July 2000: THIS MONTH'S HIGHLIGHTS

This month our review of important developments in psychiatric services over the past 50 years focuses on the American Psychiatric Association's 1978 Conference on the Chronic Mental Patient, convened to develop policy recommendations for dealing with the growing number of former state hospital patients with long-term and severe mental disorders who were receiving inadequate care in the community (see page 869). In an accompanying commentary, H. Richard Lamb, M.D., examines the reasons behind the failure to anticipate the needs of this large group of patients and discusses why the conference and its recommendations were so important (see page 874). In the Taking Issue column, Michael Faenza, M.S.S.W., argues that mental health advocates will have more success if they focus more broadly on services for all Americans in need, rather than on services only for those with the most severe illnesses (see page 843).

Persons with mental disabilities comprise one of the few groups of Americans still subjected to restrictions at the voting booth, Paul S. Appelbaum, M.D., notes in this month's Law & Psychiatry column. As of 1997, a total of 44 states barred voting by some subgroups of persons with mental illness or mental retardation. Dr. Appelbaum acknowledges that drawing a reasonable line between those who are and those who are not capable of voting is no easy task, but he emphasizes that persons with mental disabilities have strong interests in overcoming obstacles to voting. The sustained neglect of their needs is the result, in part, of their lack of political clout, he observes (see page 849).

Community-based services are widely assumed to be culturally relevant when they meet the linguistic and geographic needs of ethnic minorities and are provided by ethnic minority staff. However, Concepcion Barrio, Ph.D., points out that such a view fails to take into account family practices, conceptions of mental illness, expectations of providers, and other factors that also determine cultural relevance. Dr. Barrio conducted a literature review to identify findings that are useful in developing culturally relevant services in community support programs and offers a series of practical guidelines based on her review (see page 879).

Rehospitalization rates have long been considered a measure of the effectiveness of treatment. Whether they also provide insight into the effectiveness of discharge planning is the subject of a study reported by E. Anne Nelson, Ed.D., and her colleagues, who focused specifically on whether keeping at least one outpatient appointment after discharge would have an effect on patients' rehospitalization rates. They found that patients who did not comply with at least one appointment were two times more likely to be rehospitalized than those who kept at least one appointment. They conclude that stabilization from inpatient care appears to be sustained over time for patients who keep follow-up appointments (see page 885).

Discharging a patient against medical advice (AMA) has come to be seen by some physicians as a kind of disclaimer that automatically exonerates the physician if the patient's discharge has an unfortunate consequence. Patrick J. Devitt, M.B., M.R.C.Psych., and his coauthors reviewed the literature to determine whether case law supports that view. They summarize four cases in which medical authorities and physicians were sued for malpractice even though they discharged a patient against medical advice. In all cases the defendants were exonerated, but not because the patient was discharged against medical advice (see page 899).

•A study of where veterans received treatment for mental disorders found that the vast majority were treated in mental health clinics, in contrast to patients in community and private-sector samples, for whom care was more evenly distributed between medical and specialty mental health settings (see page 890).

•In the Datapoints column, Glenn W. Currier, M.D., M.P.H., examines the association between psychiatric hospital bed reductions and mortality among persons with mental disorders in seven industrialized countries (see page 851).

•Jules Ranz, M.D., and his associates report on a survey of the roles filled by psychiatrists who are medical directors in community settings (see page 930).

•The books section features a series of books examining how neuropsychiatry and neuropsychology assessments can lead to improved diagnosis and patient care (see page 939).