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Biomedical subjects

L R Mosher

Publications and source records attributed to L R Mosher.

At least 19 recordsLinked to original sources
PubMed1999

Soteria and other alternatives to acute psychiatric hospitalization: a personal and professional review.

The author reviews the clinical and special social environmental data from the Soteria Project and its direct successors. Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute and long-term clients deemed in need of acute hospitalization can be returned to the community without use of conventional hospital treatment. Soteria, designed as a drug-free treatment environment, was as successful as anti-psychotic drug treatment in reducing psychotic symptoms in 6 weeks. In its modified form, in facilities called Crossing Place and McAuliffe House where so-called long-term "frequent flyers" were treated, alternative-treated subjects were found to be as clinically improved as hospital-treated patients, at considerably lower cost. Taken as a body of scientific evidence, it is clear that alternatives to acute psychiatric hospitalization are as, or more, effective than traditional hospital care in short-term reduction of psychopathology and longer-term social adjustment. Data from the original drug-free, home-like, nonprofessionally staffed Soteria Project and its Bern, Switzerland, replication indicate that persons without extensive hospitalizations (<30 days) are especially responsive to the positive therapeutic effects of the well-defined, replicable Soteria-type special social environments. Reviews of other studies of diversion of persons deemed in need of hospitalization to "alternative" programs have consistently shown equivalent or better program clinical results, at lower cost, from alternatives. Despite these clinical and cost data, alternatives to psychiatric hospitalization have not been widely implemented, indicative of a remarkable gap between available evidence and clinical practice.

Antipsychotic Agents↗
PubMed1998

Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness.

OBJECTIVE: Severe and persistent mental illnesses are often lifelong and characterized by intermittent exacerbations requiring hospitalization. Providing needed care within budgetary constraints to this largely publicly subsidized population requires technologies that reduce costly inpatient episodes. The authors report a prospective randomized trial to test the clinical effectiveness of a model of acute residential alternative treatment for patients with persistent mental illness requiring hospital-level care. METHOD: Patients enrolled in the Montgomery County, Md., public mental health system who experienced an illness exacerbation and were willing to accept voluntary treatment were randomly assigned to the acute psychiatric ward of a general hospital or a community residential alternative. There were no psychopathology-based exclusion criteria. Treatment episode symptom improvement, satisfaction, discharge status, and 6-month pre- and postepisode acute care utilization, psychosocial functioning, and patient satisfaction were assessed. RESULTS: Of 185 patients, 119 (64%) were successfully placed at their assigned treatment site. Case mix data indicated that patients treated in the hospital (N = 50) and the alternative (N = 69) were comparably ill. Treatment episode symptom reduction and patient satisfaction were comparable for the two settings. Nine (13%) of 69 patients randomly assigned to the alternative required transfer to a hospital unit; two (4%) of 50 patients randomly assigned to the hospital could not be stabilized and required transfer to another facility. Psychosocial functioning, satisfaction, and acute care use in the 6 months following admission were comparable for patients treated in the two settings and did not differ significantly from functioning before the acute episode. CONCLUSIONS: Hospitalization is a frequent and high-cost consequence of severe mental illness. For patients who do not require intensive general medical intervention and are willing to accept voluntary treatment, the alternative program model studied provides outcomes comparable to those of hospital care.

Adult↗
PubMed1996

Residential alternatives to hospitalization for patients with severe and persistent mental illness: should patients with comorbid substance abuse be excluded?

Residential alternatives to hospitalization for adults with severe mental illness in crisis were not designed for, and often exclude, persons with coexisting substance abuse disorders. Given high comorbidity rates, however, it is important to know whether residential alternatives can be effective for patients with dual diagnoses. To explore the impact of comorbidity on treatment outcomes, structured interviews were conducted at admission and discharge with 92 consecutive admissions to a residential alternative. Using the Structured Clinical Interview for DSM-III-R, two groups were identified: 24 patients with and 68 patients without comorbid substance abuse disorders. At admission, the two groups were similar in demographic and clinical characteristics. The treatment was effective independent of comorbidity; at discharge, treatment success, symptom improvement, and patient satisfaction were similar for both groups. Persons with coexisting substance abuse disorders remained in residence a week longer, but the difference was not statistically significant. Residential alternatives appear suitable for patients with dual diagnoses.

Adult↗
PubMed1995

The treatment of acute psychosis without neuroleptics: six-week psychopathology outcome data from The Soteria Project.

BACKGROUND: Today's treatment of acute psychosis usually includes short-term hospitalization and anti-psychotic drug treatment. The Soteria project compared this form of treatment (control) with that of a small, home-like social environment, usually without neuroleptics (experimental). METHOD: Newly diagnosed, young, unmarried persons with DSM-II schizophrenia were randomly assigned to treatment in two experimental and two control settings. Subjects and families were assessed at admission on 29 independent variables. Treatment environments were studied by means of Moos', COPES or WAS scales. Three dependent six week psychopathology outcome measures were collected. RESULTS: The groups were comparable on 25 of 29 admission variables. The environments of the two experimental and two control settings were different from each other. The milieus were similar to each other within each condition. At six weeks, psychopathology in both groups had improved significantly, and similarly, and overall change was the same. CONCLUSION: Specially designed, replicable milieus were able to reduce acute psychotic symptomatology within six weeks, usually without antipsychotic drugs, as effectively as usual hospital ward treatment that included routine neuroleptic drug use.

Acute Disease↗
PubMed1983

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Italy.

Italy's mental health law of 1978 brought dramatic changes in mental health care to Italy by immediately closing large state hospitals to new patients. The law mandated a trend begun 20 years earlier by a group of professionals dedicated to dismantling large psychiatric hospitals. It is based on models developed by these professionals to move hospitalized patients into the community and to care for them through teams of former hospital personnel working with local social agencies. In 1974, the professionals founded Democratic Psychiatry, a society whose aims included continuing to dismantle the hospitals. The work of the society and the provisions, problems, and successes of the mental health law are summarized. The author believes that valuable lessons can be learned from the gradualism inherent in the models used in devising the law and from the national health insurance support that implemented it.

Chronic Disease↗
PubMed1981

Diagnosis of schizophrenia: a critical review of current diagnostic systems.

The data relevant to the evaluation of six systems for diagnosing schizophrenia are reviewed. They are summarized in terms of the reliability, predictive validity, specificity, and comprehensiveness of each system. Unfortunately, none, of these systems (Schneider's First-rank Symptoms, New Haven Schizophrenia Index, Flexible System, Feighner Criteria, Research Diagnostic Criteria, and DSM-III) have established construct validity. It is noted therefore that they are all, in a sense, arbitrary. Choosing one over another cannot be data-based. Because the elevation of any one diagnostic system to an official status is thought to be premature, clinicians and researchers alike are advised to exercise caution and openmindedness in their use of DSM-III. There is as yet no evidence that its criteria for schizophrenia are either less arbitrary or better (in identifying a group of "true" schizophrenics) than those of other systems or DSM-II.

Diagnosis, Differential↗
PubMed1980

Psychosocial treatment: individual, group, family, and community support approaches.

The authors present an overview of research on psychosocial treatments for schizophrenia. Findings from studies of four therapeutic approaches--individual psychotherapy, group psychotherapy, family therapy, and community support systems--are discussed in detail. The usefulness of each type of therapy is critically assessed on the basis of available data from controlled outcome studies. The authors make recommendations regarding high-priority areas to be addressed in future studies of psychosocial treatments.

Antipsychotic Agents↗
PubMed1979

A non-neuroleptic treatment for schizophrenia: analysis of the two-year postdischarge risk of relapse.

The efficacy of antipsychotic drug maintenance in reducing the risk of relapse among previously hospitalized schizophrenic patients has been well documented. However, data from an ongoing study comparing two cohorts of young first admission schizophrenics--one receiving neuroleptic-oriented treatment on the wards of a community mental health center (CMHC), the other an intensive interpersonal approach in a small homelike facility in the community (Soteria House)--raise questions about the routine use of neuroleptics with this population. Our questioning of this practice is based on data analyzed from these two cohorts by means of the life table, a statistical technique appropriate for longitudinal studies. Data are presented in two ways: (1) The overall effectiveness of the two independent treatment programs (Soteria, N = 32, vs. CMHC, N = 36) is compared in terms of the probabilities of not being readmitted over the 2-year postdischarge interval. (2) Analyses that look at the influence of the original treatment setting and postdischarge antipsychotic drug status on readmission rates are presented. Program comparisons reveal Soteria patients to have a consistently higher survival rate than CMHC patients throughout 2 years postdischarge. At 12 months postdischarge, the cumulative probability of remaining well (no readmissions) significantly favors the Soteria patients (p less than .05, Mantel chi2). The overall results of the Soteria program were achieved despite the fact that all CMHC patients received neuroleptics during their original inpatient stays and about 50 percent were maintained on neuroleptics up to the point of readmission or study termination, whereas only 10 percent of Soteria subjects were treated with or maintained on neuroleptics. The survival rates by postdischarge drug status and program affiliation show the Soteria no-drug group to have the highest proportion of survivors at almost every interval throughout 24 months, the CMHC drug-maintained group to have the lowest survival rate, and the CMHC unmaintained group to be surviving at a rate generally comparable to the Soteria no-drug group.

Actuarial Analysis↗
PubMed1979

Research on the psychosocial treatment of schizophrenia: a summary report.

The authors present an overview of research on psychosocial treatments for schizophrenia. Findings from studies of five therapeutic approaches--individual psychotherapy, group psychotherapy, family therapy, milieu therapy, and community support systems--are discussed in detail. The usefulness of each type of therapy is critically assessed on the basis of available data from controlled outcome studies. The authors make recommendations regarding high-priority areas to be addressed in future studies of psychosocial treatment.

Aftercare↗
PubMed1978

Community residential treatment for schizophrenia: two-year follow-up.

Two-year outcome data from a study comparing two kinds of treatment given similar groups of young, newly diagnosed, unmarried schizophrenic patients deemed in need of hospitalization are reported. The experimental program, Soteria, is a nonmedical, psychosocial program with minimal use of antipsychotic drugs; it is staffed by nonprofessionals and located in a home in the community. The control program is a short-stay, crisis-oriented inpatient service in a community mental health center where neuroleptic drugs are the principal treatment. The experimental group had significantly longer initial stays, and only 8 per cent received neuroleptics during their initial admission. Over the two-year follow-up period, there were no significant differences between the groups in readmissions or levels of symptomatology. However, experimental subjects significantly less often received medications, used less outpatient care, showed significantly better occupational levels, and were more able to live independently.

Adolescent↗