Faculty Bibliography

The clinical research ward run as a therapeutic community has been criticized as inefficient and scientifically unsound. This article discusses the therapeutic community as a research ward and identifies certain misconceptions which underlie many criticisms. The following myths are discussed and refuted: (1) There is an insurmountable community-research chasm. (2) The therapeutic community induces stress that interferes with research. (3) Patient passivity is engendered by research and this is destructive to the therapeutic community. (4) Symptoms are exacerbated by a research ward that is disruptive to the community. (5) Normal research subjects cannot live in a therapeutic community without pathologic psychic changes. These inaccurate myths are seen as a reflection of attempts to oversimplify very complex clinical and research issues. The use of mythology to simplify experiments, to artificially "clarify" complex issues, or to "protect" patients is seen as a disservice. The therapeutic community and research are syntonic when both receive appropriate support.

Several factors press for change in the psychiatric hospital of the 1980s, including knowledge obtained from recent controlled studies of outcome of different approaches and length of hospital stay, changes in the social-political-economic climate, and new methods of organizing the delivery of services. In the proposed model of inpatient treatment, the primary use of hospitalization will be for brief treatment (three to 21 days). For a very small subgroup, longer hospitalization may be needed. The hospital will also be used for triage and disposition of persons with a broad range of problems, which will rarely take more than three days. Complementary changes will be required in training and research; a promising training model may be continuous care teams by which trainees can manage chronic, multiproblem patients through different levels of care within and outside the hospital. Research must move to the out-of-hospital settings if the new patterns of care are to be understood and improved.

The difficulties of performing prospective psychiatric follow-up studies have recently increased due to growing concern over the ethical issues involved. In a study to determine the efficacy of different lengths of psychiatric hospitalization 235 patients were followed for 2 years after study hospitalization. Data were obtained on more than 90 per cent of the patients. The cost of performing 100 follow-up interviews ranged from $9,169 for patients living within a 6-mile radius of the study site, to $17,942 for patients living within the contiguous United States. It is concluded that through persistent effort useful data can be obtained by follow-up of psychiatric patients, while maintaining ethical standards which include respect for the rights and wishes of the patient.

Prognostic value of the Premorbid Asocial Adjustment Scale (PAAS) was examined for a mixed group of 135 schizophrenics. The PAAS had nonsignificant correlations with three global outcome measures 1 and 2 years after admission for the patient group as a whole. However, the previous finding that the PAAS had prognostic value for nonchronic schizophrenic patients was confirmed. Prognostic correlations were significant for the half of the subjects who were above average in prehospital functioning, and were even higher in the younger half of this subgroup. The scatterplot of the prognostic relationship suggested the expected triangular shape, with poor prognosis associated with poor outcomes and good prognosis associated with mixed outcomes.

Virtually all modern inpatient psychiatric units operate on the assumptions that family presence, when the identified patient has schizophrenia, does affect outcome and that adding brief family intervention to the treatment prescription will enhance hospital and posthospital outcome. Often the family intervention is believed not adequate in terms of duration or frequency or quality (since trainees are the family therapists), given the standards of some experienced family clinicians. This report addresses these issues by comparing outcome measures for hospitalized patients with schizophrenia by (a) presence of a family and (b) amount and/or kind of family intervention. Most importantly, we wished to learn if global outcome would show change by virtue of family therapy (within the constraints imposed by the above limitations of family intervention).

A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. Results of a two-year follow-up of a sample of 74 nonschizophrenic subjects are reported here. Two years after admission there were no statistically reliable differences in functioning between short-term and long-term subjects with diagnoses of either affective disorders, or neurosis and personality disorders (including hysterical personality disorder). The findings reported do not support extended hospitalization for patients with these diagnoses. Caution regarding these findings is suggested by an anecdotal impression that short-term hospitalization may not have allowed for proper diagnosis and treatment for some persons in the affective disorder group.

A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. The results of a two-year follow-up of a sample of 141 schizophrenic patients are reported here. The differences favoring long-term subjects that were apparent at one year postadmission had decreased by two years postadmission. However, there appears to be an interaction between prehospital functioning and length of hospital stay, with subjects who had good prehospital functioning doing better at two years when assigned to long-term hospitalization. Subjects with poor prehospital functioning did about equally well, regardless of length of stay, and may even have showed some tendency to do better with a shorter hospital stay. This reversal of effect was more prominent for women, although this sex difference was not statistically significant.