Faculty Bibliography

Caseload and daily volume requirements present clinical and administrative challenges in organized settings primarily serving the public sector. These challenges are examined through lenses of systems-level fiscal viability, population health, and patient experience. Framed by previous efforts in caseload methodology, illustrative data collected from members of the American Association of Community Psychiatrists are discussed, with consideration of issues of professional effort and burnout. A systematic effort is needed to develop guidelines for caseload and volume expectations that support recovery outcomes, account for practitioner skills, and promote high-quality clinical encounters.

OBJECTIVE: The authors outline the unique ethical challenges that psychiatry residents face in working with individuals who are homeless and mentally ill. The authors also propose steps to develop effective teaching methods with residents working with these patients. METHODS: The authors reviewed literature relevant to the training of psychiatry residents in ethics and treating individuals who are homeless and mentally ill. RESULTS: The authors summarize current literature and, with the use of case examples, provide guidelines for effective teaching. CONCLUSIONS: Teaching psychiatry residents who are working in the community with individuals who are mentally ill and homeless needs to address a number of unique ethical conflicts that arise in this area. The authors outline approaches to this teaching.

OBJECTIVE: The aim of this study is to analyze qualitative data collected during field-testing of an instrument to assess psychiatric residents' experiences with systems-based practice (SBP). METHODS: A total of 237 psychiatry residents from 6 levels of training in 12 different psychiatry residency training programs responded to a 60-item instrument measuring their experiences with SBP during residency. Qualitative techniques adapted from content analysis were used to review narrative responses to open-ended questions on the instrument. RESULTS: Certain themes emerged in the residents' answers reflecting their opinions about the opportunities for (and barriers to) performing SBP in their work. CONCLUSIONS: Psychiatric residents express an eagerness for opportunities to learn about and perform SBP but often feel constrained by the lack of resources, teaching, and supervision. Moreover, many residents desire a better understanding of healthcare economics and how to factor cost consideration into clinical care.

Alcohol and drug use are commonly associated with the experience of homelessness. In order to better understand this, we explored the prevalence of drug and alcohol use as it related to successful re-housing within a sample of first-time single homeless adults at municipal shelters. From within this sample, we compared the features of recurrent homelessness with those of chronic homelessness and of being stably housed. We interviewed 344 subjects upon shelter entry and followed each one every six months for 18 months using standardized social and mental health measures. We analyzed baseline assessments relative to housing experiences during follow-up using Chi square and multinomial logistic regression. Eighty-one percent (N = 278) obtained housing over 18 months, of which 23.7 % (N = 66) experienced homelessness again. Recurrent homelessness was more common among those with a high school education and if initially re-housed with family. Bivariate analysis resulted in the observation of the highest rate of alcohol and other drug use among this recurrent group and multinomial logistic regression supported this only with the coupling of arrest history and diagnosed antisocial personality disorder. With relatively high rates of recurrent homelessness, there were differences between subjects who experienced recurrent homelessness compared to those who were stably housed and with chronic homelessness. That alcohol and other substance use disorders were associated with recurrent homelessness only if they were linked to other risk factors highlights the complexity of causes for homelessness and a resultant need to organize them into constellations of causal risk factors. Consistent with this, there should be initiatives that span bureaucratic boundaries so as to flexibly meet multiple complex service needs, thus improving outcomes concerning episodes of recurrent homelessness.

OBJECTIVE: This study assessed the prevalence, diagnosis, and treatment of major depressive disorder and generalized anxiety disorder among New York City adults. METHODS: As part of the first community-specific Health and Nutrition Examination Survey in the United States, depression and anxiety were assessed in a representative sample of 1,817 noninstitutionalized adults in 2004. RESULTS: A total of 8% had major depressive disorder and 4% had generalized anxiety disorder. Respondents with depression were more likely to be formerly married, publicly insured, younger, and U.S. born. Only 55% of adults with depression were diagnosed, and 38% of those with depression or anxiety were in treatment; individuals with a diagnosis of depression were more likely to receive treatment than those without a diagnosis (61% versus 7%; p<.001). Immigrants with depression were 60% less likely to be diagnosed than their U.S.-born counterparts; immigrants arriving in this country ten or more years ago had slightly more anxiety than immigrants arriving less than ten years ago (3% versus 2%, not significant). Among respondents with anxiety, 23% reported disability compared with 15% of those with depression. Compared with adults with neither diagnosis, adults with depression or anxiety were twice as likely to smoke tobacco (p<.05), adults with depression were twice as likely to have diabetes (p<.01), and those with anxiety were twice as likely to have asthma (p<.01). CONCLUSIONS: Mental disorders are often disabling and inadequately diagnosed and treated. Foreign-born adults experience barriers to diagnosis and treatment despite having less depression; anxiety may increase with time since immigration. Increased awareness of and linkage to mental health services are needed, especially in larger, more diverse urban communities.