Faculty Bibliography

Since its beginning some 25 years ago, family therapy has become a widely used madality. The field is developing its own theoretical foundations, training institutions, and body of outcome research; the authors review some of the changes, especially those of the last two or three years. One major development is the growing differentiation of family therapy models and techniques; related are increasing attempts to delineate selection criteria and to provide empirical data for special matches of problems and treatments. The field has moved from its early preoccupation with schizophrenia to concern with new target populations, such as families disrupted by divorce. Family therapy is also being used more often in the treatment of hospitalized patients and of substance abusers. The outcome research is growing in extent and sophistication; the positive results indicate a continuing prominent role for this modality.

Clinicians' attitudes about the posthospitalization outcome of patients who are irregularly discharged from the hospital (i.e., against medical advice or AWOL) have been pessimistic, but unsystematic follow-up data of such patients compared with regularly discharged patients suggest that outcomes for the two groups are similar. Because of this discrepancy, the authors used data from a controlled, systematic study of a large sample of voluntary inpatients that measured global outcome over 2 years. Their findings suggest that 1 year and 2 years after admission, most patients who were irregularly discharged had outcomes similar to those of patients with regular discharges. There was, however, a subgroup of irregularly discharged patients who had worse outcomes.

PIP: The effects of progesterone on the central nervous system and target organs are described along with its role in reproductive functions. The literature relating to mood and behavioral changes associated with progesterone, progestins, and oral contraceptives (OCs) is summarized and reviewed, and the role of progesterone in the phenomena described is examined. The role of progesterone and the progestins in producing mood and behavioral change is still essentially unknown. On the basis of available data the following is postulated: progestins are a likely causal factor in the depression and loss of libido assoicated with OCs. A falling level of progesterone is a possible causal factor in the premenstrual syndrome and in postpartum disorders. It plays a limited or no role in mood and behavioral changes associated with menarche, menopause, and involutional melancholia. The mechanism of action to account for decreased sexual behavior, depression, and fatigue is highly speculative. It may be a combination of progesterone's sedative effects, decreases in monoamine levels, and depressive action on cerebral metabolism. The mechanism to account for decreases in anxiety, irritability, negative affect, and increased activation is also speculative. Its mood-stabilizing action may be a combination of its anticonvulsant effect, depression of neuronal arousal level, and inhibition of stimuli, originating in the hypothalamus and reticular formation, which are going to the cortex. Most women using OCs for their contraceptive properties can expect minimal change in mood and sexual behavior. It is unknown whether OCs cause depression, but interpretation of the data in the literature does not support such an association. For women who have experienced severe premenstrual tension in the absence of other psychiatric illness, OCs may prove useful. The choice of OC would depend on the presence/absence of a history of premenstrual irritability. For women with psychoses with premenstrual exacerbation, OCs may have a place as a part of a regimen including lithium and/or antipsychotic medications. Needed at this time are carefully controlled experiments with progesterone and other hormones in humans, on a prospective basis, over a long period of time, with correlations with neurophysiological and endocrinological measures and employing crossover and double-blind techniques. OABL- eng

The physical environment of a treatment program affects patient outcome, but how and to what degree is not known. However, decisions about the design of the environment must be made, and they must be made in the face of cost and building-code constraints and widely varying patient characteristics and treatment models. The authors describe the design principles and philosophies they followed in the remodeling of an in-patient treatment and research service in a university psychiatric hospital and indicate where cost and code constraints resulted in a less than ideal solution. They point out that many apparent amenities, such as a ward kitchen, are significant milieu therapy resources, and they advocate the involvement of all levels of staff in the planning process.

The study evaluated the relationship between therapist personality and treatment success for 141 schizophrenics and 94 non-schizophrenics randomly assigned to short or long hospitalization. The 47 therapists were self-rated on the Whitehorn--Betz A--B scale in both the original and the Campbell versions. Outcome was assessed on the Health--Sickness Rating Scale and the Psychiatric Evaluation Form at discharge and at 1 and 2 year follow-up. The hypothesis of greater success for A--type therapists with schizophrenics was not confirmed, nor were alternative relationships evident in the data.