Toward a public policy on the chronic mentally ill patient.

This paper outlines the problems posed by the chronic mentally ill, which have become a national disgrace. The historical background of deinstitutionalization is reviewed, issues critical to an understanding of the problems of the chronic mental patient are examined, solutions are suggested, and a public policy on the chronic mental patient is proposed.

Why psychiatrists leave the public sector.

The flight of psychiatrists from public mental health facilities must be halted if the sickest psychiatric patients--the severely and chronically mentally ill--are to receive the best care and treatment possible. The author emphasizes the need for commitment by organized psychiatry, universities, and communities to support the public sector and those working in it. He examines the factors that influence psychiatrists to enter public service and those that eventually cause them to leave.

Deinstitutionalization: avoiding the disasters of the past.

The reasons for the problems created by deinstitutionalization have only recently become clear; they include a lack of consensus about the movement, no real testing of its philosophic bases, the lack of planning for alternative facilities and services (especially for a population with notable social and cognitive deficits), and the inadequacies of the mental health delivery system in general. Providing care for the chronically ill and preparing for future deinstitutionalization means that the issue must be reconceptualized not as one of where people should be housed but as the need to provide the full range of treatments and services that are available in a total institution. Attitudinal and institutional biases and discriminatory practices must be combated, planning for community facilities and services must be improved, and funding for both institutional and community services must be provided during the phasing down of institutional services.

Opposition to "coercive continuing medical education and mandatory recertification".

A district branch survey on attitudes toward obligatory continuing medical education (CME) and mandatory recertification indicated that most respondents approved the concept of lifelong learning. However, proposed methods of implementation of CME were criticized on grounds of commercialization, bureaucratization, poor quality, wasting time and money, excessive external control over learning, and flawed requirements. Objections to mandatory recertification centered mainly on an abhorrence of Board-type examinations.

Progressive systemic sclerosis (PSS) and malignancy, pulmonary and non-pulmonary.

In contrast to the 15-20% incidence of the coexistence of acute dermatomyositis-polymyositis and malignancy, it has been accepted traditionally that the association of progressive systemic sclerosis, a disease with several features that may overlap the former condition, and malignancy is purely fortuitous. This experience has not been altered by the material presented in this review. However, the factual coexistence has been illuminated by a review of the pertinent literature and presentation of 12 previously unpublished case reports.

Cancer associated with collagen-vascular disease.

Two cases of cancer, each associated with a different collagen-vascular disease, are reported. The first patient, a 71-year-old white man, had a history of acute dermatomyositis and malignancy for a few weeks only. Death was associated with adenocarcinoma of the lesser curvature of the stomach with metastases to the liver and beyond.

Microscopic examination of urine.

Two methods of expressing microscopically observed leucocytes, erythrocytes, and casts in urine, both with centrifugation, one quantitatively (per ml) and the other per high-power field (H.P.F.

Introduction.

The signs which one ordinarily associates with gout, such as subcutaneous nodules, podagra, arthritis, and elevation of blood uric acid level, do not necessarily make for a diagnosis of that condition, as Dr Talbott and his associates explain. Gout is still frequently misdiagnosed, in spite of renewed interest in it, because of ignorance of its many facets, which are described in this symposium. One of the most important of these may be the "gouty diathesis" which appears to be associated with significant disease, particularly coronary heart disease.

Treating gout: successful methods of prevention and control.

For control of acute episodes of gout, administration of a full course of colchicine is the preferred method of therapy. This drug also is useful in prophylaxis of recurrent attacks, taken daily in combination with one or more drugs that influence uric acid metabolism. Weight reduction if the patient is obese, a balanced diet with restriction of foods high in purine content, and high fluid intake also are recommended.

Reactions of schizophrenics to life-threatening disease.

This contribution reports a study of chronic schizophrenics hospitalized in state hospitals who suffer from serious and life-threatening medical and surgical illnesses. Four primary findings are described and discussed: lack of verbalization of pain and discomfort; bodily self-mutilation; toleration and exhibition of loathsome lesions; and inability or unwillingness to tolerate medical care. Some examples of exceptions to these four findings are also presented.

Differences between nonprofessional recovering alcoholic counselors treating Bowery alcoholics: a study of therapist variables.

Several treatment variables have been suggested as critical in the outcome of psychiatric therapy. These can be categorized as patient variables, therapy variables, and therapist variables. This study utilized a homogeneous Bowery-patient population, treated in a comprehensive inpatient treatment and rehabilitation program, and attempted to assess differences among nonprofessional recovering alcoholic counselors.

Acute dermatomyositis-polymyositis and malignancy.

A partial review of selected published case reports of AD-P associated with malignancy has been enhanced by the presentation of pertinent data on 15 unreported examples of the association. It is noteworthy that the first case in current literature of AD-P associated with a malignancy was described in 1916. The brief clinical report of a patient with proximal muscle weakness and skin lesions, with the obvious association with a malignancy (adenocarcinoma of the stomach), describes an example that has been repeated many times with different types of tumors but with essentially no variations in the clinical findings.

Administrative receivership and troika management.

The authors describe the use of troika management and administrative receivership to upgrade a unit in a state mental hospital. The experiment included a three person unit chief, transitional leadership, and collective decision making.

The elements of community consultation.

Psychiatrists are involved in both clinical and institutional consultations. Although the tradition of psychiatric consultation for medical patients is well established and adequately described, there are few contributions concerning the conceptual framework for community consultations and few case examples. In order to provide a framework for conceptualizing consultation work this communication presents an example of a consultation to a community agency and discusses some of the specific elements in community consultation.