[Rehabilitation of psychiatric patients by half-way house admission--a catamnestic study]

In order to observe the course of rehabilitation of mentally ill persons a catamnestic study was done of 16 mainly schizophrenic former residents of the halfway house for mentally ill in Nuremberg. Along with the rehospitalization rate, the criteria for success were progress in the living and working fields. Concerning the course of illness and independent living very good results were found for the rehabilitation course. Reintegration into the working process could be advanced during the stay, stagnated however after the stay. Classifying the course of rehabilitation, overall or partial success was achieved in more than 80% of the patients interviewed. The stay in a halfway house, hence, is a good possibility for medical rehabilitation of younger patients with long-term mental illness. However, it also turned out that out-patient follow-up treatment and care is of great importance for the social relationships of the often isolated patients.

Capacity for self-care of persons with mental illnesses living in community residences and the ability of their surrogate families to perform health care functions

Persons with chronic mental illnesses have a higher prevalence of medical illnesses and higher mortality rates than the general population. Those living in the community are usually linked with mental health services but are expected to manage their own medical care. The ability to manage their health care and the ability of "surrogate families" to assist them were measured among residents and staff of supervised community residences. In its surrogate role, the agency promoted routine health examinations and follow-up care. Its staff was a central resource for the residents, who sought out staff members for assistance with their health problems. However, residents and staff alike lack knowledge about health problems, medications, and approaches to modifying unhealthy lifestyle practices. Although residents identified lack of knowledge about sexually transmitted diseases as a major concern, staff indicated discomfort with this topic. These findings suggest the importance of supporting chronically mentally ill persons and residential staff in managing residents' health care functions.

Prospective study of clinical and social outcome of stay in small group homes for people with mental illness

BACKGROUND

Small group homes operating according to the principles of supported housing have, during the past five years, become a cornerstone of the housing services for the long-term mentally ill in Copenhagen.

METHOD

During a 2.5-year period, 47 long-term mentally ill persons were examined at the time of entry to a group home programme. Residents' psychopathology, social integration, mastery and quality of life were measured by structured interviews, including the Present State Examination (PSE-10); and their social functioning was recorded by interview with the staff. Forty-four of the residents were re-examined at follow-up after a mean of 1.1 years using the same instruments. Data on hospitalisation were obtained through the Danish Psychiatric Case Register.

RESULTS

Eighty-three per cent of the residents remained in the programme during the first year. They showed a significant improvement in subjective quality of life, PSE total score, social integration, functioning and hospitalisation index. The number of reciprocal supportive contacts in the social network increased. Lower baseline PSE total score was associated with adherence to the programme, and the improvement in quality of life during their stay was predicted by reduction in symptoms and improvement in social integration.

CONCLUSIONS

A rehabilitation strategy of supplementing standard psychiatric treatment with a programme of small supportive group homes improves the quality of life, psychosocial functioning and community tenure of the long-term mentally ill.

A prospective psychotherapy outcome study

OBJECTIVE

To assess the outcome of 31 patients treated in a day and semi-residential psychotherapy setting.

METHOD

Patients had moderate to severe personality difficulties and were referred when current therapy was insufficient or because of the severity of their problems. Eighty-one percent had a Cluster C and 19% a Cluster B (Borderline) Personality Disorder diagnosis (DSM-III-R). Therapy was psychodynamically and feministin-formed and included a sociopolitical dimension. Rating scales used were the Symptom Checklist 90, Goal Attainment Scale, Global Assessment Scale and measures of health resource usage, which were completed pre-treatment, post-treatment and at 4-, 12- and 24-month follow-up.

RESULTS

Mean duration of therapy was 4 months (68 therapy days). All clinical rating scales demonstrated marked improvements following treatment (p < 0.0001) which were sustained at 2-year follow-up. There were also improvements of health resource usage.

CONCLUSIONS

The results document the clinical efficacy of psychotherapy in this setting, provide support for the philosophy of practice, and suggest that psychotherapy outcome can be evaluated at reasonable financial cost in many settings.

Residential alcohol detoxification: new role for mental health nurses

This article discusses the philosophy and practice of a community-based residential detoxification service for people with alcohol problems. The service is provided on a direct-access basis and has a team of 19 nurses who are supported by a GP practice. The article highlights issues relevant to nursing in this community facility by referring to three case studies. The case studies demonstrate that this client group finds it difficult to access other forms of health and social care. The case examples emphasize both the qualitative aspects of nursing care and the decision-making involved in this type of service. The authors suggest that large populations with complex needs can be served by nursing-led services adopting a 'direct access' approach.

Lack of insight among outpatients with schizophrenia

OBJECTIVE

This study investigated the prevalence of lack of insight among outpatients with schizophrenia and the relationship between lack of insight and other variables, including whether patients received professional residential supervision.

METHODS

A total of 87 stable outpatients with schizophrenia were drawn from community programs in a public-private mental health system. Subjects' clinical symptoms and insight about their illness were assessed using the Positive and Negative Syndrome Scale, a battery of neuropsychological tests, and the Social Functioning Scale.

RESULTS

The illness insight of 43 subjects, or 49.5 percent, was at least moderately impaired. Twenty-one subjects, or 25 percent, had severe insight deficits. In a multiple regression analysis, 40 percent of the variance in lack of insight was predicted by ratings of the severity of delusions, difficulty with abstract thinking, lack of social activities, and absence of anxiety. Patients who received professional residential supervision had more impaired insight than those living independently or with family.

CONCLUSIONS

Insight deficits are common among stable outpatients engaged in community-based care. These deficits have implications for patients' use of limited services such as residential supervision.

[Social integration of patients of a long-term institution]

With a mean duration of hospitalisation of 28 years the patients of a long-term hospital had on the average only 2.6 visits from outside in one year. Above all the frequency of visits depended on the age, the duration of illness, the distance of the hospital to the homes of the patients and on communication inhibiting symptoms. In a three years follow-up the social integration of patients could be improved by specific rehabilitative treatment. Contacts to persons from outside the hospital and activities inside increased significantly. Improvement was not possible for patients whose homes were very far away and who had communication inhibiting symptoms at the outset of the follow-up.

[Epilepsy and personality disorder--a now 9-year inpatient-ambulatory treatment continuity]

We present the development of an 9-year therapeutic relationship with a patient suffering from epilepsy and a severe personality disorder. Despite serious doubts in the beginning the patient gained an unexpected degree of independence. The development of the case indicates that it was decisive to prevent discontinuation of the personal relationship due to separation of in-patient and out-patient treatment. Only by personal continuity over years it has been possible for the patient to continue therapy with the consequence of getting a satisfactory autonomy.

The mental health of single homeless people in Northampton hostels

Much research evidence about homelessness and health relates to large population centres with correspondingly large homeless populations. Such results may not necessarily apply to small towns such as Northampton. A local need was identified for information relating to health and access to health care for homeless people. Seventy five single, homeless people temporarily residing at open access hostels in Northampton were interviewed. The interviews covered: recent accommodation histories recent physical health mental health access to health care current social contacts, life style and aspirations The General Health Questionnaire (GHQ30) was administered to allow assessment of the levels of mental morbidity in the population studied. The results presented here relate to mental health issues. Current mental health problems were reported by 53% of the sample (40 people); of these only 40% (16 people) were receiving treatment. Three people had been admitted to a psychiatric hospital within the past year. Using standard scoring, the GHQ30 identified as cases 72% (44) of the 61 homeless people who completed the GHQ. It was concluded that levels of mental morbidity were higher in the homeless group than would be expected in the general population. This finding, mirrors those of studies in larger population centres. The main form of access to mental health services appeared to be via hospital admission. Any GP treatment offered was likely to be medication. There was no mention of Community Psychiatric Nurse involvement in treatment or care. The results may indicate a significant level of unmet need for mental health intervention amongst the local homeless population.

Alcoholic patients' decisions about halfway houses. What they say, what they do

Because of the important role of halfway houses in the recovery of many alcoholic patients, patients' attitudes toward accepting placement in a halfway house were studied in a state hospital's alcohol rehabilitation program. Verbal intentions to accept or not to accept placement were measured at the beginning and again toward the end of the program sequence. Both assessments showed a strong correlation with the patients' actual behaviors. The relationships between intentions and ultimate choices were moderated both by the amount of time between observations and, independently of the passage of time, by the subjects' experience with or knowledge about halfway houses. Changes over the course of the program were mostly positive (favorable toward going and actually doing so). These shifts mainly involved the people who had been initially undecided about placement in a halfway house. Amount of time spent in the rehabilitation program was unrelated to patients' initial intentions toward going and had little bearing on their final decisions.

Outcome of domiciliary care after inpatient alcoholism treatment in male veterans

Current literature is ambiguous as to the impact of extended treatment services following hospitalization on outcomes such as abstinence. This study compares the outcomes of care for 276 veterans who completed inpatient treatment for alcoholism, 77 of whom (28%) were transferred to a domiciliary and the remainder of whom were discharged directly into the community. The domiciliary group of alcoholics differed at baseline from alcoholics discharged to the community with significantly higher psychiatric comorbidity and lower social support, both negative predictors of treatment outcome. A multiple logistic regression model was used to assess the impact of domiciliary placement on: (a) 3-month abstinence comparing the time after discharge from either the domiciliary or the inpatient treatment unit and (b) 12-month abstinence after discharge from the inpatient treatment unit, including patients placed in the domiciliary. Controlling for baseline differences, domiciliary placement was found to be a significant predictor of abstinence (odds ratios of 2.3 for 3-month and 2.5 for 12-month abstinence, p < or = 0.01). In a survival analysis, domiciliary placement was also a significant predictor of time to readmission after treatment discharge with a risk ratio of 0.2 (p < 0.01). Our results demonstrate a protective effect of domiciliary after-care for high risk alcoholics after inpatient treatment.

Effects of halfway house placement on retention of patients in substance abuse aftercare

One hundred twenty-four male veterans were enrolled in the Birmingham VAMC Outpatient Substance Abuse Clinic (OSAC) aftercare program following inpatient treatment for alcohol, cocaine, or mixed alcohol-cocaine abuse/dependence. Forty-two of the patients were concurrently admitted to a nearby halfway house (HH) while the remaining 82 patients made community-based (CB) living arrangements. Chi-square analysis showed the two groups were matched, p > .05, in regard to age, race, marital status, presenting problem, and referral source. The CB group experienced significantly, p < .05, higher early dropout (40 vs 0%) from aftercare. Of the others engaging in treatment, the HH patients stayed in OSAC aftercare 60 days longer and had significantly, p < .01, more clinic visits. A higher proportion, p < .01, of HH patients completed each of four treatment milestones: education group, psychological testing, psychological interview, and treatment planning/update. On average, the HH patients remained in OSAC an additional 90 days after their halfway house discharge. Although not significantly different, p > .05, the frequency of HH patients receiving administrative discharge status of Treatment Complete was twice (28.2%) that of CB patients (15.1%). It is concluded that concurrent halfway house placement can aid in aftercare retention and completion.

Alcohol misuse: a detoxification project

This article describes the structure and philosophy of an innovative unit for detoxifying clients suffering from alcohol misuse. It attempts to provide treatment in partnership with the people it was designed to serve. The author discusses the various aspects of the project and reviews the way it has developed since its inception. He emphasises the nursing-led approaches employed to meet the needs of clients who use its facilities and expertise.

Changes in the quality of life of people with learning disabilities who moved from hospital to live in community-based homes

This paper describes a longitudinal study of the change in quality of life experienced by 36 residents of community-based homes after leaving a hospital for people with learning disabilities. The measure used to evaluate quality of life was Living in a Supervised Home: A Questionnaire on Quality of Life (Cragg and Harrison, 1986). The questionnaire was completed before and after the study group left the hospital. The analyses of the scale shows that there has been a considerable improvement in the quality of life of people who have moved from hospital to community-based homes. Specific data are presented from quality of life sub-scales relating to the use of community facilities and contact with other members of the community.

Staff stress and satisfaction in small staffed houses in the community: 1

In this article, the first of two parts, the sources of stress and satisfaction experienced by nursing and social service staff working in group homes with young people with severe learning disabilities are investigated. It focuses on the stresses and satisfactions arising out of the performance of the direct care role for staff working in ordinary housing in the community.

Abused women and peer-provided social support: the nature and dynamics of reciprocity in a crisis setting

Research has demonstrated clearly the positive effect social support can have on health. Peer-provided social support, in the forms of both one-on-one peer counseling and peer support groups, is encouraged by health care providers as an effective and inexpensive way to enhance mental health in at-risk client populations. This article examines data from two studies that included information about the use of social support by abused women during their stay in a transition house. Analysis revealed a potential for problems when vulnerable clients offer support to other vulnerable clients. The ability to offer support was viewed by the "givers" to be evidence of their own recovery. Women needed to give this support, and, therefore, it was often difficult to know whose needs were being met. The complexities of these relationships are discussed. An understanding of the issues involved will ensure that maximum benefit with minimum risk can be derived by participants in supportive exchanges between peers.

Community-based persons with mental retardation: opportunities for health promotion

The public policy of supporting the mentally retarded in community-based, group home environments provides an exciting opportunity for nurses to develop health promotion and self-care programs to increase the independent living capacity of this population. This article discusses the issues raised and solutions developed by nurse practitioners working with adults with serious medical problems and diminished cognitive capacity.

Helping clients build links with their neighbours

How does the effort we put into helping clients build links with their immediate neighbours compare with the time spent getting them out of their immediate street and into the local community? This article is aimed at purchasers and providers and examines the problems associated with establishing good relationships between clients and their neighbours. It also discusses the importance of finding the right property for clients' needs.