A pilot study of assertive community treatment for patients with chronic psychotic disorders

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.

Providing assertive community treatment for severely mentally ill patients in a rural area

OBJECTIVE

The authors' goals were to describe an assertive community treatment program developed for patients in rural South Carolina and to evaluate the effect of the program on rates of hospital utilization and cost of care.

METHODS

Twenty-three patients with chronic psychotic disorders living in rural areas of South Carolina were assigned to an assertive community treatment program. The patients' average number of days per year in the hospital, length of stay per admission, number of admissions per year, and estimated annual cost of care during the five years before assignment to the program and during a period from four to 26 months after assignment were compared.

RESULTS

The intervention was associated with a 79 percent decrease in hospital days per year, a 64 percent decrease in the number of admissions per year, a 75 percent decrease in the average length of stay per admission, and a 52 percent reduction in estimated direct cost of care.

CONCLUSIONS

Although the methods of assertive community treatment may need to be modified to suit the travel requirements and other characteristics of rural settings, the study results suggest that the model can be successfully used in rural areas.

Managing agitation in the critical care setting

Pharmacologic control of the agitated ICU patient requires preliminary assessment of the underlying causes of agitation. Reversal of correctable abnormalities, consideration of drug reaction, withdrawal and pain management should be addressed first. Delirium is the most common cause of agitation in the ICU and often has multiple causes. Pharmacologic management of agitation can be safely accomplished by intravenous haloperidol with or without lorazepam, as outlined above.

Oral contraceptives and panic disorder

BACKGROUND

There are no published reports of an association between triphasic oral contraceptives and the development of panic disorder.

METHOD

The authors describe two cases in which the use of triphasic oral contraceptives in women appear to have precipitated panic disorder. Treatment with the triphasic oral contraceptives was stopped and the patients were followed for 2 years.

RESULTS

Both subjects had rapid and total resolution of their panic disorder symptoms following cessation of triphasic oral contraceptive medications.

CONCLUSION

Triphasic oral contraceptives in some predisposed women may lead to precipitation of panic disorder.

Strategies for operational efficiency in a general hospital public inpatient unit

Operational strategies for maximizing efficient utilization of beds were carried out in a 12-bed psychiatric inpatient unit for public patients in a general hospital. Developed through a public-academic collaboration, the unit is part of a community-based system of care. The average length of stay is ten days. Medical staff are university faculty and residents. Treatment focuses on resolution of the symptoms or behavior that led to the patient's hospitalization and includes rapid stabilization using crisis management and somatic therapies and rapid mobilization of aftercare resources. Other strategies for promoting efficient provision of services include clearly defined staff roles and a structured format for discussing clinical information.

From the benches to the trenches : training residents to provide emergency outreach services-a public/academic project

The Charleston Area Mental Health Center and the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina have collaborated to form a comprehensive emergency service with mobile capacity. The service is staffed by an interdisciplinary team of professionals from public and academic psychiatry. Psychiatric residents are fully integrated into the service. A description of the program demonstrates how such liaisons can promote improved access to high-quality services, while enriching the training of psychiatrists through outreach experiences.

New directions in research on assertive community treatment

Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements--alone and in combination--on different subgroups of clients.

Inducing catatonic patients to eat with daily administration of amobarbital sodium

Intravenous amobarbital sodium can facilitate food ingestion by immobile catatonic patients. We have described a case in which this technique was used, citing its advantages over tube feedings.

[A clinical case of chronic thrombotic thrombocytopenic purpura]

This is a TTP report of the case of a 29 year old female who entered into apparent complete clinical remission, after EP with fresh frozen plasma and corticotherapy. Unusual large plasma Factor VIII: vWF by two-dimensional Immunoelectrophoresis is the biological change described by Moake and Sufficient in itself to confirm the chronic TTP diagnosis.

Decentralized services for public hospital patients: a cost analysis

Dr. Sharfstein's introduction: In this era of cost containment and fiscal constraint, it is critical to consider alternative methods of delivering public psychiatric care that emphasize decentralized approaches, shortened lengths of stay, and innovative clinical interventions. This month's report dramatically illustrates the cost savings that can be achieved in a decentralized treatment program, particularly costs associated with the judicial process and involuntary commitment. The need for high-quality services at the local level is greater than ever.

Surface charge of resident, elicited, and activated mouse peritoneal macrophages

The surface charge of resident, thioglycollate-elicited, and Trypanosoma cruzi-activated mouse peritoneal macrophages was analyzed using cell electrophoresis. All macrophages had a net negative surface charge. Activated macrophages had a lower zeta potential and a higher isoelectrophoretic point than resident and elicited macrophages. The populations of resident, elicited, and activated macrophages were heterogeneous in terms of surface charge. The analysis of the effect of the pH of the solution in which the macrophages were suspended on their cellular electrophoretic mobility (EPM) indicated that their surface contained both positively and negatively charged dissociating groups. The contribution of sialic acid residues to the surface charge was determined by analyzing the effect of neuraminidase treatment on the EPM of the cells. Activated macrophages possessed more sialic acid residues exposed on their surface, and sensitive to the neuraminidase from Clostridium perfringens, than resident and elicited macrophages. Treatment of the cells with the neuraminidase from Vibrio cholerae, however, reduced the surface charge of all macrophages in about the same extent. Macrophages had their mean EPM reduced when incubated in the presence of Ca++, suggesting that some cell surface anionogenic sites have Ca++-binding capacity.

Atypical somatoform disorder following infection in children--a depressive equivalent?

Thirteen cases are reported wherein, following an upper respiratory infection or gastroenteritis, children developed a syndrome involving predominantly somatic complaints and objective signs of dysphoria. The syndrome picture was strikingly protracted compared to the convalescence period that would be expected following transient infectious illnesses. Psychiatric consultation was requested primarily because of extensive nonconclusive medical evaluation by the primary care physician. Most of the children showed a striking inability to recognize or acknowledge dysphoria. A multifactorial etiologic hypothesis that considers possible complementary roles of emotional, cognitive, and biological factors is offered to explain the development of this highly dysfunctional syndrome.

Surface charge and ultrastructure of the cell surface of resident and thioglycolate-elicited mouse peritoneal macrophages

The cell surface of resident and thioglycolate-elicited mouse peritoneal macrophages was analysed using cell electrophoresis, ultrastructural cytochemistry and freeze-fracture. Both macrophages have a negative surface charge as evaluated by the binding of cationic particles (colloidal iron hydroxide and cationized ferritin) to the cell surface and determination of the cellular electrophoretic mobility (EPM). Elicited macrophages showed a more regular and intense binding of colloidal iron particles at pH 1.8 to their cell surfaces than resident macrophages. No differences were observed in the binding of cationized ferritin particles at pH 7.2 to the cell surface of resident and elicited macrophages. Both macrophages had the same mean EPM. Neuraminidase treatment of the cells did not interfere with the binding of cationic particles to the cell surface and with the EPM of the cells. With the freeze-fracture technique no special array of intramembranous particles was observed in the plasma membrane of the macrophages. Differences in the distribution of intramembranous particles in the P and E faces of the plasma membrane were observed between resident and elicited macrophages.

Unusual complications of antipsychotic drugs

Phenothiazines have been responsible for pigmentary changes in the skin (phototoxic reaction) and for pigment deposits in the cornea, lens and retina, which can result in blindness. Reversible agranulocytosis has also been reported with these agents. Psychotic exacerbation, including a form responsive to antiparkinsonian agents, may occur with high-potency antipsychotic drugs. Neuroleptic malignant syndrome, usually following high-dose therapy in young men, is a disorder of thermoregulatory mechanisms.