Mental health after psychiatric treatment

Mental health after psychiatric treatment

Mental Healtit after Psychiatric T r e a l ~ l l e n l I~!t S'rANL~,:Y T . Nl~c~x~.'.t. AND T ~ O X t A S S. [_,AN(:NElt HE AIM Olr NIEI)ICAI_, TI~EAT...

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Mental Healtit after Psychiatric T r e a l ~ l l e n l I~!t S'rANL~,:Y T . Nl~c~x~.'.t. AND T ~ O X t A S S. [_,AN(:NElt HE AIM Olr NIEI)ICAI_, TI~EATNIENT is t o r e s t o r e t h e p a t i e n t t~) t ~ o r m a l h e a l t h . " ' N o r m a l " m a y l ) e rtason-d)ly- d e t e r m i n e d in t h e b r a n c h e s ()t" m e d i c i n e w h i c h d e a l w i t h t h e b o d y . I n p s y c h i a t r y , " ' n o r m a l " is m o r e ( l i t f i c u l t to define and indeed has been found to span a wide range from good menial health to psycho'pathology i m p a i r i n g t o l i f e ' s a d i u s t m e n t . ~':t W h e n is t h e psychiatric 1)atient "'back t o n o r m a l " ? T h e a i m of this report is t o c o n t r i b u t e to the tmderstanding o f t h i s ( l U e s t i o n l)v c o m p a r i n g tht- m e n t a l h e a l t h l e v e l o f a g r o t q ) o f l ) s y e h i a t r i c p a t i e n t s w i t h t h a t o f ;in ~mtreate(l population.

T

.XI ETI IO D."; Tht, .~tudv is based on d a t a co]lectc'd in c o n . t ' c t i ( m with .'t pr,'vah.nt.t" r.tudv ~ff mental health in a residential area of Nc"w "t'~rk City. t.:-" A qu('stionnairt'-b~nided ilttt.rview wa~. administ,'rt'd to l(St'i0 resl~Ond,,nts st'let'ted trot~t tl.. population by r a . d o n t pr~ct,durt's. A.; sot.~ as the itderviews wt.rt, c<)tuph.ted, the ~t[ice s t a l l sifted the i~ffor,,mtiozt intt~ tw~ catt'~.orit.s to |~e plact'd t ~ slIIIIIII;Irv form.., fi~r evahtati~)t~ l}v p,s.xchiatrist.,,. T h e first s u m m a r y form conl;tint.d all i~Jt~r~ittit~ w h i c h t.ould be a;dt'l~ c~.t,.t',,t'd t o th% psychiatrist w i t h o u t r~.v,.aling tilt- social f i m c t i o n i n g ~ff tht" rt.spt~th.nt. It co~tai'n(.d qu~,~.tions relating t~ s) nq)toms, history t)f illness, a~.! l)roj,.t'tit,h.~ w h i c h ~night di.,ch~s~' j~sycl~()path~h~gy. A H.qfln] health ratin~ was ~l~;t~l~. i~.h,p~.ndentl) ~n~ thi~ ,,,ynq~t~m~;dic matprial. It is the r.'tting used in the tindingx rppc~rt~.d })eh~w. T h e st'uond su~,miarx" form (-(.~tain(.(l ;ill th,- rt'lllilinlltt~ nmt~.riai ln.rtaitfin~ to ~.,~t'i;l| ;.liustntt,nt. int'h](iin~ fan~ilv data. ~.d.catit).. o(.c~q)ati(m, so(.it)~.t,(~tt()nti(" sUlt~t~;, ~.ti~ni(" ;~n(I rt,ligi(~ts ;tlfiliations, :(~cial c(.~t,er~s ~t~l w(~rri~.,,, rs'('r~'ationai int~.rs.sls a n d idle infi)r~natio~ al)ollt previous l~s~chiatrit. Ir~',dln,'ltt. A .~el);,r;d~, ..q~tal h,';0th r';ttiltg w;i,. n~;id,, t)n lilt' c o m p l e t e itff~)rttmti(.~. I"inal nu.ntal healtl: rating, s, aftt'r rec~mciliation ()t t l . ' ditl~,rences t~t till" tw,, rating psyel,iatrists, r~,suit~,d i~t ;t four-p~i~t s~-ah, ~ff n . , n t a l h~-alth: ( ! ) "'kVell~with¢.tt significant .,,ymptt)ms"; { 2) "'Ntild .',ymptot~ts"; ( 3 ) "'Nl~ah'ratt" s v~q~t~ms"; ;tt.! ( 4 ) "ll,q~air,'d In,qdal "l'l~e respond,,nts" t r e a t n . . n t stat,is was established i)v st.v,'rai url)s~,-rt'lt'rl'lltqllg pr(it'~'(lures. T h e respondettts w e r e dirt.cth" asked w h e t h t ' r durittg tlwir lifo'time tht'v lind ~,vt.r ,,.'en ','arioll~ m e d i c a l Sl)~,ciailists. att.)ttg tht's)t a p.%vchi,itrist and a "'herr,, si)t.t.ialiM." A .~t'l)arate survey ¢)f all psychiatric fa(rilities a n d persons e n g a g e d in private treattnt.nt it) the t.'ilr a n d dista~')t e n v i r o r m . , n t was ~nadt- for l)atiettts fro~. the s t u d y area. ()f the total s a ~ p l t , of 16(i0 rt, sl)(mdetds, :223 ( 13.4 per c'e.t ) s a w a psyc'hiatrist prof't,s.siotudly.

Tltis report l,~" ]rom the Cor.eH l'rotcram in Soci.[ l',~ychiatry condut'tt'd in the l)t'p,trtmt't#t o] l),~'ychtatry o] the N e w York tlosi~ital (l'ttytte ~Vltitttt'y l'.~yt:hi.trit: Clinic), the D,.partment o] Psychiatry o/ the Cornell Univer,,.ity Ml'dical College. a . d the l)epetrtmet,t o] SociohJgy o] Cornell Unlt'ersity. l'hl.,, re.~.earch was sttpported by [tttuis prot:ids.d by the (.ra.t l:oundation and the llt~alth Ht',~earch. Council o] the City o] N e w York. S'r,~xt.t.;~" T . Mtcltav:t., NI.I.).: A.~;~i.~,tont l'role.,.~or o] Psychiatry, IJeportmettt o/ l'.s,yt'htatry, cortlell Uttlver,,,lty ,tlcdltyal Colh'l~s', Nq,w York, iX'. Y. "l'ttoM^s S. LANc;XI':It, l'Jt.I).: A.~,,i,~tant l'rop'ssor o] Psychiatry (Sot'|elegy), i)t,partmt'tJt o[ l',~.yt'htatry, N e w York Untt~g,r,vtty School o/Medicine, N e w York, N. Y, i 2;J

(.io.xfpi;I.:HJ.:~,~vt~ i%~'c'Jll,~'/,~', V o l .

7, NcJ. o ( A p l u J , ) ,

191t(t

127

.~.li:,NTAI, tlI.'AI.Tli AI:Ti".]{ I ' S Y C I I I A T I t I ( ; TIiI'.'A'I'a\ll'~NT

T a b l e l . - - D i s t r i b u t i o n o[ 3feudal llealth Ratings o[ Psychiatric Paticttts a~tl N o n p a t i e n t s Mental Health liar iI,l¢'~ \Ve ! I X1 l i d

Patient-~ A

0.9'¢,

6.5.+,

;3°.5

Nh)dt,ruh-

:21 .()

Impaired

,15.6

Totals

B

1i4

Nonpatients

21.1%

34.3

4°.9

28.7

'30.7

3{)-" .o 1(18

15.3 1437

( N := 10(1{~4 ) A: P a t i , , n t statiss k n o w n to r a t i n g p s y c h i a t r i s t . B: P a t i e n t s t a t u s not k n m v n to r a t i n g p s y c h i a t r i s t .

The .~tudv was presented to the respondents as at medical sttrvev and therefore no | , o b i n ~ was throe ;d)out IIH. nalurt" anti extent t)f the contact with tl/t; psy'ehiatrist. They Inav h,v," had a ,me-interview c, msultation, extensive psy'c-hotherapy, physical therapies, or h(,spitalization it) a mental institution. Vor brt.vitv of description all those w h o had seen a p,,yc!tiatrist will l)t' rt, f t . r r t ' d to ;ts "'])atients.'" "|'ht" ,|t'si.t2,t~ of t|m inxt'xtig~ation providvd t~pporttmity t() study mental health r-ltin,,s. :.,. of p , th'tmts math. prior t() tht" knowh.dge that tht.v had st'ell ~1 ];svchiatrist. Inadvertently, the l),)chiatrixts wt.r,, tippt'd ot1 on tht" psychiatric treatment status in approximately one-half tl,. p~yclziatric path'nts. The hdorlnath)n w a s c(nltahlt-d ill ;Zli item desi~rlalte(] " ' N u l n I i v r o f spt'cialists svt.n.'" i n t t ' l ~ t ] t . d to c(mvt'V It) thp rating psychiatrists a notion of the care. or l~erhaps ;llso morbid p r ~ ' o c t ' u p a t i o n , w h i c h t i m respondent devoted to treatment o f illness. l,i

!0,"; ,p.SlUmdt'tds w h o had svt.n a psyt.hiatrist, the office staff m e r e l y filled i .

t h e total

m m d , - I of .si)vci:dist.s on this lit=='. In i14. abl)reviations of the various specialists seen t)v It.. rvN)oruh.nt~such as surg~'t,n, or(" .~lu,ciali.~t. ps)'chi;drist or nerve spe=.ialist~were rvcorch,cl. Thl,s tl.' rating psxchi;drist was informt,d ~t~ the psychiatric treatment status of tht.st, rt'sp.ndvtds, t()m' summar~ tt~rut t~f a reslmndt-nt wht~ had seen a psychiatrist was tmt , t x a i l a l d e ;It thv tilnt" t)| tile s t a t i s t i t ' a l t-ailt'ulatti,)ns. ) |{ I:;SU 1:i'S

"!'!,' (listril)t=tiotl in T a t ) h , i s h o w s tirol w h e n tilt, p s v d l i a t r i s t s k n e w t h e y w e r e r a t i n g a r('spot~del~l w h o h a d s e e n a p s y c h i a t r i s t , t h e y r a t e d t h e r e s p c n d v n t " ' i m p a i r e d " more, o f t e t t t h a n w h e n t h e y v c e r e n o t a w a r e o f t h e r e s p o n d e n t ' s p a t i e n t s t a t u s ( p < .10. c h i s q u a r e ) . I n c o n t r a s t to t h i s s m a l l , s t a t i s t i cally doul)tful diflm'('nce I~etween the rati6gs of the two patient groups, the menial health of the Imnpalients was significantly better than that of either o f t h e l~vo p a t i e n t g r o t q ~ s (i 7 < .(R)I. c'hi s q u a r e ) . T h i s s t a t i s t i c a l a s s o c i a t i o n , s i g n i f i c a n t as it is, n e e d s t o h e f u r t h e r e x a m i n e d f o r ' a p p r o l ) r i a t e i n t e r p r e i n i i o n . T h e first c o n c e r n is t h e p o s s i b i l i t y t h a t t h e c o r r e l a t i o n m i g h t | m (It,(, t o c h a r a c t e r i s t i c s o f t h e s a m p l e s o t h e r t h a n p a t i e n t s[atus. A dilig(mt search revealed only two factors significantly related to m ( ' n t a l h e a l t h b y w h i c h t i m t w o p o l m h t t i o n s d i f [ e r e d . T h e first is a g e . M e n t a l I . . a l t h w a s f o u . d to })c, s i g n i f i c a n t l y c o r r e l a t e d w i t h ag, e: t h e y o u n g e r t h e a g e , IIH, l m t t o r t h e Ira,Ilia| h e a l t h r a t | t i t s . ; T h e s e c o l | d is s o e i o t , C O l l o l n i c s l a t u s ( S I . S ) : t h e h i g h o r t h e S E S , th(, b e t t e r t h e m o n t a l h e a l t h . ~ T i m |);client g r o t q ) is )'t)llltJ,~er ( 3 8 , 7 # : 0 . 7 0 V t ' i | r s , N -%: ° ~ 3 ) I l l ; i l l th(. lt()l)p a t i e n t g r o t q ) (41,,3 ::~ ( ) . 0 9 ) , t ' a r s , N :::- 1 4 3 7 ) (1) < 0.()] ). ",i'he [)ati(:ll| s a m l ) ] t '

108

3IICllAEL

AND

L~,N(;NI'~I{

T a b l e 2 . ~ 5 1 c l ~ t a l l l e a l t h Batings of "'Ct:rrent'" Psychiatric

Patients C o m p a r e d with "'Ex-1 " ' atlent.s " "' Per Cent Current

~Vell Mild Moderate Impaired

~ 15.0 55.0 30.0

N =

40

100.g

Paticnt.~

P e r C e n t l~:x-Pnt=ents

4.,t 37.2 18.6 39.9 183

also c o n t a i n s a h i g h e r p r o p o r t i o n of r e s p o n d e n t s of the upl~er sociot~conomic level ( p < 0.001). I f t h e f a c t o r s of a g e a n d S E S w e r e t h e o n l y d e t e r m i n a n t s of t h e mt:ntal h e a l t h of t h e p a t i e n t g r o u p , t h e i r m e n t a l h e a l t h s h o u l d h a v e b e e n b e t t e r t h a n t h a t of t h e n o n p a t i e n t s . Since, to t h e contrat')', the m e n t a l h e a l t h of t h e p a t i e n t s is w o r s e , t h e w e i g h t i n g a g a i n s t this c o r r e l a t i o n b y the a g e a n d S E S factors only serves to e n h a n c e t h e significance of t h e finding. D e s p i t e y o u n g e r a g e a n d h i g h e r SES, the m e n t a l h e a l t h of t h e p a t i e n t s is d i s p l a c e d toward the "'Impaired" range. T h e 223 r e s p o n d e n t s w h o h a d seen a p s y c h i a t r i s t c a n b e f u r t h e r subdiv i d e d into t w o g r o u p s a c c o r d i n g to t h e interval f r o m t h e last visit to t h e p s y c h i a t r i s t . A s m a l l e r p r o p o r t i o n c o m p r i s i n g 40 r e s p o n d e n t s s a w the psy'c h i a t r i s t w i t h i n 4 w e e k s p r e c e d i n g t h e d a t e of t h e i n t e r v i e w . It w a s "assumed t h a t t h e s e r e s p o n d e n t s w e r e p r o l m b l y still in a t h e r a p e u t i c r e l a t i o n s h i p . T h e r e m a i n i n g 18,3 r e s p o n d e n t s r e p o r t e d l o n g e r i n t e r v a l s since their last visit to t h e p s y c h i a t r i s t . T h e a s s u m p t i o n w a s m a d e t h a t t h e s e p a t i e n t s w e r e no l o n g e r in the u s u a l t h e r a p e u t i c r e l a t i o n s h i p w i t h p e r i o d i c a n d reasonal)Iv fTeq u e n t visits to a p s y c h i a t r i s t . E i g h t y - f i v e p e r c e n t of the c u r r e n t p a t i e n t s w e r e r a t e d in t h e t w o mort, severe ratings: "'Moderate symptoms" and " I m p a i r e d by symptoms" (Table 2). O n l y 15 p e r c e n t w e r e f o u n d in t h e "'Mild'" r a t i n g a n d n o n e w e r e r a t e d "~,Vell.'" In c o n t r a s t , 41.6 p e r c e n t of the p a t i e n t s w h o h a d p r e s u m a b l y c o m p l e t e d t h e t r e a t m e n t r e l a t i o n s h i p w e r e r a t e d as relatively f r e e of distress w i t h m i l d s y m p t o m s or no s y m p t o m s w h a t s o e v e r . T h e d i f f e r e n c e in t h e d i s t r i b u t i o n of m e n t a l h e a l t h r a t i n g s b e t w e e n the c u r r e n t p a t i e n t s a n d e x p a t i e n t s is statistically significant at the .01 level (chi s q u a r e ) . Both c u r r e n t a n d e x p a t i e n t s laave w o r s e m e n t a l h e a l t h t h a n n o n p a tients ( p < . 0 0 1 ) . T h e e s t i m a t e of t h e position of a r e s p o n d e n t on a m e n t a l h e a l t h scale m a k e s it p o s s i b l e to c o m p a r e i n d i v i d u a l s or g r o u p s of i n d i v i d u a l s w i t h ont" a n o t h e r , a n d to assign t h e m f u n c t i o n a l e t f e c t i v e n e s s from the s t a n d p o i n t ~ f m e n t a l h e a l t h o r illness. H o w e v e r , tlmse o r d i n a l r a t i n g s l e a v e the clinician u n i n f o r m e d a b o u t the q u a l i t y a n d significance of the s y m p t o m s w h i c h m a y b e i n t e r f e r i n g w i t h the r e s p o n d e n t s " social a d j u s t m e n t . F o r t h e p u r p o s e of c o m m u n i c a t i o n in t e r m s f a m i l i a r to professionals, the m e n t a l h e a l t h r a t i n g of e a c h r e s p o n d e n t w a s s u p p l e m e n t e d w i t h an e s t i m a t e of the clinical c h a r a c t e r of t h e r e s p o n d e n t ' s s y m p t o m s . D e s i g n a t i o n s f r o m clinical l~sychiatry, d e r i v e d mostly f r o m o b s e r v a t i o n s on p a t i e n t s w i t h s e v e r e m e n t a l disorders, wpr,.." se-

3II£N'I'AL

IIEAI.'I'il

129

AFq'l¢l~ i:'SY(:IIIATI~I(; TliEA'I'NIrI'~NT

T'd~le 3.~Distributiol~ o / P s y c h i a t r i c Patients b y Diagnostic T y p e 1 ) D ~ nt, s t it: T y p~_,

Orgamic Psyclmtic Neurotic: Psychosomatic l'c-rsomditv Irai t type "kVell Nmm>tic (psychosomatic) Nmtrotic ( trait ) Totals

Pit t l e a ts

N o n la~tt i e n t~

16 51 95 1I 6 9 i1

13 86 ,177 92 15fJ 089 83

:2,1

2-11

223

t,437

Patients ('5~ o f T o t ~ d s )

.'55.2

37.2 16.6 10.7 3.7 3.0 11.7 9.1 13.4

l e t t e d to d e s c r i b e the mild d e v i a t i o n s in l~ehavior of o u r " n o r m a l " s a m p l e p o p u l a t i o n . T h e s e d e s c r i p t i o n s are n o t i d e n t i c a l in q u a l i t y a n d c e r t a i n l y n o t in de~rt,t., w i t h t h o s e seen in h o s p i t a l i z e d clinical east.s.~"~ T h e d i a g n o s t i c categori~,s ust.(l in Tad)If 3 are not diagnoses. They are m e r e l y used to dc'scril)e tht- c h a r a c t e r of the s y m p t o m s f o u n d in these nomnal r e s p o n d e n t s . T h e du;'d c h a r a c t e r i z a t i o n s in the t a b l e result from a d d i t i v e a d j u d i c a t i o n of disa g r e e m e n t s ill classification 1Lv the t w o p s y c h i a t r i s t s of tht; "'Neurotic" a n d "'Psychosomatic'" t y p e s in on~, i n s t a n c e a n d tl~e N e u r ) t i e " a n d " T r a i t " t y p e s in t})e second.'-' T a b l e .'3 slmws that resl)onclents w h o s e p r e v a i l i n g s y m p t o m s w e r e j u d g e d to he of (ttl o r g a n i c ()r ps)'ehotic n a t u r t ; ~ a n d thus. in the usual clinical sense, w e r e mor~. s e r i o u s ~ h a v e r'onsi(h.ral)lv h i g h e r t r e a t m e n t rates. The t r e a t m e n t rates of the" orgalJic a n d p s y c h o t i c t.vpes differed s i g n i f i c a n t l y at the 0.01 level wht'n tested i~(livitluallv agai,~st tim t r e a t m e n t rates o f the r e m a i n d e r of tht. sample. N o t e w o r t h y 1.'r~" is the o b s e r v a t i o n t h a t r e s p o n d e n t s w i t h pers(malitv trait-t)'pe s y m p t o m s ( o u r d e s i g n n t i o n for c h a r a c t e r d i s o r d e r ) a r c e o n s p i c u ( m s by t h e i r r e l a t i v e a v o i d a n c e of p s y c h i a t r i s t s ( p < 0.00l ). O n tht" whoh,, t h e findi~gs of T a b l e .3 i n d i c a t e t h a t l a r g e r p r o p o r t i o n s of r e s p o n d e n t s w h o h a v e st-~.n a p s y c h i a t r i s t are a p t to h a v e s y m p t o m s w h i c h the c l i n i c i a n considt.rs sevt.re a n d d i s a b l i n g . T h e i n d e p e n d e n t o p e r a t i o n of s y m p t o m c.t,araeterization thus confirms t h e f i n d i n g of r e l a t i v e l y g r e a t e r imp a i r m t , n t in the p a t i e n t group. A t h i r d comparisma of m e n t a l h e a l t h in the patit.llt a n d n o n p a t i e n t g r o u p s e v o l v e d from tlu. answei's to c e r t a i n items of the q u e s t i o n n a i r e i n d i c a t i v e of lasydmpatholo,gD'. T h u s , in these c o r r e l a t i o n s , t h e f a c t o r of j u d g m e n t b y a p s y c h i a t r i s t is eliminat~.tl, q~H, m e t h o d is bast-d p u r e l y on i n t e r n a l e o m p a r i sons betwe~,n q u e s t i o n n a i r e items. T h e findings are prt.st.'nted in T a b l e 4. T h e s e qtmstions are tak¢.n ollt of c o n t e x t of t h e i r p o s i t i o n in the q u e s t i o n naire, a n d for s i m p l i c i t y t h e i n t r o d u c t o Q " s t a t e m e n t s a n d i n s t r u c t i o n s a r e o m i t t e d in tim talkie, l lowev¢.r, the p s y c h o p a t h o l o g i c a l sigmifieance of t h e s e qlmstions is s e l f - e v i d e n t . On t h e w h o l e this third, i n d e p e n d e n t d m r a e t e r i z a tion of tim p a t i e n t a n d nonpati(rnt p o p u l a t i o n s d e m o n s t r a t e s that l a r g e r n u m bers c~f tht, patit.I~t sul~sample are a p t to a g r e e with items i n d i c a t i v e of psychol)athology. "Fh(. dispirit('d state of metltal ht:alth of the patients reflected itself also in

1:30

3IICIIAEL

A N D I.AN'I:NI-~tl

T a b l e 4 . ~ P e r c e n t a g e s el P a t i e n t s a n d N o n p a t i e n t s I V h o E n d o r . s e d

Statements el Psychopathologic Significance P a t i t , n ts

any good reason? I have had periods of days, weeks, or months when I couldn't take care of things because I couldn't "'get going.'" [ have personal worries that get m e down physically. [ get pains in m y back that interfere with m y work. A person has moments when he feels he is a stranger to himself. I)o you feel you have had your share of good luck in life? ( disagree response) You sometimes can't help wondering if a n y t h i n g is worthwhile anymore. Did you t-vet have to stop working for any long 1)erio(ls because of health reasons? I Has your work ever affected your digestion, s h ' e p , t)r upset your health in a n y other wavPt "i"ot a l,~

Norl Da tit.n t.,~

( ';; )

(*i;;)

2,S.(i

2:2.(;

p

:33.9 35.9 20.2

1:3.8 18.0 14.3

p < .(R) | p < .001 p < ,05

,1.9.5

35,N

1}
22.7

I 7..5

1) -C .1 ()

:32..7

26.-1

1) < , 0 ~

37.3

2, I ,,S

p <7 . 0 0 1

.5-t.t)

:~,b;.:]

I ) <:. J ttl 1

223"-'

! ,437:

Questionnaire Item I ) o y e l l s o l l l e t i i l l e S f e e | p e o p l e a r e tl~dtillst y O l l w i t l l o l l t

<2 .

I0

JApt)]ies to men ;rod nt,ver married w()men only (1".296 patients. 771 n¢mpati~,nts). '--'Percentages were c-aleul;tted from totals of those who a~ret,d and (lisagre~¢l with .statvments. Totals vary slightly for e a c h itt,m d u e to fail,re of an occasional r t - s l } O r l t l e n l h} give a definite answer. ,Fable 5 . ~ S e l J - E s t i m a t e s

oJ l l e a i t h in P s y c h i a t r i c P a t i e n t s a n d N o n p a t i e n t s

Health Estimate

Patients

Nonpatient.~

l'a tien t.q t,~ o f T o t a l )

Excellent flood Fair

75 79 50

5114 627 252

13.0 I 1.2 16.(i

18

-18

J~(Jor Dor~'t know,

Totals

27.3

no ans~ver

223

1437

13.4

an e s t i m a t e m a d e b y tile p a t i e n t s t h e m s e l v e s . At t h e b e g i n n i n g of t h e (luest i o n n a i r e i n t e r v i e w , w h i c h w a s i ) r e s e n l e d t o t h e r e s p o n d e n t s a s a h e a l t h invest/gation concerned with improvement o f m e d i c a l c a r e in t h e c o m m u n i t y , e a c h r e s p o n d e n t w a s a s k e d : " ' l l o w is y o u r h e a l t h n o w ? ' " A s t h e q u e s t i o n w a s p h r a s e d , it p e r t a i n e d t o h e a l t h in g e n e r a l a n d t h e i n t e r p r e t a t i o n o f its m e a n ing was left to the respondent. The respondents were given a choice of four categories: excellent, good, fair mM poor. The respondents who had seen a p s y c h i a t r i s t t e n d e d to e s t i m a t e t h e i r h e a l t h as fair a n d p o o r m o r e o f t e n t h a n d i d t h e n o n p a t i e n t s ( p < 0.01, e h i s q u a r e , T a b l e 5 ) . T h e r e s p o n d e n t s " j u d g ments of the state of their own healtla may thus he indieativ(' of emotion:tl

well b e i n g a n d a c c e p t a n c e of t h e m s e l v e s at one e n d of the scale, of m o r b i d d e s p a i r ;rod dissalisfaetitm at the other, t h e latter m o r e l)revah,nt ;umnL~ psyc h i a t r i c patients.

* I I:;N'I'AI. I I l':kl.'l'l I .a,l:Tl']li

I'SY(71 i I k ' l ' l l l ( ' ;

"rlll:~;'~'I'MI.]NT

.l~l

Co.x I.\ l a.:NU'SA,',a) lXTi.:m U~E'I'ATIONS Tim findings of this rt?port s h o w t h a t p s y c h i a t r i c p a t i e n t s , e v e n a f t e r (ermin a t i o n of th(,rapy', ]rove worse a v e r a g e m e n t a l h e a l t h t h a n a c o n t r o l p o p u l a tion w h i c h h a d not e x p e r i e n c e d p s y c h i a t r i c t r e a t m e n t . T h o u g h ~)ot anticipate(l, this f i n d i n g is not ttnreasozmt)le or impr()bable. If a comparal)le~ p o p u lation w e r e to })e strrt.*e]led for a c h r o n i c disease, s u c h as a r t h r i t i s , t u l ) e r e u l o sis. or h e a r t disease, t h e i n d i c e s of i m p a i r m e n t w o u l d l)e e x p e c t e d to b e h i ~ h e r in r e s p o n d e n t s w h o h a d b e e n t r e a t e d for t h e disease. Is s h o u l d n o t be s u r p r i s i n g th(-refor(' to find m o r e evi(h:',nec', of m e n t a l i m p a i r m e n t in p e r s o n s xvho h a d l>et,n t r e a t e d for m e n t a l illness. I)o the [iudings m e a n that p s y c h i a t r i c t r e a t m e n t fails to r e s t o r e l)aticnts to n o r m a l m e n t a l h e a l t h ? (2linical e x p e r i e n c e s e e m s to s u p p o r t an a f f i r m a t i v e a n s w e r to (his q u e s t i o n . T h e c l i n i c i a n is f a m i l i a r w i t h cases vehich d o ,,','ell o v e r a s p a n of years, t h e n b e c o m e ill. n e v e r to r e c o v e r t h e i r f o r m e r level of f u n c t i t m i n g d e s p i t e t r e a t m e n t . I n d i v i d u a l s of this t y p e m a y l)e wei. g,htingr o u r p a t i e n t s a m p l e t(>ward the i m p a i r e d c a t e g o r y , thus b r i n g i n g d o w n the average ~nental h(-alth level })clew that of the. e o m l ~ a r a b l e n o n i ) a t i e n t g r o u p . T h i s t h e r a p e u t i c a l l y n i h i l i s t i c i n t e r p r e t a t i o n of t h e findings is l)ased on the p r e m i s e that the m e n t a l h e a l t h lex'(-I of t h e n o n p a t i e n t s f u n c t i o n s us a c o n t r o l for th(' t r e a t e d g r o u p . S u c h a premisc*, is n o t n e c e s s a r i l y / e n a b l e . It is p r o b a bh, that the' g r o u p of r e s p o n d e n t s w h o e v e n t u a l l y b e c a m e p s y c h i a t r i c p a timers n(.ver f l m e t i o n t ' d , as a g r o u p , at. t h e m e n t a l h e a l t h level of t h e n o n p a t i e n t pt~l)ulatit)n, l)ut r a t h e r at a n a v e r a g e level displac,,'d s o m e w h a t in t h e (lir(,ction of t h e i m p a i r e d . T h e l)etter int'nta] h e a l t h of the "expatients'" c o m p n r e d w i t h t h a t o f t h e "'current" p a t i e n t s sug,~ests t h a t ther(, is p r o g r e s s i o n t o w a r d b e t t e r m e n t a l h e a l t h with t r e a t m t m t . T h e grolq) o|- 183 (,xpatients c o n t a i n e d 8 i n d i v i d u a l s w h o xv(.r~, rated "'\V(.II.'" In c o n t r a s t , t h e (-urrt'nt p a t i e n t g r o u p c o n t a i n e d n o n e w i t h this ratin~. In a d d i t i o n . . 3 7 . ' 2 p e r cent of tilt, e x p a t i e n t g r o u p h a d "'mild symptoms.'" w h i c h l)v d e f i ~ i t i o n of the r a t i n g s e h e m e w e r e of little e()ns(e(lU(mc-t, t(~ t h e i r a d j u s t m e n t to life. Tog(:tht-r t h e s e t w o e;ttegories constit u t e d 41.6 p(-r cent of the e x p a t i e n t s u l ) s a m p l e , l t a d the m e n t a l h e a l t h of t h e s e e x p a t i e n t s l)(.(q~ t h e s a m e p r i o r to ,the visit to t h e p s y c h i a t r i s t , t h e y w o u l d h a v e prol>ably h~id no n e e d to seek p s y c h i a t r i c c o n s u l t a t i o n . It s e e m s p r o b a b l e , tht-rt-'ior(., that .their m e n t a l h e a l t h was w o r s e p r i o r to p s y c h i a t r i c t r e a t m e n t a n d t h a t t h e p r e s e n t p s y c h i a t r i c r a t i n g r e p r e s e n t s an i m p r o v e m e n t o v e r t h e status p r i o r to ps.vehiatric c o n s u l t a t i o n . Classitrication ot: a ps.vchiatrie p a t i e n t in the " ' m o d e r a t e s y m p t o m " or "'imp a i r e d " g r o u p did not nec-essarilv meal~ f a i l u r e of i m p r o v e m e n t w i t h p s y e h i a t rio t r e a t m e n t . T h e "lmpairt~l'" classification r e p r e s e n t e d all d e g r e e s of imp a i r m e n t . S o m e respondents in this category" w e r e o n l y s l i g h t l y i m p a i r e d b y t h e i r s y m p t o m s . ,,vhil(e o t h e r s w e r e f i m e t i o n i n g w i t h g r e a t difficulty. A p a t i e n t m i g h t h a v e i m p r o v e d c o n s i d e r a b l y a n d still r e m a i n e d irJ tile " ' I m p a i r e d " classification. .klissing frurn o u r sampl(- w e r e p a t i e n t s w h o w e r e c u r r e n t l y h o s p i t a l i z e d in institutions. A cerJsus ()f h o s p i t a l facilities p e H o r r n e d s i m u l t a n e o u s l y la'it}l t h e

1232

.NIICIIAEL A N D L A N G N E R

interview of the community sample placed these at 502 p+:,r 100,000 pol~ulation.X.p, l'-,s On a prorated basis, 8 patients would have been added to our "current" patient group. All of these would have been in tide "'incapacitated" subdivision of the "Impaired" group. The addition of these 8 patients to the "eun-ent'" patient group would have increased the difference b(+tx een the mental health levels of tide two patient subdivisions, thtls contributing further to the extent of the presumed improvement in the patients who had terminated psychiatric treatment. Both patient groups contained respondents who h a d experienced hospital treatment and had been discharged to resume their life in the community. Ten previously hospitalized patietats had visited at psy'bhiatrist within 4 w e e k s of the interview and presumably were,, still in treatment, while only 17 were in t.7-te considerably+ larger group of expatients. Itere again the current patient group is weighted heavily with the more serious patients who had been hospitalized. The greater n u m b e r of ex-hospital patients in the current patient group may be an indication of selectivity in this group. Patients with more serious problems remain in continued contact with a psy'ehiatrist. The clinician's interest in the findings is concerned with the degree of improvement achievable through 1)syehiatrie treatment. Is it possible theoretically to bring about improvement to a level equal to that of individuals who have not found it necessary to engage in treatment? The level of mental health found in the expatient population may be a eonapromise between the potential of psychiat~- and a level of adjustment at which treatment is discontinued as a consequence of practical considerations. The patients may have accepted as suftqeient for their needs the minimal level of improvement at which the.v can function independently of the psychiatrist's help. To insist on further treatment to increase the patient's mental health cat)acities may be idealistic, perhaps even overambitious and perfectionistic. The level of functioning of the expatients ma-¢ not be optimal. It is not even average, but it is sufficient. SU+XI-~IARY

The average mental health leve! of a group of 22,3 psychiatric patients was found below that of a comparable not~patient population of 1437 respondents. F o r t y patients considered to be currently seeing a psychiatrist were found to have a worse average mental health level than 183 patients in whom therapy had presumably been completcxl. The latter group contained 41.6 per cent patients who ,,,,'ere given a mental health rating indicative of relatively good psychiatric adjustment with the implication that they had improved with treatment. The more impaired level of mental health in the patient group was not considered evidence of failure of treatment but rather inteq~reted as tide minimal level of mental health functioning compatible with termination of psychiatric treatment.

3II~NTAL }IEALTt.I AFTEIt PSYCII1ATFIIC TREAT~\IENT

13~3

REFERENCES

1. Srole, I,.. l.,angner, T. S., Michael, S. T.,, Opter, M, K,, and Rennie, T, A. C.: Mental l lealth iu the Metropolis: The Midtown Manhattan Study, Vo]. I. "l'horvms A. C. Rennie Series in Social Psychiatry. New York. McGraw-Hill, 1i~c., I962, 2. Lal~gta:r. T. S.. ar:d Michael, S. T,: Life Stress and Mental Health: The Midtow~ Manhattan Study, Vol. II. Thomas A. "C. Rennie Series in Social Psychiatry. (;lencoe, II1., Free Press of (;lencoeo 1963. 3. l,eighton, Dorothea C., t larding, J. s.. .\lacklin. I), B,, Macmillan, A. M., and o

1,eighton, A. H.: The Character of Danger: Psychiatric Symptoms in Selected Communities, Vol. III. The Stirling County St!ldy of t'sychiatric Disorder and Sociocu]tural Environment. New York. Basic Books,: 19f33, 4. Michael, S. T.: Social attitudes, socioeconomic status and psychiatric symptoms. Acta Psychiat. Neurol. Scand. 35:509-517, 1960.

5. Michael, S. T,, a n d L~ngner, "FI S.: Social mobility and psychiatric symptoms. Dis, Nerv, S)'st. Monogr. Supp, 24:1--4, 1963.