Best Practices: Don't Forget the Sickest Patients

To the Editor: In the February 2002 issue, Carpinello and her colleagues (1) described New York State's campaign to implement evidence-based practices for people with serious mental disorders. However, as is often the case in discussions of best practices, the treatment needs of patients with chronic schizophrenia who remain in state hospitals were virtually ignored.

Given the authors' emphasis on research evidence, the omission of social-learning-based inpatient programs for these patients is surprising. First, such patients are the most severely mentally ill and the most expensive to treat, and their care is most influenced by political and administrative decisions (2). Second, data on inpatient social learning programs for people with chronic schizophrenia provide some of the strongest evidence for the effectiveness of any intervention in psychiatry (2). Unfortunately, the number of behaviorally oriented inpatient programs that follow the empirically validated techniques first described by Paul and Lentz (3) is small, despite the effectiveness of such programs, which is all the more reason for the inclusion of their component behavioral procedures into the best practices movement.

The six-year study by Paul and Lentz (3) demonstrated the clear superiority of an intensive behavioral milieu over other types of inpatient treatment. More than 97 percent of patients who had been considered nondischargeable from a state hospital setting could be discharged within two years of entering the social learning program, in most cases with significantly fewer medications and with positive community outcomes. This and later reports described specific techniques for functional assessment of behavior, milieu management, group administration, staff prompting in response to a wide range of patient behaviors, and assessment of staff fidelity to these procedures. Programs that have adopted similar procedures have also demonstrated remarkable success in enabling long-stay state hospital patients to be discharged from the hospital and to live successfully in the community (4).

Given the consistent success of such programs over the past 25 years, one must wonder why intensive behavioral inpatient programs are almost never mentioned in discussions of best practices in psychiatry. We can only speculate as to the reasons, but we suggest that they may include a lack of awareness of behavioral treatment techniques or data on their effectiveness; a misunderstanding of behavioral interventions, including the perception that they are punitive; a political decision to emphasize "consumer-centric" care and the misperception that behavioral treatment is incompatible with this position; an insufficient number of state and county mental health administrative personnel who have expertise in development of behavioral programs; and a move away from public mental health investment in patients who require continued inpatient care.

Whatever the causes, available evidence clearly indicates that such programs are the most clinically effective, cost-effective, and humane treatment options for the sickest patients we treat (5). We therefore encourage those who are in a position to set best-practice agendas for public mental health to consider the evidence on the treatment of institutionalized patients who have schizophrenia and to bring these best practices into the campaign.