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A growing theoretical and practical body of knowledge recognizes the common clinical concerns of chronic psychiatric patients who are homosexual and promotes their affirmative inclusion in psychiatric programs for other persons with chronic mental illness. This paper provides a clinical context for understanding essential issues in the inpatient and outpatient treatment of chronic psychiatric patients who are gay men or lesbian women. Such patients are largely an ignored or invisible subgroup in long-term psychiatric programs and in the gay and lesbian community. They are dependent on therapeutic communities, residences, and families that are heterosexually acculturated and often unaware of their needs. Most have experienced antihomosexual prejudice and the stigmatizing effects of mental illness. Affirmative models of treatment can be adapted to this population but must be modified to accommodate their psychiatric deficits. Increased efforts to destigmatize both mental illness and homosexuality are needed.

Treatment of chronic mentally ill inpatients in public settings can be a difficult endeavor due to lack of adequate resources and problems in recruiting and retaining qualified staff. Psychologists can make a valuable contribution in state mental hospitals, offering a range of services that may be unknown to other disciplines. The authors describe seven areas in which clinical psychologists can facilitate quality patient care, including assessment, psychotherapy and rehabilitation, behavior modification, ward treatment programming, student and staff training, research, and administration. They also discuss ways to deal with conflicts that develop between personnel from various mental health disciplines, such as those around issues of control, prescription privileges for nonphysicians, and clinical decision making.

In a study designed to investigate the pattern of substance use disorders among a group of chronic mentally ill patients in Toronto, 102 patients completed the Structured Clinical Interview for DSM-III-R and a modified substance-use-disorder module of the Diagnostic Interview Schedule. Forty percent of the sample met criteria for substance use disorders, and 49 percent for personality disorder. Among patients with personality disorder, all those with a personality disorder in cluster B (that is, with antisocial, borderline, histrionic, or narcissistic personality disorder) had a substance use disorder, while the majority of patients in cluster A and cluster C were not substance abusers. In the overall sample, the group with substance use disorders was significantly younger than the group without. In contrast to findings of previous studies, women met criteria for substance use disorders as often as men did.

The author describes experiences gained over 18 years of conducting a therapy group for chronically ill psychiatric patients that focuses on spiritual beliefs and values. The group is held in a day treatment center and is attended by both men and women, whose ages have ranged from 22 to 60 years. Staff concerns that discussion of religious and spiritual material would foster patients' delusional ideation or strengthen their defenses and be counterproductive to treatment or that patients could not tolerate diverse systems of beliefs have not been borne out. Such groups foster tolerance, self-awareness, and nonpathogenic therapeutic exploration of value systems. Group rules contributing to its success are tolerance of diversity, respect of others' beliefs, a ban on proselytizing, and open membership.

The Robert Wood Johnson Foundation chose the University of Maryland Mental Health Policy Studies Program to conduct an independent national evaluation of its Program on Chronic Mental Illness, a large-scale demonstration in which nine cities across the country are participating. The national evaluation aims at describing the implementation of the program and assessing its impact on clients. The evaluation effort comprises five groups of interrelated studies: a site-level study, a community care study, housing studies, financing studies, and disability and vocational rehabilitation studies. Taken together, the components of the evaluation should provide evidence that will help create new structures and processes in large cities for delivering care to persons with chronic mental illness.

Successful involuntary psychiatric outpatient treatment requires identifying patients who are suited to such treatment and ensuring that the service system is able to deliver the treatment. Based on his clinical experience, the author has developed ten sequential guidelines that can help clinicians identify patients who are appropriate for involuntary outpatient treatment. The sequential order of the guidelines means that a patient must meet the criteria for each guideline before being evaluated on subsequent guidelines. The guidelines assume that the patient has a chronic mental illness and a history of dangerousness to self or other because of that illness. The author believes that achieving consensus about who should receive involuntary outpatient treatment is an important first step in permitting evaluation of the efficacy of the approach.

A federal law passed in 1986 required states to develop service plans incorporating each state's own definition of chronic mental illness. This study considered whether the state definitions can be used to identify comparable populations of chronic mentally ill patients and to obtain a meaningful national estimate of the number of such patients. The study applied definitions of chronic mental illness used in ten states to a representative sample of patients receiving public mental health services in West Philadelphia over a two-year period. The prevalence estimates of patients defined as chronically mentally ill ranged from 38 percent using the Hawaii definition to 72 percent using the Ohio definition. The National Institute of Mental Health definition, used as a reference point, produced a prevalence estimate of 55 percent. The authors conclude that the considerable variance among the states in prevalence estimates renders the sum of state counts of chronic mentally ill patients of limited use.

Oregon is one of three states that allows persons to prepare a legal document-and advance directive-to stipulate the mental health treatment they wish to receive should they lose their decision-making capacity. An informal one-page questionnaire on the use of advance directives for mental health treatment in the state was enclosed in newsletters sent to families and care providers of persons with severe and persistent mental disorders. Responses were received from 156 people; they reported that 64 advance directives had been completed by consumers, 40 surrogate decision makers had been appointed, and ten consumers had used their advance directives when in crisis. In each case, the consumer's wishes were honored. The small response to this preliminary survey suggests the need for further education about advance directives among mental health care consumers, their families, and providers.

The authors describe development of an automated system to provide caregivers in a regional mental health service in Calgary, Alberta, with access to information about persons with chronic mental illness served by the system. All participating organizations provided input about system design features and data elements. Issues of confidentiality of records were addressed. A working model demonstrated to caregivers was rated as useful and understandable by more than 90 percent of respondents.

Editor’s Note: The Robert Wood Johnson Foundation’s Program on Chronic Mental illness was desi_ to test the impact of local mental heatlh authorities on organization ofservices and dinical outcomes. Nine cities were sekcted as sitesfor theprogram, which was the largest privately funded demonstration ever conducted in the mental health arena. A series of evaluation studies of the program’s impact have been published in the general health policy literature. To highlight some of the major findings for Psychiatric Services readers, editorJobn A. Talbott, ltD., talked with Howard H. Goldman, MD., Ph.D., who coordinated the evaluation studies. Dr. Goldman is professor ofpsycbiatry and director of the Mental Health Policy Studies Program at the University of Maryland School ofMedicine. The following is an edited transcript of their discussion.

The Robert Wood Johnson Foundation Program on Chronic Mental Illness provides support for broad change in the organization, financing, and delivery of services in public systems of care for chronic mentally ill persons. To address the lack of an organizational locus of responsibility in these systems, the foundation proposed that each of the nine cities participating in the program create a mental health authority that would centralize administrative, clinical, and fiscal oversight. The authors present site-by-site observations of the developing mental health authorities at the end of the program's two-and-a-half-year planning phase. They conclude that although the Robert Wood Johnson Foundation grant represented a significant incentive for innovation, at this relatively early stage in the demonstration authorities at only a few sites bad achieved direct clinical responsibility for chronic mentally ill persons. Although services had expanded, no site had yet developed a comprehensive system of care that i...

Homelessness as a dimensional concept reflecting instability of community living arrangements was examined in an urban state hospital's sample of 187 aftercare patients with chronic mental illness. According to ratings by outreach clinicians, 17 percent of the patients were predominantly homeless, and 10 percent were occasionally homeless over the six months before evaluation. Younger, male patients were more likely to be homeless. Homelessness was strongly associated with abuse of alcohol and street drugs, treatment noncompliance, and a variety of psychosocial problems and psychiatric symptoms. Homeless patients were viewed by their primary clinicians as attracted to the hospital as a living alternative and, during prospective one-year follow-up, had a much higher rate of rehospitalization.

The shifts in the pattern and locus of mental health care arising from the deinstitutionalization movement have resulted in a lack of definitive information on the scope of the problem of chronic mental illness. In addition, there is a lack of consensus on the boundaries that define the chronically mentally ill population, boundaries that can guide national policy-makers in a more scientific assessment of needs. In a national study following up the recommendations of the President's Commission on Mental Health, the authors developed a detailed definition of the chronically mentally ill population based on diagnosis, disability, duration of illness, and the institutional and community settings in which chronic mental patients may be found. They used prevalence data from a number of sources to arrive at a national estimate of between 1.7 million and 2.4 million in the target population, including 900,000 in institutions.

Three criteria--diagnosis, duration, and disability--are gaining currency in efforts throughout the United States to define the concept of chronic mental illness in a precise manner. However, there is presently no consensus on the specific character or relative importance of these criteria. Nor is there consensus on the nature of the interrelationships among these elements. These conceptual concerns must be resolved if uniformity in service planning and research on the chronic mentally ill is to be achieved.

Present psychiatric facilities in general hospitals are extremely inadequate. Only 279 of 4,761 United States general hospitals offer any kind of adequate inpatient psychiatric service. Although half of all hospital beds are now used for treatment of chronic mental illness, yet general hospitals provide only 4% of beds for acute psychiatric disorders. Psychiatric personnel is below minimum numbers. Training programs are insufficient to meet the demands, as witness 14 completed units unable to operate for lack of personnel. Only 309 of the total 4,761 general hospitals train psychiatric personnel. Medical schools do not place enough emphasis on psychiatric teaching, training, treatment, and research in general hospitals. Only 52 of the 73 medical schools use them, and only 9 use all clinical departments for the integration of psychiatry. Voluntary health insurance coverage of psychiatric disorders is disgracefully lacking. Only 10% of Blue Cross and 4% of Blue Shield plans studied provide the same benefits...

The evidence is strong that bimedial lobotomy is superior in treatment of chronic mental illness to either conventional bilateral lobotomy or unilateral lobotomy. The reduction in anxiety, tension, hostility, and impulsivity is dramatic; the improvement in initiative and ability to form object relationships, the increased capacity to work and to get along, the recession of psychotic symptoms—all were most significant and important. In group situations, patients who received bimedial operation were more interested in interaction, more alive to group needs, more productive and organized in their activities than patients receiving the other operations. Psychological tests suggest that they made definite gains in abstraction capacity. There was no mortality in the total series of cases. The immediate postoperative morbidity of bimedial surgery was no greater than other operations and the incidence of untoward complications no greater than for conventional bilateral lobotomy. For the present, at the Boston Psy...

4. Bachnach LL: Continuity of cane for chronic mental patients: a conceptual analysis. American Journal of Psychiatry 138:1449-1456, 1981 5. Billig N, Levinson C: Homelessness and case management in Montgomery County, Maryland: a focus on chronic mental illness. Psychosocial Rehabilitationjournal 11:59-66, 1987 6. Engel G: The clinical application of the biopsychosocial model. American Journal of Psychiatry 1 37:535-544, 1980 7. Lamb HR: Rehabilitation in community mental health. Community Mental Health Review 2: 1-8, 1977 and admission clinic. In the initial study, reported here, we wished to determine the frequency with which patients made various requests on a self-report form and the frequency with which clinicians failed to detect patients’ requests during the initial screening interview. We also analyzed the data to identify any patterns in the types of requests that were more or less likely to be detected. We hypothesized that the usual clinical interview would miss a substantial number of patient requests.

The papers in this special issue represent a synthesis of understanding about a wide spectrum of concerns related to women’s health. The selection of topics and approaches is by no means cornprehensive, but one aim is to explore new territories and perspectives. Some of the authors make an initial foray into this area, while others build upon their previous work and take their thinking a step further. The decision to publish an issue devoted to concerns of wornen represents an exciting direction for H&CP. Dr. Jeffrey Geller glimpses a century and a half of history and uses women patients’ own words to recount their poignant experiences with psychiatric treatment. Dr. Geller’s historical review also reminds us that we may be heading perilously back in the same direcnon if the problems of the mentally ill are not substantively addressed. In an incisive review article on the chronic mentally ill woman, Dr. Leona Bachrach reminds us of the pitfalls of generic reductionism. She makes it clear that one must attend quite specifically to the plight of women with chronic mental illness and also points out that because we have “desexed”