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July 2004: This Month's Highlights
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.7.747
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This month two articles and a Taking Issue commentary focus on improving the outcomes of substance abuse treatment, and a brief report presents further evidence that teenagers' self-reports of substance use should raise red flags for caregivers' attention to a host of related problems. Inpatient care is also a focus this month, with papers on predictors of hospitalization, the atmosphere and working conditions on psychiatric wards, and the use of physical restraints.

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What key treatment strategies produce successful outcomes in community drug treatment programs? To help answer this question, Yih-Ing Hser, Ph.D., and coauthors used a large data set from the California Treatment Outcome Project (CalTOP) to examine relationships between treatment processes and outcomes among clients of 36 outpatient drug-free and residential treatment programs in 13 California counties. They conducted path analyses to relate the quantity and quality of services received during the first three months of treatment to treatment retention and outcomes at nine-month follow-up. Their findings suggest a number of key elements of the treatment process that, if strengthened, have the potential to substantially enhance substance abuse treatment outcomes (see page 767).

The use of legal mandates to improve adherence to community-based treatment among persons with serious mental illness is controversial. Little research has been conducted on consumers' attitudes toward involuntary outpatient commitment and other forms of mandated community treatment. Using a sample of 104 consumers with schizophrenia, Marvin S. Swartz, M.D., and his coauthors studied consumers' appraisals of the fairness and effectiveness of mandated community treatment and related pressures. These researchers were able to pinpoint a number of personal characteristics likely to lead a consumer to believe that he or she would benefit from various formal and informal treatment-adherence sanctions and to believe that such sanctions are imposed in the consumer's best interests (see page 780).

As parents who are caring for adult offspring with mental illness age, they become increasingly concerned about what will become of their offspring. Clearly, residential planning is an important issue for these families, but many families don't make plans. What determines how much residential planning families actually undertake? Gregory C. Smith, M.S., Ed.D., conducted a study to identify predictors of the extent of residential planning by applying the conceptual framework of the Double ABCX model of family coping and adaptation in a sample of 157 mothers of offspring with mental illness. The results suggest several steps that service providers can take to ensure that older parents of adults with mental illness plan adequately for the future—for example, encouraging them to recognize age-related changes in themselves that signal the need to plan for residential care (see page 804).

Psychiatric advance directives have been one of the more promising innovations in recent years to give patients a greater say in their care. However, there have always been concerns that these directives could be used to preclude future treatment, particularly treatment with medications, even in the case of patients who become psychotic and are involuntarily hospitalized. As Paul S. Appelbaum, M.D., explains in this month's Law & Psychiatry column, a recent decision by the U.S. Court of Appeals for the Second Circuit, involving a Vermont woman with paranoid schizophrenia, has brought such concerns closer to reality. Dr. Appelbaum notes that although the Second Circuit's opinion applies directly to only Vermont and New York, this court is an influential one whose opinions may well be echoed in other circuits throughout the United States (see page 751).

•A program for reducing the use of physical restraint on three psychiatric units of a university hospital has demonstrated that certain aspects of staff training can ensure that hospitals meet their restraint-reduction goals (see page 818).

•The Economic Grand Rounds column proposes several cost-containment strategies in response to the latest round of increases in health care costs (see page 761).




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