Faculty Bibliography

In a randomized clinical trial of Inpatient Family Intervention (IFI) for 169 inpatients with schizophrenia, affective disorder, and a residual group of other diagnoses, results suggested significant effects favoring IFI for patients and their families. The treatment effects were limited to females and to two diagnostic groups: chronic schizophrenia patients and the bipolar subgroup of affective disorders.

Recent research suggests that, despite the development of effective psychiatric treatment, there is marked underuse of care. This pilot study had the objective of dissecting the process of care in an attempt to understand outcomes for patients with major affective disorder and for their families. Twenty-four patients with a DSM-III diagnosis of major affective disorder were identified 12 to 18 months after hospital admission in three countries (Italy, Japan, and the United States). The patients, their families, and their doctors were interviewed separately and then together, using instruments measuring delivery of treatment (using an ideal treatment criteria set) and percentage of achievement of treatment goals. These measures were then (using parametric and nonparametric statistics) correlated with resolution of the index episode and the patient's global outcome (using the Global Assessment Scale). The data demonstrated that physicians delivered about half (52%) and, subsequently, achieved about half (54%) of what would be considered ideal care to patients and other family members. The mean resolution of the index episode at follow-up was only 3.0 (on a 0- to 5-point scale). There was a significant positive association between the most important outcome measure, i.e., the resolution of the episode, and the achievement of treatment goals for both the patient (p less than .07) and the family (p less than .005). Patients and families with the best resolutions received significantly more good treatment than those with the worst resolutions (p less than .02), most notably with regard to medication (p less than .002).

Recent reviews of the results of the important Italian Psychiatric Reform have been unusual in that they have ranged from very enthusiastic to very negative. No recent report has focused on extrapolating from the Italian experience the pluses and minuses that might be applicable to the U.S. system of delivery of mental health services so as to improve the care of the seriously mentally ill. In this paper I will summarize my observations and clinical research during 6 months in Italy, emphasizing what has not been reported by others; I will analyze the impact of the Italian changes on Italian practice and try to identify in a balanced way any inferences that can be drawn from the Italian experience that add to ideas now current in the United States about treatment of the severely mentally ill.

This is the last of a series of four papers, here focussing on schizophrenia, which report followup data up to 18 months from a randomized clinical trial of a psychoeducational family intervention (IFI), which was added to medication and limited to the inpatient phase of treatment, after which post-hospital care was not controlled. Our data suggested that patients with poor prehospital functioning (i.e., the chronic patients) may benefit from inpatient family intervention, but this therapeutic effect appears to be limited to females and does not appear until 18 months postadmission. Families of patients with schizophrenia also show benefit from having received IFI, the effect is seen earlier than with the patients, and is associated with achieving the goals of IFI. The results in the IFI group could not be accounted for by improved post-hospital medication compliance, but they may be related to this group's greater tendency to obtain further family treatment after discharge.

In 1978 a major psychiatric reform drastically changed the Italian psychiatric system by the closing of admissions to mental hospitals and the development of psychiatric units in general hospitals and of alternative services in the community. The paper presents the results of a study in which two treatment environments set up according to the reform, i.e. a psychiatric unit in a general hospital and a community mental health center run by the same staff, were examined using the Ward Atmosphere Scale (WAS) and the Community Oriented Programs Environment Scale (COPES). In addition, validity studies of the Italian versions of the WAS and COPES are presented. Both instruments were found to be feasible and useful, easily understood, easy to administer and relatively well accepted by the psychiatric staff. The quality of the two scales has been confirmed by psychometric analysis, with the exception of the independence of scales. No major differences between the two environments emerged, both showing characteristics consistent with the new treatment philosophy.

This paper reports the results at follow-up of a randomized clinical trial of combining family intervention with drug treatment during hospitalization for patients with affective disorder. The results suggest that female bipolar patients and their families benefited from family intervention, whereas unipolar patients and families did not. Patient outcome was positively correlated with the achievement of the goals of family intervention.

Several studies document sex differences in premorbid and intermorbid role functioning, showing less functional deficit among females. The specific nature of sex differences in role functioning is still poorly understood. The purpose of the present study was to investigate sex differences in symptomatology and role functioning in a sample of 92 inpatients hospitalized for an episode of DSM-III-diagnosed schizophrenic disorder. Patients were randomized at hospital admission to either of two treatment conditions: (1) multimodal hospital treatment with the addition of an inpatient family intervention (IFI) or (2) multimodal hospital treatment without IFI. Results indicated (1) sex differences in levels of substance abuse and antisocial behavior (worse for males both at admission and followup)--dimensions of psychopathology unrelated to the core features of schizophrenia; (2) superior family and occupational functioning in females at followup; and (3) superior clinical response of females to IFI. Data on family response to IFI suggest some ameliorative effects of IFI on critical family attitudes toward female patients as well as greater family compliance with IFI treatment among the families of females. Sex differences in intermorbid family and occupational functioning and response to a family-based psychosocial intervention are discussed in light of data on rejecting family attitudes toward the patient and sex differences in symptomatology. The possible influence of sex-differentiated social role demands on response to IFI is also discussed.

The quality of care typically rendered to seriously mentally ill patients in this country does not reflect the extraordinary expansion and refinement in recent decades of scientifically based psychiatric diagnostic and therapeutic capacities. In this paper, the authors examine reasons for the disparity between the quality of the scientific base and the quality of care, citing recent historical influences and contemporary obstacles, and then propose strategies for change.