Dilemmas of medical ethics in the Canadian Penitentiary Service.
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There is a unique hospital in Canada-and perhaps in the world-because it is built outside prison walls and it exists specifically for the psychiatric treatment of prisoners. It is on the one hand a hospital and on the other a prison. Moreover it has to provide the same quality and standard of care which is expected of a hospital associated with a university. From the time the hospital was established moral dilemmas appeared which were concerned with conflicts between the medical and custodial treatment of prisoners, and also with the attitudes of those having the status of prisoner-patient. Dr Roy describes these dilemmas and attitudes, and in particular a special conference which was convened to discuss them. Not only doctors and prison officials took part in this meeting but also general practitioners, theologians, philosophers, ex-prisoners, judges, lawyers, Members of Parliament and Senators. This must have been a unique occasion and Dr Roy's description may provide the impetus to examine these prison problems in other settings. (+info)
Technique evaluation of foster care in chronic psychiatric disorders.
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Foster care received by 178 patients with chronic psychiatric disorders discharged from Hamilton Psychiatric Hospital in the years 1966 through 1969 was studied by technique evaluation. Residents were followed for 3 years by means of health records. The achievement of operational objectives of the program (Homes for Special Care) was compared with two types of outcome--emergency readmission to hospital and discharge to the community. Emergency readmission was associated with rural location of the foster home, inferior quality of the home operator and smaller size (i.e., fewer residents) of the home. Discharge to the community was more common among younger, female residents whose previous psychiatric hospitalization had been relatively brief. In general, prescription audit was not a fruitful way of evaluating quality of health care. (+info)
Systematic review of the effectiveness of planned short hospital stays for mental health care.
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OBJECTIVE: To determine the effectiveness of planned short hospital stays versus standard care for people with serious mental illness. DESIGN: Systematic review of all randomised controlled trials comparing planned short hospital stay versus long hospital stay or standard care for people with serious mental illness. SUBJECTS: Four trials enrolled 628 patients. MAIN OUTCOMES MEASURES: Relapse; readmission; death (suicides and all causes); violent incidents (self, others, property); lost to follow up; premature discharge; delayed discharge; mental state (not improved); social functioning; patient satisfaction, quality of life, self esteem, and psychological wellbeing; family burden; imprisonment; employment status; independent living; total cost of care; and average length of hospital stay. RESULTS: Patients allocated to planned short hospital stays had no more readmissions (in four trials, odds ratio 0.93, 95% confidence interval 0.66 to 1.29 with no heterogeneity between trials), no more losses to follow up (in three trials of 404 patients, 1.09, 0.62 to 1.91 with no heterogeneity between trials), and more successful discharges on time (in three trials of 404 patients, 0.47, 0.27 to 0.85) than patients allocated long hospital stays or standard care. Some evidence showed that patients allocated planned short hospital stay were no more likely to leave hospital prematurely and had a greater chance of being employed than those allocated long hospital stay or standard care. Data on mental, social, and family outcomes could not be summated, and there were few or no data on patient satisfaction, deaths, violence, criminal behaviour, and costs. CONCLUSION: The effectiveness of care in mental hospitals is important to patients, carers, and policy makers. Despite inadequacies in the data, this review suggests that planned short hospital stays do not encourage a "revolving door" pattern of care for people with serious mental illness and may be more effective than standard care. Further pragmatic trials are needed on the most effective organisation and delivery of care in mental hospitals. (+info)
Amoebiasis among institutionalized psychiatric patients in Taiwan.
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Although information on amoebiasis among institutionalized psychiatric patients is available, reports on the relationship between behaviour and this infection are not abundant. From July 1995 to June 1996, stool and blood samples were collected from 565 patients in three psychiatric hospitals of North Taiwan. Stool samples were examined using the direct smear and formalin-ethyl acetate sedimentation techniques as well as ProSpecT Entamoeba histolytica Microplate Assay kit. Blood samples were examined by the Amebiasis Serology Microwell ELISA kit. Among these patients, 14 (2.5%) harboured one or two species of intestinal parasites. There were 6 (1.1%) E. histolytica/E. dispar cyst passers: 5 positive in stool ELISA test and 2 with antibodies against E. histolytica. Among demographic factors, type of psychiatric disorder and disability, only a significant sexual difference in seropositivity of E. histolytica was observed. These findings indicate that the infected patients acquired the infections before they entered the hospitals. (+info)
The management of epilepsy in a hospital for people with a learning disability.
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The study examined changes in the use of antiepileptic drugs (AEDs) in a large hospital for people with a learning disability over a 2 year period, the use of investigations, and the presence of medication side-effects. The surveys were carried out in 1993 and 1995/6. In 1993, 27% of patients were being treated for epilepsy and in 1995/6, 30.1%. Ninety percent and 82.4% of patients, respectively, were receiving one or two AEDs. In the second survey there were fewer prescriptions for phenobarbitone (5.8% vs. 12.5%) and an increase in the use of lamotrigine (21.6% vs. 5%), gabapentin (5.8% vs. 0) and vigabatrin (3.9% vs. 2.5% in 1993). Side-effects were recorded in 6 (11.8%) patients. Seven (21.2%) patients receiving carbamazepine were found to have hyponatraemia. Of the 54 electroencephalograms (EEGs) requested, 41 (76%) were reported as abnormal. Six CT brain scans had been conducted, of which five were abnormal. People receiving antipsychotic drugs had fewer seizures than average. (+info)
Assertive community treatment for people with severe mental illness: the effect on hospital use and costs.
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OBJECTIVE: To determine the effect of the Program for Assertive Community Treatment (PACT) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness, and to test for variations in this effect with program staffing levels and patient characteristics such as race and age. DATA SOURCES/STUDY SETTING: Data are taken from a randomized trial of PACT in Charleston, South Carolina for 144 patients recruited from August 1989 through July 1991. STUDY DESIGN: Subjects were randomly assigned either to one of two PACT programs or to usual care at a local mental health center. Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis. DATA COLLECTION METHODS: Data were obtained from Medicaid claims, chart reviews, subject, case manager, and family interviews; searches of the computerized patient and financial databases of the South Carolina Department of Mental Health and relevant hospitals; and searches of the hard copy and computerized financial databases of the two major local hospitals providing inpatient psychiatric care. PRINCIPAL FINDINGS: PACT participants were about 40 percent less likely to be hospitalized during the follow-up period. The effect was stronger for older patients. Lower PACT client/staff ratios also reduced the risk of hospitalization. No evidence of differential race effects was found. Given some hospital use, PACT did not influence the number of days of use. CONCLUSIONS: Controlling for other covariates, PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics. This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to-date CMHC office-based case management program. (+info)
Do aftercare services reduce inpatient psychiatric readmissions?
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OBJECTIVE: To determine whether aftercare services reduce the likelihood that children and adolescents will be readmitted to inpatient psychiatric facilities. DATA SOURCES/STUDY SETTING: Analyses of data from the Fort Bragg Demonstration. Data were based on 204 sample individuals (children and adolescents), all of whom were discharged from inpatient facilities during the study period. STUDY DESIGN: These analyses use hazard modeling to examine the impact of aftercare services on the likelihood of readmission. Comparisons of individuals for whom the timing of aftercare services differ are adjusted for a wide range of individual characteristics, including client demographics, diagnosis, symptomatology, and psychosocial functioning. DATA COLLECTION/EXTRACTION METHODS: Detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. This information was taken from structured diagnostic interviews and behavior checklists, including the Child Behavior Checklist and Diagnostic Interview Schedule for Children, completed by the child and his or her caretaker. Information on the use of mental health services was taken from insurance claims and a management information system, and was used to identify the period from discharge to readmission and to describe the client's use of outpatient therapy, case management, intermediate (or stepdown) services, and residential treatment centers during this period. PRINCIPAL FINDINGS/CONCLUSIONS: Using Cox models that allow for censoring and that include the use of aftercare services as time-varying covariates, we find that aftercare services generally do not influence the likelihood of inpatient readmission. For the lower middle class families included in this study, the estimated effect of aftercare is not statistically significant and has limited practical significance. When we look at specific forms of aftercare, we find that outpatient therapy has the largest effect and that stepdown services in intermediate settings have the smallest. We also identify family and individual characteristics that influence the likelihood of readmission. (+info)
Drug resistance patterns among hospitalized tuberculous patients in Rio de Janeiro, Brazil, 1993-1994.
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The purpose of this study was to analyze the prevalence and risk factors for drug resistance among hospitalized patients in two tertiary care centers, an acquired immunodeficiency syndrome (AIDS) reference center and a sanatorium, in Rio de Janeiro, Brazil. From 1993-1994, 389 patients were diagnosed as having tuberculosis (TB). Isolates from 265 patients were tested for in vitro susceptibility to rifampin and isoniazid. Resistance to one or more drugs was detected in 44 patients (16.6%) and was significantly more common among recurrent cases in both hospitals (p=0.03 in the AIDS center and p=0.001 in the sanatorium). Twenty seven patients (10.2%) had isolates resistant to both isoniazid and rifampin. Multi-drug resistance was associated with human immunodeficiency virus (HIV) infection among patients who had never been treated for TB. In conclusion, drug-resistant TB is high in hospitalized patients in Rio de Janeiro, especially among HIV infected patients. Therefore, measures to control TB and prevent nosocomial transmission need urgently to be set up in the Brazilian hospitals. (+info)