Faculty Bibliography

Many mental health authority and program administrators would like to implement behavioral health practices that have been demonstrated to be effective. Leading practice implementation involves promoting behavior change in health care providers. Reviews of the general medical literature on practice change conclude that education alone has little impact on practitioner behavior and that intensive, multifaceted interventions that attend to local circumstances have the greatest likelihood of affecting change. This article briefly reviews the literature on health care practice change and offers some strategy suggestions for administrators who are leading evidence-based practice implementation initiatives.

The authors examine current challenges confronting psychiatry in caring for homeless people with psychiatric disorders. After reviewing how psychiatry has historically addressed homelessness and mental illness, the authors discuss the roles that the profession has developed in working with homeless populations. These roles, which encompass clinical, administrative, academic, and advocacy functions, have evolved as a result of trends both in homelessness services and within the profession of psychiatry. Challenges implicit in this evolution are discussed, including recent trends in homelessness, particularly an increase in prevalence, especially among families and children and some clinical subpopulations. The authors propose that these epidemiological trends are affecting the mental health care needs of homeless people. To be effective and credible in continuing to help solve the problems of homeless people with psychiatric disorders, psychiatry must adapt to these new challenges, using the roles it has developed.

OBJECTIVE: To develop treatment recommendations for the use of antipsychotic medications for children and adolescents with serious psychiatric disorders and externalizing behavior problems. METHOD: Using a combination of evidence- and consensus-based methodologies, recommendations were developed in six phases as informed by three primary sources of information: (1) current scientific evidence (published and unpublished), (2) the expressed needs for treatment-relevant information and guidance specified by clinicians in a series of focus groups, and (3) consensus of clinical and research experts derived from a formal survey and a consensus workshop. RESULTS: Fourteen treatment recommendations on the use of atypical antipsychotics for aggression in youth with comorbid psychiatric conditions were developed. Each recommendation corresponds to one of the phases of care (evaluation, treatment, stabilization, and maintenance) and includes a brief clinical rationale that draws upon the available scientific evidence and consensus expert opinion derived from survey data and a consensus workshop. CONCLUSION: Until additional research from controlled trials becomes available, these evidence- and consensus-based treatment recommendations may be a useful approach to guide the use of antipsychotics in youth with aggression.

The development of process measures for the assessment and improvement of care for schizophrenia is at an early stage. As part of a national inventory of mental health quality measures, we identified 42 process measures developed to assess the quality of schizophrenia care. A greater proportion of measures assessed pharmacotherapy than assessed psychosocial interventions or other clinical processes, such as assessment, continuity, or coordination. Twenty-five measures (60%) were based on research evidence linking measure conformance with improved patient outcomes, while 17 (40%) were based on clinical consensus or opinion. Only 12 measures (29%) were fully operationalized. Few were tested for validity or reliability. A number of demonstration projects currently under way should expand the pool of well-developed and tested measures. Further research and consensus development will be needed to identify common measurement priorities, reduce the data collection burden, enhance the interpretability of results, and allow for comparisons of clinical practice across facilities and health care systems.

Administrative and pharmacy data bases represent a largely untapped resource for clinical decision support and quality improvement. In this study, we examined the feasibility of using New York State Office of Mental Health (NYSOMH) data bases to develop an automated clinical report to support implementation of schizophrenia guidelines. First we reviewed the structure of existing data bases for capacity and limitations in supporting guideline implementation. Second, we identified schizophrenia guideline recommendations and adherence measures that would be the focus of our implementation. Third, a preliminary report was programmed, based on operational definitions of the guideline recommendations. Finally, we developed user groups to define content and format of new reports, through an iterative process of field testing, feedback, and revision. Our experience suggests that administrative and pharmacy data bases, despite their limitations, can be used to develop guideline-based clinical decision support tools for schizophrenia with high physician acceptability.

BACKGROUND: This study in North India compared acute brief psychosis--defined by acute onset, brief duration and no early relapse--with other remitting psychoses, over a 12-year course and outcome. METHOD: In a cohort of incident psychoses, we identified 20 cases of acute brief psychosis and a comparison group of 43 other remitting psychoses based on two-year follow-up. Seventeen people (85%) in the acute brief psychosis group and 36 (84%) in the comparison group were reassessed at five, seven and 12 years after onset, and were rediagnosed using ICD-10 criteria. RESULTS: At 12-year follow-up, the proportion with remaining signs of illness was 6% (n = 1) for acute brief psychosis versus 50% (n = 18) for the comparison group (P = 0.002). Using ICD-10 criteria, the majority in both groups were diagnosed as having schizophrenia. CONCLUSIONS: Acute brief psychosis has a distinctive and benign long-term course when compared with other remitting psychoses. This finding supports the ICD-10 concept of a separable group of acute and transient psychotic disorders. To effectively separate this group, however, the ICD-10 criteria need modification

A 33-year-old pregnant woman at 26 weeks gestation, who had a history of bipolar mood disorder, type I, was admitted to the hospital for hypomania and poorly controlled diabetes mellitus. The patient had had her first episode of affective illness at age 28, after the birth of her second child. After an initial postpartum depression, she had cycled into a manic state. She had subsequently been hospitalized seven times for acute mania. A combination of valproate and chlorpromazine had proven effective in managing most of her manic episodes, while her two most severe episodes had been successfully managed with bilateral ECT

This paper concerns the diagnostic classification of nonaffective acute remitting psychosis (NARP), which we also term acute brief psychosis. We argue that NARP can be delineated from both schizophrenia and the affective psychoses and considered as a single diagnosis. As indicated by the term NARP, four criteria would be central to the diagnosis: 1. nonaffective, 2. acute onset (over less than two weeks), 3. recovery within a brief duration (less than six months), and 4. psychosis broadly defined. We review the rationale and the empirical evidence for this proposed classification.

This paper presents an overview of the diagnoses and short-term course of acute psychotic illnesses--affective as well as nonaffective--in a developing country setting. In the Chandigarh Acute Psychosis Study (CAPS) in Northern India, a cohort of 91 cases of acute psychotic illness were assessed for symptoms, diagnosis, and course ratings at multiple intervals over a 12 month period; cases were drawn from a rural and an urban clinic, permitting comparison of patients in these two settings. Non-affective (mainly schizophrenic) patients were found to be the predominant group (51%), followed by manic (26%), and depressive (19%) patients. Overall the acute psychoses had an excellent short-term course and outcome, a result which held across all diagnostic groups and both the rural and urban setting. Rural and urban patients were similar in diagnostic distribution and course of illness. Investigations of such cases can expand our view of the possible manifestations and course of psychotic disorders, and may have implications for diagnosis