Psychiatric services : a journal of the American Psychiatric Association
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The purpose of this article is to inform mental health professionals about the empirical literature on medical and psychiatric encounters and the influence of communicative behaviors on specific encounter outputs and treatment outcomes. ⋯ Twenty-five articles in medicine and 34 articles in psychiatry were selected. Medical communication researchers have observed associations between physicians' communicative skills and patients' satisfaction, patients' adherence to treatment recommendations, treatment outputs, and patients' willingness to file malpractice claims. The research has also shown that primary care physicians can be more responsive to patients' concerns without lengthening visits. In psychiatry, the literature can be organized into four discrete categories of research: negotiated treatment and the customer approach, therapeutic alliance, Gottschalk-Gleser content analysis of patients' speech, and content analysis of psychiatric interviews.
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Review
Managed behavioral health care in the public sector: will it become the third shame of the States?
Managed behavioral health care is increasingly being used in public mental health systems. While supporters cite potential benefits, critics describe dire consequences for individuals with serious, long-term mental illness. ⋯ Believing that analyzing history may prevent repeating some of its mistakes, the authors compare the antecedents, benefits, and negative effects of deinstitutionalization with those of the public-sector managed behavioral health care systems being developed today. Lessons learned from the earlier era include the need for careful general and technical planning; for assignment of responsibility, including monitoring, to the public sector; and for a focus on clients and the special needs generated by severe mental illnesses.
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Many physicians believe that documenting a discharge as "against medical advice" protects them from legal actions for adverse consequences related to the discharge. The authors examined case law for evidence of such protection. ⋯ Good clinical practice and thorough documentation remain the best legal protection. Discharging a patient against medical advice may provide partial protection, but it is not a royal road to legal immunity.
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The presence of severely mentally ill persons in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. ⋯ Clinical studies suggest that 6 to 15 percent of persons in city and county jails and 10 to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and chronic mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of mentally ill persons are arrested compared with the general population. Factors cited as causes of mentally ill persons' being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of mentally ill persons who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.