COMMUNITY MENTAL HEALTH TREATMENT: W H A T WORKS FOR WHOM? Jeraldine Braff, M,A. Monroe M. Lefkowitz, Ph.D,

The research literature does not establish with any consistency an integrated model of what type of patient functions best in what type of community setting, The findings do, however, identify the relationship of certain patient characteristics to rehospitalization: number of prior hospitalizations, length of hospitalization and history of unemployment being positively related; educational level, occupational level, and race being unrelated: and sex. marital status, age. and diagnosis being inconsistentlv related, oAlso identified in the literature were those community programs that were found to be the most effective based on a review of ~our outcome measures including recidivism, symptomatologT, social functioning, and employment. The community mental health movement has precipitated the attempt, within some states, to consolidate a diverse mental health service delivery system. In many localities, this effort has led to the phasing out and, on occasion, the actual shutdown of state inpatient psychiatric facilities. ~-4 Because one result of consolidation of psychiatric centers is the return of patients to community settings under varying degrees of structure and supervisi~m, clinical staff is posed with the urgent question of appropriate placement° In this context, "'appropriate" suggests that a determination has been made of the characteristics o f patients and community settings; then the question, stated explicitly, becomes "what type of patient functions best in what type of community setting?" Associated with this formulation are the problems issuing from the attempt to develop a taxonomy of patient characteristics and to construct an operational definition of "patient functioning." Even assuming the resolution of these problems, clinical staff members are faced with the more imposing problems of drawing a functional relationship between patient typology developed at the psychiatric center and patient functioning as assessed in the community setting. Underlying such a functional relationship ave the rational and empirical processes that yield, on the one hand, a set of patient-predictor T h e a u t h o r s are a f t l l i a t e d with the New York State D e p a r t m e n t of Mental H y g i e n e , 44 H o l l a n d A v e n u e , Albany. N.Y. 12229. PSYCttIA IRIC QUARTERI.Y, Vt)L 51(21 1979 0o33-2720/79! 14o0~1119 $00.95

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variables and on the other a satisfactory measure of patient restoration. Thus the model is, ideally, a multiple regression in which patient characteristics (type) are the independent variables that are used as predictors of the dependent variable~some objective measure of successful functioning in a community setting. Consolidation of psychiatric centers makes appropriate patient selection for community.settings an immediate and pressing concern. The purpose of this :Japer, therefore, is to review the relevant research literature with a view towards synthesizing the many diverse findings and determining what is known about the relationship of patient characteristics to functioning in a community setting. Accordingly, major emphasis is placed on outcome studies. In a majority of' the studies reviewed, the data were reported in terms of outcome and predictor variables. Due to methodological problems inherent in the research, however, this paper will report, first, on the findings related to the various measures o f outcome and, second, on the findings related to the variables associated with outcome. Those community programs that appear to be the most effective in terms o f the outcome variables studied, and the relationship of certain socio-demographic characteristics to hospital readmission, are discussed. Finally, although the literature is extensive, it is plagued with methodological problems. These problems form the basis for discussion in the last section.

FINDINGS A review of the literature on community treatment progTams yielded findings that can be classified into fi)ur substantive areas. The first area deals with program effectiveness as measured by fl>ur (mtcome criteria: (1) recidivism, (2) symptomatotogy, (3) social functioning, and ~4) employment. ()n the basis of these combined variables, the six most effectire programs are identified in the second section, tbllowed by a discussion in the third section of the relationship between level of functioning and type of residential setting, as well as of the importance of continuity of care. The fourth section reviews the relationship of various demographic characteristics to outcome. Based on these characteristics, a profile is constructed o f the patient who has the greatest probability of remaining in the community. Program Effectiveness as Assessed by Four Outcome Variables T h e follow-up studies vary in the type of program setting, target population, treatment modality, follow-up focus, and time period being studied: yet, they are similar in that all of the studies establish one or more criteria on which the follow-up is based. Because of the multiplicity of criteria used in evaluating program effectiveness, discussion in this section is limited to

121 j. BRAFFAND M. M. LEFKOWITZ

those variables used most frequently and whose definitions permit basic comparisons. The variables will be discussed in order of the frequency with which they appear in the literature. The findings are presented in sequence from the mos: convincing evidence for the positive impact of a program on the outcome variable being studied to findings in which no relationship or conflicting evidence has been found. Recidivism. The criterion fimnd most often in the literature as a measure of a patient's successful community adjustment is rehospitatization. In general, based on the literature reviewed, recidivism rates were lower for patients who participated in a variety of community programs. Treatment in two o f three well-designed experimental programs consisted of d r u g and d r u g plus therapy for schizophrenic patients a,6 while the third consisted of therapy in a clay hospital setting for a diagnostically mixed group ,.;f patients, r Consistent with these findings are those by Anthonv et al. ~ ira their literature review on recidivism. They found, for exampte, that many forms of moderate community support programs, such as aftercare clinics, as well as various types o f transitional facilities, such as family care, day care, and halfway houses, reduce recidivism- when these rates were compared to the base rates thev established for traditional inpatient programs as long as the patients remained members of the facility. Similarly, Erickson '~ found that continuity of aftercare was responsible for reducing rehospitalization in several other outcome studies which he reviewed. Favorable recidivism rates were also found in a majority of the nonexperimental studies reviewed. ~~"t 6 Particularlysignificant are the findings by Kirk .4 that aftercare visits may be more effective in reducing readmission among the more chronic patients than among the less chronic, and that of the more chronic, rehospitatized patients, readmission rates and community tenure ~ere better for those with six or more aftercare visits. Taking all the patients in Kirk's sample into consideration, the patients most likely to be rehospitatized were those with less than ! I clinic visits. Strikingly similar is the finding that of a sample of New York State patients released to the community those patients most likely to be readmitted are those with less than ten clinic visits. L7 In most of the studies reviewed, rehospitalization rates were found to be lower while patients remained in community care programs. There are indications, however, that these rates are not maintained on a long-term basis following termination from the program. .8a9 A few studies cast some doubt on the effectiveness o f aftercare in preventing readmission. Mayer, Hotz, and Rosenblatt (see Kirk '4) found that patients who continued in aftercare had a higher rate of readmission than those who dropped out. Similarly, Franklin et ala0 and Brown et at, 2~ found that patients who had more contact with community mental health agencies had higher readmission rates, and, in a study by Lamb and Goertzet = patients in a high-expectation communitv program were rehospitalized significantly more than patients in a low-expectation program. In comparing the favorable recidivism rates for different types of pro-

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grams, it is difficult to establish the superiority of one program over another. Most programs demonstrate rates that are lower than what might be expected if no post-hospital intervention occurred (40 to 50% in one year), s but no one type of treatment setting, be it aftercare, day-hospital or halfway house, has consistently demonstrated recidivism rates lower than the 20 to 35% found in all of them. The most promising finding is that the elderly, chronic schizophrenic p~tient, who traditionally has remained on hospital rolls longer than any other category of patient and who, when released, has had higher readmissi(m rates, now stands a reduced chance of rehospitalization if intensivelv followed up in the community with a variety of comprehensive treatment modalities?'6" ~,~aaa-', 6 While the findings on recidivism are somewhat conflicting, a variety of community treatment programs appear capable of helping the patient remain in the community. However, recidivism rates do not address the issue of level of functioning. The three outcome variables most commonly found in the literature that address this issue are symptomatology, social functioning, and employment. All three variables are studied relatively infrequently compared with rehospitalization and, typically, it is in the experimental study where they are explored.

Symptomatology. The findings on symptom reduction, e.g., withdrawal, bizarre behavior, substantiate the benefits of community care, but again, they do not establish the superiority of any specific treatment approach. Unlike recidivism, symptom reduction has been studied so infrequently that data exist for only a few of the many different types of community programs. Three well-designed experimental studies. Pasamanick et at., a Herz et al., r and Test and Stein 2r found more improvement in their experimental patients than in their controls during one to txvo years of program participation. Pasamanick studied drug treatment with supportive therapy' fi)r male and female schizophrenics while Herz studied day hospitalization for a diagnostically mixed group of patients. Fhe patients in the coping skills program evaluated by Test and Stein were also a sexually and diagnostically mixed group. Similarly, Chien and Cole. ~:' in their follow-up of chronic, long-term schizophrenics living in landlordsupervised apartments, found a "much improved" to "very much improved" mental condition after four and a half years of accumulated placements. In Saenger's ~° sample, a diagnostically mixed group of patients who received aftercare treatment showed more improvement in symptomatology after a year than patients who received no services. Treated psychotics showed significantly more improvement than untreated psychotics. Based on his literature review of outcome studies, Erickson ~ found that, in general, a greater impact was made in the area of symptom reducti¢)n than psychosocial functioning, z8"2:~ In the same review, a study bv Caffey et al a° revealed that groups receiving aftercare demonstrated less average pathology at follow-up, alth¢)ugh none ()f the groups showed dramatic differences.

123 j. BRAFF AND M. M. LEFKOWITZ

Experimental studies by Wilder et al. a~ and Davis et at. a2 found no significant difference in symptom reduction between their experimental and control groups. And, while Brill et al. a3 found that symptoms were reduced in patients receiving experimental d r u g treatment when they were compared to untreated patients, there was no marked difference in the improvement seen in the five treatment groups. Day hospitalization for diagnostically mixed groups o f psychiatric patients, whether used as an alternative to traditional inpatient treatment a~ or as post-release follow-up care, = produced no significant difference in symptomatology when compared to controls who were either hospitalized or who received no care following release. However, neither study had baseline data to determine whether symptomatology was any different at follow-up. In general, the data speak favorably for those limited community programs where symptom reduction was the criterion. Inasmuch as patients in several of the experimental community-based programs fared no worse than in-hospital control patients, it is suggested that these community programs are viable alternatives to traditional hospital care. The remaining data support the positive effects on symptom-reduction o f post-hospital community programs that use such combined treatment approaches as drugs and therapy, day hospitalization or supervised living. Although it is not possible to establish the comparative effectiveness of these programs because of the different measures used, the importance of the findings is suggested bv the absence of data that indicate a significant increase or worsening o f symptoms while a patient is participating in the program.

Social Functioning. The outcome measure studied somewhat tess frequently than symptomatology, but which also addresses the issue of communitv adjustment, is social functioning. The few studies that examined this variable showed that patients generally improved. Two nonresidential treatment programs that combined various forms of drug and therapy improved the socialization skills and interpersonal relationships of experimental patients during their one to two years of" program participation. a'6 Similar improvements were found in patients who participated in a high-expectation halfway house, 22 landlord-supervised apartment living, ~5 aftercare, ~° and a coping-skill program. 2r The only conflicting findings were those by Brill et al. a3 who found that, while all the treatment groups improved, neither the specific drug nor the length of the therapy sessions was the crucial factor in producing the improvement. Employment. T h e last variable that is studied with any frequency and that rounds out the picture of community adjustment is employment. Although the findings on employment were positive in a majority of the studies reviewed, conflicting evidence was found in a sufficient number of studies to render the positive effects o f community programs less than conclusive. Experimental studies bv Herz et al. r Stein et al~.a4 and Brill et al. aa revealed that patients who participated in programs involving day hospitalization, coping skills, and d r u g plus therapy did better on work-related

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variables than did control patients. In Herz's study, however, follow-up was limited to the first four weeks of participation when the control patients were still hospitalized and, therefi)re, unable to perfi)rm an occupational role. Similarly, while the experimental patients in Stein's study spent significantly less time unemployed and significantly more time in sheltered employment than control patients, there was no significant difference between the two groups in time spe!lt in competitive employment. Experimental patients, however, earned significantly more income through competitive employment during the 8- and 12-month data-collection periods than did controls. Finally, while all the experimental groups in Brill's study improved in work adjustment when compared to the control group, no significant difference in improvement was found among the different treatment groups, making improvement unrelated to the specific drug or length of the therapy sessions. Patients in a variety of other community treatment settings have also shown improved levels of vocational functioning. L°'a~-a8 After six months of follow-up, Wilder a9 found a full employment rate of 53% for the graduates of a halfway-house program, a rate that exceeded the base rate established by Anthony et al. 8 for traditional in-hospital programs. And, while employment was significantly increased for patients in the lodgesociety program examined bv Fairweather ~" these improvements were not maintained after termination of the program. In conflict with the above findings are those by Pasamanick et al a and Davis et al. ~8 Pasamanick's home-care d r u g program could not demonstrate any positive impacto n employment while the program was in operation. In a five-year follow-up of the same program bv Davis et al t8 there was no significant difference in work-related variables. All groups had dropped in vocational level. Both experimental and control patients in the program of dav hospitalization studied by Wilder et al a~ showed poor work perfbrmance, with no differences between the two groups; and, only 17,% of the day-hospitalization patients in Vitale and Steinback's a~ study were employed after six months. Beard's study ~2 of day and evening aftercare services had no impact on employment when experimental patients were compared to control patients after one year. Similarly, Purvis and Miskirains 4a found no significant difference in vocational success for three different groups in aftercare treatment. While the findings suggest, although not unequivocally, that community care programs generally have a positive impact on a patient's ability to function in the community, there remains a need to identify more specifically those programs which are the most effective. In an attempt to identify these, each program was rated according to how manv of the four outcome measures were examined and whether the findings were positive or negative, The assumption was that the more we knew about a program in terms of its outcome, the better able we were to compare it to other programs. Obviously, the most fruitful comparisons were based on those studies in which multiple criteria were utilized. In this fashion, six programs were identified which were more effective than any of the others reviewed in the literature fi~r which sufficient data were available.

!25 j. BRAFF AND M. M. LEFKOWITZ

The Most Effective Programs Based on Outcome Measures

Nine of the studies reviewed examined at least three of the four outcome variables. In six of these studies, at least three of the outcome criteria were found to be positive, suggesting that while patients participated in the six different programs they made favorable community adjustments. These programs included landlord-supervised apartments, ~'~dav hospitalization, r two combined drug and therapy programs a'" a~.t.ercare, TM and training in community living, ar However, since there is such wide variation in the components of any specific program, no generalizations can be made about the efficacy of similar programs based on these data. For exampte, while the patients in the program of day hospitalization evaluated bv Herz adjusted better than control patients, the day-hospitalization programs studied bv Wilder et al a* and Davis et al a2 had no significant impact on experimental patients when compared to control patients. What is suggested very simply, is that patients in the six specific programs mentioned above made favorable adjustments based on the variables studied.

Other Zssues Related to Ozzzcome

Although they do not fall within the framework of the findings presented above, there are additional findings related to program outcome which are important to mention. First, while a variety-of community care programs seem to have a positive impact on one or more of the variables o f community adjustment, the data suggest that settings which provide li{tie more than custodial care are the least effective of all residential facilities. Heinemann et a144 for example, found a correlation between residential setting and level of flmctioning, boarding home residents being more impaired than non-boarding home residents. Consistent with these findings are those bv Lamb and Goertzel aa wh~ found that high-expectation settings (e.g.. halfway house plus psychiatric day treatment) contribute more to a patient's level of vocational and social functioning than do low-expectation settings (e.g. boarding homes). [For a description of a halfway house, see Klein, 1972] 45 Using New York State as an example, Easton & states that high-expectation settings typically serve the younger, less chronic mental patient with rehabilitation potential while low-expectation settings (e.g. long-term custodial care) serve the older, more disabled and chronic, inept person. Yet, according to Lamb and Goertzel, a'~ mental health professionals are unable to predict with any consistency which long-term patients will benefit from exposure to a high-expectation program. In combining this finding with their finding on the increased effectiveness of highexpectation settings, they conclude that such programs should be available to all long-term patients entering the community. The final issue pertaining to community care of discharged patients concerns the extent and con tinuitv of support services provided. I f patients are left on their own to attend clinic when indicated, take medication as prescribed, or ~btlow other prescribed treatment, the probability-is high

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that they will be remiss in any or all of these areas.t3"47 Since achieving and maintaining a maximum level o,f functioning and avoiding rehospitalization are often dependent on following prescribed treatment, the need for intervention at this level is obvious. Similar conclusions were reached by Davis et aP 8 when, several years after termination of their program, experimental patients experienced an erosion of the improvements made during treatment. Although their focus was different, their conclusion was similar, specifically, that there is a need for continued surveillance and community treatment. Logically this would apply to getting patients into treatment and keeping them there as well as to continuing treatment as needed. Another function of such surveillance, in cases o f d r u g maintenance, would be to monitor the side effects of long-term treatment with phenothiazines. Tardive dyskenesia is such a possible side effect) 8"~9 Having identified the most effective programs as well as certain of the factors that appear to contribute to program effectiveness, the need remains to clarify the functional relationships betv~een patients and programs.

C~)rrelates ~¢ Ozztcom~" Although there are indications that some programs work better ~han others in reintegrating patients into the community, it is more difficult to determine the type of patient based on demographic characteristics for whom specific program components have positive or negative effects. Once treatment outcome is defined, most of the studies reviewed do not go far enough in determining the correlates of outcome, relating outcome and its correlates to program components, controlling, by the technique of multivariate anatvsis, for the effect of third variables, or determining the intercorrelation among variables. Fontana and Dowds a° attempted such analysis, but did not carry it far enough. As a result, it is generally unknown whether outcome is a function o f treatment, of certain patient characteristics, of environmental factors, or a combination of all three. Most of the studies reviewed confine their investigations to the correlates associated with readmission. A multitude of variables have been analyzed in order to determine their prognostic value. For the most part, the findings are so contradictory that it is difficult to establish the validity of any one, or set of predictors. As Fontana and Dowds (p. 231) state, "the search for consistent predictors o f rehospitalization has produced many more failures than successes. ''5° Apparently, the state of the art of prediction in 1975 is as ambiquous as it was in 1962 when Katz and Cole stated that "attempts to predict response to treatment on the basis of patient background factors have been rarely successful". ~ Nevertheless, some findings appear to be more consistent than others. The most convincing evidence for a relationship between the variables and recidivism will be presented first, followed by those findings in which no relationship or conflicting evidence has been found.

127 j. BRAFF AND M. M. LEFKOWITZ

Positively related variables. T h e variables most frequently cited in the literature as having a relationship to rehospitalization are total number of prior hospitalizations, length of prior hospitalizations, diagnosis combined with chronicity, and employment history. In their literature review on recidivism, Buell and Anthony 52 found that a high n u m b e r of previous hospitalizations was associated with a high probability of recidivism. A similar relationship was found by Kirk, 14 the New York State Legislative Commission on Expenditure Review, ~7 and Rosenblatt and Mayer, 53 who also found the relationship substantiated in two dozen other studies they reviewed. Wessler and Iven 54 reported that readmissions accounted for 58% of the total admissions over a three-year period, an amount they considered to be a significant disproportion. The only conflicting evidence was that by Lewinsohn? 5 who tbund no relationship between number o f hospitalizations and ability to stay in. the community. Closely related to the variable of prior hospitalization is length of prior hospitalizations. Findings in four studies reviewed by Buell and Anthony ~2 suggest that the longer the time spent in all past hospitalizations, the more likely it is that the patient will return to the hospital. Lee a~ and Kirk found that the longer the last hospitalization, the more likely it was for the patients in their samples to be rehospitatized. In Lee's study, the level of significance of this relationship increased when the number of convalescent leaves was combined with the length o'f hospitalization to form a Departure Index. Christensen 57 and Levenstein 5s found length of stay significantly related to readmission, but their findings were not in the expected direction. Christensen, for example, found that although the patients who avoided rehospitalization had fewer prior admissions, their total !ength o f stay was twice that of the readmitted patients. Levenstein, on the other hand, found that the shorter the first hospitalization, the greater the probability of readmission. At the other end of' the spectrum is the finding by Davis et al a2 that length of prior hospitalization was not significantly related to rehospitatization in either their experimental or control groups. Similarly, data from New York State do not substantiate that either a short or long length of stay is a greater deterrent to readmission. ~r The data on diagnosis are sufficiently inconsistent to prevent any:conclusion as to its effectiveness in differentiating patients who return to the hospital from those who remain in the community. Data on the readmission of patients by diagnostic category in a 1972/1973 New York State sample indicate that patients diagnosed as having "major affective disorders" had the highest reentry rate (64%), followed by patients diagnosed as schizophrenic (50%), personality disorders (38%), and neurotic (29%). ~r T h e schizophrenics in Winston's et aP ~ sample and the psychotics in Saenger's ~° sample were less likely to be rehospitalized if they were treated in aftercare. The readmitted patients in Kirk's 14 sample were more likely to be diagnosed psychotic, while the females with schizophrenic reaction ~:ho were treated in a day-hospital program evaluated by Wilder et al ax were more liketv to be found in the community after two years than those treated

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as regular inpatients. In contrast, a review by Buell and A n t h o n y 'v' disclosed three studies that f o u n d diagnosis to be ineffective in differentiating those patients who remained in the community. These findings are consistent with those by Davis et al a2 and C u m m i n g and Markson. a'~ A l t h o u g h the findings on diagnosis alone are ambiguous, the relationship becomes more clearly d e f i n e d when it is combined with measures o f chronicity (typically defined as length o f hospitalization and/or n u m b e r of prior hospitalizations). Four stucties reviewed by Buell and A n t h o n y ae as well as one by Kirk ~4 f o u n d that the combined variables differentiated between patients who were readmitted and those who were not. Kirk's Chronicity Index combined n u m b e r o f previous hospitalizations, length o f last hospitalization, psychotic diagnosis and e m p l o y m e n t status. Patients with high chronicitv scores (history of prior hospitalizati(ms, considerable time spent in hospital, psychotic and marginally employed) were twice as likely to be readmitted as were those with tow scores. Similar{y, Fontana and Dowds a° f o u n d chronicity to be superior to any other single predictor o f rehospitalization. T h e i r c h r o n i d t y index was comprised o f n u m b e r o f prior hospitalizations, (short) length o f time since last psychiatric hospitalization, (psychotic) diagnosis, consideration and rejection of outpatient treatment, (large) n u m b e r of years since last e m p l o y m e n t and service connection for a psychiatri c disability, O t h e r studies differentiated between acute psychotics and chronic psychotics and neurotics, the ibrmer d e m o n strating longer c o m m u n i t y tenure than the latter when they spent less than two years in prior hospitalizations (see Buell a n d A n t h o n y ) ) z Being u n e m p l o y e d or only marginally employed was f o u n d to be related to a t i k e l i h o o d of readmission in several studies. ~°,~4"ar-~ Only one studv reviewed by Buell and A n t h o n y a2 revealed no relationship. Negatively and im~or~sistet~tB, related variables. Generally, educati(mal level, ~

Community mental health treatment: what works for whom?

COMMUNITY MENTAL HEALTH TREATMENT: W H A T WORKS FOR WHOM? Jeraldine Braff, M,A. Monroe M. Lefkowitz, Ph.D, The research literature does not establis...
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