, fateful life events. In a comparison of 96 patients with major depression and 404 community residents with no apparent depression, the odds that a person would have experienced one or more events meeting criteria for fatefulness and disruptiveness was 2.5 times greater in the depressed group.