Articles on Special Populations Published in Psychiatric Services Between 1950 and 1999

Although several surveys of the contents of psychiatric journals have been published, to our knowledge none has examined articles on special populations. Sabshin and Brodie (1) surveyed psychiatric research trends in the United States from 1963 to 1972. They examined the types of psychiatric research published in several journals but did not identify articles that focused on issues related to special populations.

Nakajima and colleagues (2) addressed the representation of special populations in cover art. They found that between 1983 and 1991 a total of 97 Hospital and Community Psychiatry cover illustrations depicted individuals. In 68 of these illustrations the race of the individuals could be determined. Fifty of these (74 percent) depicted whites only. Seven (10 percent) depicted people of color—four African Americans and three Native Americans or Pacific Islanders. Eleven covers showed both whites and nonwhites. The authors asserted that of the 18 covers depicting people of color, seven (39 percent) contained stereotyped images. The authors also found that 21 covers showed men in traditional gender roles, and 19 showed women in such roles. The authors concluded that none of the cover art of Hospital and Community Psychiatry showed people outside traditional gender or racial stereotypes.

Manson (3) found that more than 2,000 journal articles and book chapters were published between 1980 and 1995 on the mental health of American Indians and Alaska Natives. However, we found no studies in the literature that focused on more than a single special population.

In this study we examined each issue of this journal published between 1950 and 1999. The journal began publication as the A.P.A. Mental Hospital Service Bulletin, and the name was changed to Mental Hospitals with the seventh issue of volume 2. In January 1966 it was renamed Hospital and Community Psychiatry, and in January 1995 the name was changed to Psychiatric Services.

Methods

Our search included review articles, original articles, brief reports, and columns. Issues of the A.P.A. Mental Hospital Service Bulletin were essentially newsletters, and thus we defined an "article" as any text that had its own headline. Special populations were defined as groups of psychiatric patients that traditionally have not been a major focus of psychiatric research. We tallied articles that covered issues related to the mentally retarded population, women, gays and lesbians, children and adolescents, elderly persons, parents and families, communities and villages, and racial and ethnic groups. The community-village category includes articles that focused primarily on community psychiatry or community mental health centers. Patients' families and communities are a more recent focus of scientific investigation and represent the expanded scope of treatment within psychiatry. Family, friends, and other social supports should be integrated into the planning, implementation, and evaluation of treatment. Thus we decided that these populations warranted individual consideration.

Articles that covered more than one racial or ethnic group were counted in the multicultural category. Two examples of articles in this category are "Training Psychiatric Staff to Treat a Multicultural Patient Population" (4) and "Utility of Dual Diagnosis Services for Consumers From Nonwhite Ethnic Groups" (5). The parent-family category includes articles that address psychiatric issues that are directly linked to parenting and family functioning.

We found that most articles could be readily classified according to the criteria described above. When an article fit more than one category, we included it in each category. For example, "Culturally Syntonic Family Therapy for Migrant Puerto Ricans" (6) was placed into both the parent-family and Latino categories. The results were aggregated into five-year periods.

Results

Ten issues were published each year from 1950 to 1960, and 12 issues were published each year from 1961 to 1999. Thus 578 issues of the journal were published from 1950 to 1999. We estimated the total number of articles published during the 50-year period by counting the number of articles in one issue every three years. The 30 samples were then averaged, and the total was multiplied by 578. Thus we estimated that the 578 issues of the journal contained approximately 7,976 articles.

A total of 555 articles (7 percent) addressed special populations. Thirty-one of these fit into more than one category—27 into two categories, and four into three categories. Thus the 555 separate articles covered 589 topics on special populations.

Mental retardation

As shown in Table 1, only a few articles on mental retardation were published in the journal in the 50-year period.

Women

Thirty-eight articles on women's issues appeared in the journal during the years examined. As Table 1 shows, five articles on women's issues were published during the first three decades. This low rate would have continued during the 1980s had it not been for an October 1985 special issue with 11 articles on women and health. After a lull between 1990 and 1994, the number of articles on women increased because of another special issue in May 1998 that contained ten articles on women. The number of articles about women increased during the winter of 1997, and the higher rate was maintained through 1999.

Sexual orientation

Only two articles on sexual orientation have been published in the journal since 1950. Both were published between 1995 and 1999.

Children and adolescents

As Table 1 shows, about 12 articles on children and adolescents were published during each of the five-year periods from 1950 to 1964. The number tripled during the next five-year period because of a special issue in August 1968 that had a focus on this population. A special issue on children's mental health services appeared in September 1974. The number of articles on children and adolescents then diminished, reaching an all-time low in the 1980-1984 period. A special section on children and youth published during that period (the June 1983 issue) contained only five articles. In the next two five-year periods, the number increased. The June 1992 issue contained a special section on adolescent psychiatry that included seven articles.

Elderly persons

The distribution of articles published between 1950 and 1999 on the elderly population was bimodal. At least 20 articles were published during each of the first three five-year periods. Starting in the 1965-1969 period, fewer articles were published, until the number reached an all-time low in the 1975-1979 period. For the next three five-year periods, which included a special issue in February 1982 on mental health and aging, the number of articles on the elderly population once again exceeded 20 per period. Between 1995 and 1999, 30 such articles appeared, most of them in two special sections: one on geriatric syndromes in January 1995 and one on mental health and aging in September 1999.

Parents and families

Articles addressing issues related to parents and families first appeared in the journal during the first half of the 1960s. However, no more than four such articles were published during each of the subsequent five-year periods. Only one special issue, in December 1974, has addressed mental health and families.

Communities and villages

The articles we placed in the community-village category followed a pattern similar to that of articles on parents and families. They also first appeared in the 1960-1964 period and were consistently published during each subsequent period. Five were published in the last half of the 1960s, and no more than four appeared in each of the remaining periods.

Race or ethnicity

Table 2 lists the numbers of articles related to specific racial or ethnic groups. During the 50-year period, one article on mental health issues of people on the Indian subcontinent has appeared in the journal. Five have addressed populations in African countries, three of which were published in the 1990s. The first article about Africa, "Village Care System in Nigeria" (7), appeared in February 1967.

Considering the state of segregation in the United States before the 1960s, it is not surprising that no articles about the mental health of African Americans were published in the 1950s. Only one such article appeared in the 1960s—in January 1961. "Group Therapy for Families" described an eight-bed ward for Negro women with schizophrenia (8).

The first articles written by African Americans were unrelated to racial or ethnic issues (9,10,11) and were therefore not included in our tally. The first article on African-American issues appeared in February 1972. "The Coffee Pot Affair," by Bradshaw (12), focused on events and issues related to class, sex, race, and professional roles. It was followed in June 1972 by "Inpatient Therapy for Black Paranoid Men," by Carter and Jordan (13).

Articles on the mental health of African Americans have appeared regularly in the journal since the 1970-1974 period. However, with only two exceptions, no more than four articles were published in each of the subsequent periods. Twelve were published between 1985 and 1989, seven of which were included in a January 1986 special section on important issues in black psychiatry. Between 1990 and 1994, ten articles on African Americans were published, seven in a January 1994 special issue on psychiatric services for black patients, of which Ezra Griffith was the guest editor.

Between 1950 and 1999, a total of 36 articles in the journal have specifically addressed issues in African-American mental health.

Native Americans and Alaska Natives

Articles on Native Americans and Alaska Natives were published sporadically in the study period, beginning with one in the 1950-1955 period. Fewer appeared during the next ten years, and only one or two were published in the periods between 1965 and 1979. No articles on Native Americans or Alaska Natives were published between 1980 and 1984, and no more than four appeared in each of the last three periods we examined. In total, 15 articles on issues related to the mental health of Native Americans and Alaska Natives were published between 1950 and 1999.

Asians

Articles on issues related to Asians were published in eight of the five-year periods we examined. During each of four periods, only one article appeared, and the total did not rise above four during any period. In total, 15 articles were published on issues related to the mental health of Asians.

As with African-American authors, the first articles by Asian authors in the journal (14,15) did not focus on racial or cultural issues and thus were not included in our tally.

Latinos

Articles on Latinos followed a pattern similar to that of articles on Asian populations, although the total number of articles on Latinos was greater. The first such article, "Psychiatry in Latin America," by Sata (16), was published in June 1963. A total of 21 articles on Latino issues appeared during the period examined.

Multicultural articles

Articles focusing on more than one nonwhite, non-Euro-American population began to appear in the last half of the 1960s. Subsequently, with the exception of the 1975-1979 period, at least four multicultural articles were published in each five-year period. A total of 27 articles in this category have been published. There appears to have been a more concerted effort since the early 1980s to address multicultural issues. A special section in the February 1987 issue addressed cross-cultural issues. In March 1999, the journal launched an occasional series on special populations to further explore these issues.

Discussion

The 578 issues of this journal published between 1950 and 1999 contained approximately 7,976 articles. Seven percent—555 articles, or an average of one article per issue—addressed the mental health issues of special populations. Nevertheless, our main finding is that the journal has made continuous progress in increasing the number of articles on special populations.

During the 50-year period, only a few articles on issues related to people with mental retardation were published, and none were published in the final 40 years we examined. We believe that the journal should focus more on the mental health issues of this population.

In the 1950s and the 1970s, only two articles—one in each decade—addressed women's issues. Three articles on women's issues were published in the 1960s. Carol Nadelson, M.D., served as the first woman president of the American Psychiatric Association (APA) in 1985-1986 (17). A special issue on women's issues, edited by Dr. Nadelson, appeared in October 1985. In May 1998 a special section addressed women's issues. Six such articles were published in 1999, and we hope that the journal continues to focus on this important area. Of the 38 articles on women's issues, 79 percent (31 articles) have appeared since 1985, after the first woman APA president took office.

Only two articles on gay and lesbian issues were published in the 50-year period we examined—one in 1996 and one in 1999. We recommend that the journal devote a special section to this population in the near future.

The community-village category was modestly but consistently represented over 50 years. Given the wide dissemination and continued adaptation and refinement of assertive community treatment, as well as the focus in recent years on wraparound psychiatric services, a special section on the current use of community-based interventions might provide the field with important information in this area.

One important special population—children and adolescents—has been well represented in articles published in the journal between 1950 and 1999. The founding of the American Academy of Child and Adolescent Psychiatry in 1953 marked the beginning of psychiatry's significant interest in this population. The first issue of the Journal of the American Academy of Child and Adolescent Psychiatry appeared in 1962.

In the first 15 years of the journal, 11 to 14 articles per five-year period addressed the mental health of children and adolescents—comparatively large numbers, reflecting the growing interest in the field. Between 1965 and 1969, however, the number of such articles tripled from those in the previous five-year period, and 29 articles were published between 1970 and 1974. Most of these articles focused on the adolescent population. In subsequent periods, the number of articles fell, until it reached a low of eight in the 1980-1984 period.

However, since 1985 at least 20 articles in each five-year period have addressed the mental health of children and adolescents. In the 1980s, APA established a division devoted to inpatient and outpatient services for children (18), which may have fueled the increase in the number of articles on children. We also suspect that the growth of for-profit adolescent hospitals that began in the 1980s (19) led to an increase in the number of articles on this population. Several articles published since 1985 have focused on children and adolescents treated in such hospitals. This year the journal is introducing a quarterly column—Child & Adolescent Psychiatry—edited by Charles Huffine, M.D., which will address the often severe social and emotional problems of children and adolescents treated in the public sector. We believe that this is a critical area and look forward to the column's appearance in the journal.

We observed bimodal peaks in the number of articles addressing the mental health of elderly persons. We believe that the decline in the number of such articles after the 1960-1964 period was due to the decreased rate of hospitalization of elderly persons with mental illness. After Medicaid laws were passed in 1965, states began to shift the mental health care of elderly persons to chronic nursing facilities (20). In 1978 the American Association for Geriatric Psychiatry was created, and in 1979 APA established the Council on Aging, headed by Jack Weinberg, M.D. (21). In addition, two handbooks on geriatric psychiatry were published in 1980 (22,23). We contend that these events stimulated submission and publication of articles on geriatric psychiatry. In the 1975-1979 period, only two such articles were published, but the next five-year period saw the publication of 21 such articles.

As Cohen has reminded us (21), "the significant growth of geriatric psychiatry in the United States is largely a phenomenon of the fourth quarter of the twentieth century." Geriatric psychiatry became an official subspecialty in 1991, and the first issue of the American Journal of Geriatric Psychiatry appeared in January 1993. The increase in the number of articles on geriatric psychiatry in the journal began in 1980, well before these events. However, the field's growing interest in geriatric psychiatry in the 1990s may account for the 50 percent increase in such articles in the journal between 1995 and 1999.

Over the 50-year period we examined, more than two-thirds of the articles addressing mental health issues of racial and ethnic groups were published after 1979. Before 1965, the number of such articles averaged less that one a year. Between 1965 and 1984, the average was two articles a year, and between 1985 and 1999, it was 4.5 articles. When John A. Talbott, M.D., became editor of the journal in 1981, he appointed Ezra Griffith, M.D., to the journal's editorial board—its first black member. The appointments of two other black board members followed—Earline L. Houston, M.D., in 1984 and Carl C. Bell, M.D., in 1990. Culturally sensitive editorial board members often facilitate the publication of articles on nonwhite special populations. Of the 555 articles on special populations published in the journal between 1950 and 1999, 36 (6 percent) have addressed the mental health concerns of African Americans. This proportion is about twice that of articles addressing issues of other racial or ethnic groups.

More than two-thirds of the 555 articles we identified addressed the mental health issues of elderly persons and of children and adolescents. Within the racial-ethnic category, we identified articles on issues related to African Americans, Native Americans and Alaska Natives, Asian Americans, and Latinos. The rate of publication of articles in these categories was similar to the rate of publication for the other categories of interest—women, parents and families, and community or village.

Conclusions

Our study raises some thorny questions. Psychiatric Services and the American Journal of Psychiatry are in a unique position because they are published by the American Psychiatric Association. Should these journals follow trends and publish articles only about what most researchers in the field are studying? If that is the case, then most of the articles published would address issues related to Euro-American, middle-class, heterosexual men—which is what we found.

Should APA journals encourage the study of special populations and lead the direction of research? How far should an editor go to encourage submissions on special populations? The Surgeon General's recent report on mental health issues that are related to culture, race, and ethnicity (24) highlighted the dearth of nonwhite researchers in the field, as did the report of the National Advisory Mental Health Council Workgroup (25). These reports are testament to the fact that the available pool of strong, research-based articles on nonwhite populations by nonwhite researchers is limited. Although the policies of the National Institutes of Health require that study populations be racially and ethnically diverse (26), the Surgeon General's report noted that nonwhites are not represented in studies that evaluate the impact of interventions for major mental disorders.

As Thomas and Sillen (27) observed in 1972, psychiatric researchers are reluctant to tackle mental health issues of nonwhite populations. To complicate matters, the introduction to the Surgeon General's report (24) highlighted the complex methodological issues that make studying nonwhite populations difficult. Should scholarly publications lower their scientific standards to attract and publish articles on special populations? Do readers view articles on special populations as "affirmative-action articles" and therefore less scholarly and less important?

Our review of articles published in this journal between 1950 and 1999 indicated that an editorial policy of featuring special sections and issues by guest editors who have special interests generates articles on nonwhite populations. Our review has shown that the articles published in the journal have reflected the major interests of the field. However, in the past 20 years, the journal has also demonstrated leadership in encouraging submissions of research on special populations.

Our findings indicate that specific editorial policies can lead to the submission and publication of articles on special populations. We hope that Psychiatric Services continues to be a leader in this area and continues to encourage the submission of research articles on underserved and unserved populations. To combat "ethnocentric monoculturalism" (28), editorial boards must have members of diverse backgrounds.

As publications of the American Psychiatric Association, both Psychiatric Services and the American Journal of Psychiatry have a responsibility to publish articles on special populations. Both journals should attempt to actualize the Surgeon General's recommendation that "the mental health knowledge base regarding racial and ethnic minorities" be expanded (24). One way to accomplish this goal would be for APA's Psychiatric Research Network to focus on studying special populations.

We hope that this article will motivate all mental health researchers to study special populations, especially researchers who have an interest in this area but who may not have considered conducting research and submitting a report.

Dr. Bell is president and chief executive officer and Dr. Williamson is a staff psychiatrist at the Community Mental Health Council/Foundation, Inc., in Chicago. Dr. Bell is also director of public and community psychiatry and professor of psychiatry and public health at the University of Illinois at Chicago, where Dr. Williamson is a fellow in child psychiatry. Send correspondence to Dr. Bell at 8704 South Constance, Chicago, Illinois 60617 (e-mail, [email protected]). An earlier version of this paper was presented at the Institute on Psychiatric Services held October 25-29, 2000, in Philadelphia.

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