INPATIENT PSYCHIATRY – RESEARCH TOPICS

STACIE BURGESSER B.A. AND ANIL MITRA PH. D.

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Analyze the topics, eliminate repetition, synthesize consistently, and group according to area of interest

1.       Life skills intervention and insight for patients with Bipolar and other mental disorders. Education of patients regarding bio-psychosocial effects repeated [manic] decompensation and admission to inpatient units

2.       Leadership and efficiency in inpatient psychiatry. Therapeutic leadership is paramount in outcome; inefficiency e.g. excessive attention to non-therapeutic aspects of policy results in dilution of leadership

What is leadership? Leadership as decision and action. Relation to ‘mission.’ Kinds of effective leadership e.g. bureaucratic, autocratic and democratic models. Leadership and efficiency

What are the main diagnoses and problems in terms of expense. Research and import of therapeutic and leadership models

3.       Importance of family systems, networking and wellness models in therapeutic outcome and maintaining therapeutic community

4.       Importance of life-style: each of the following is a ‘research topic:’ nutrition – see e.g. http://glycoscience.com and anecdotal reports of successful treatment of Bipolar Disorder with diet, exercise, urban versus rural living – sunlight, fresh air, green trees and blue sky… but the point becomes lost in that, surely, each factor has an effect but treatment of real individuals is more than a research topic or a mechanical procedure… and, here, Diet and Nutrition by Rudolph Ballantine, MD, remains one of the best modern books on scientific nutrition in its style even if somewhat outdated in content; Ballantine’s approach is twofold – the standard ‘scientific’ approach in which the system of nutrients are studied and, more importantly, the comparative study of cultures, observed health and disease and diet… consider this issue as a whole as a research project

5.       Incorporation of life and long term goals in treatment planning; integration of outpatient and inpatient treatment planning. Use of computer automation in maintaining continuity over outpatient and inpatient treatment especially in chronic illness with multiple admissions

6.       Importance of respect and patient involvement in treatment and other decisions in therapeutic milieu, safety and therapeutic outcome; importance of establishing rapport before treatment i.e. listening before hearing

7.       Abnormal eating behaviors of acute psychiatric patients

8.       Rates of recovery from various disorders; and rate of recovery for first break patients

9.       Learned behaviors in a psychiatric ward

10.    Role of institutions in creating and maintaining personality disorders; identifying counter-therapeutic aspects of institutionalization and institutional treatment. If personality is formed in childhood, how can institutions contribute to their creation? First, to the phenomenon and its widespread occurrence and sub-culture by various mechanisms: learning on inpatient units, first person accounts by patients on inpatient units. Second, since in practice – according to DSM IV TR, the disorders are measured by sets of behaviors beginning by early adulthood. Finally, prevalence creates a need for description of a disorder

11.    Co-occurrence of major mental illnesses and personality disorders. Differential diagnosis. Effect of personality and other ‘secondary’ disorders and issues – substance, social etc. – on therapeutic outcome and prognosis; importance of diagnosis and treatment planning to account for effect of the ‘secondary’ disorders in mood disorders and schizophrenia. Catalog classes of dual problem. Case studies e.g. dependent personality and schizophrenia or schizoaffective disorder; narcissistic personality and bipolar disorder; covert mania or rapid cycling in borderline personality disorder

12.    Co-occurrence of disorders in general: Axis I, II, III, IV; including substance use issues and level of intellectual functioning. The issue of high-profile / difficult to treat patients: see Treatment Planning for High Profile Patients. Profiling and use of strengths (defined as a characteristic or resource that enables the client to cope with his or her disorders and problems) and weaknesses. Catalog classes of co-occurring problem. Identifying a set of characteristic profiles such as in the previous item

13.    Institutional structure, staff profiles and institutionalization. At one extreme lies the chronically mentally ill and chronically institutionalized patient. At another lies the one time consumer of services. In between are those whose path is not determined. The claim is that institutional structure, staff profile, and treatment modality is crucial in effecting outcome of such patients. Specifically, there are institutional structures, staff profiles, decision making, and choice –or lack of choice– of therapeutic modality that make for avoidable dependence on services… or that make for marginal functioning where there is potential for functioning well or better. Specific issues include the role of economics, of counter-transference and judgment, of neglecting the importance of developing trust / rapport before embarking on ‘treatment,’ of neglect of person… and the occurrence of these factors in the most well intentioned staff

14.    Programs that are more expensive per unit of therapy and or more carefully –‘scientifically’ designed– may result in lower total cost by reducing recidivism and cost of continuing care and improving level of function. Will result in a smaller mental health system and improved depth and breadth of care

15.    Approaches to improving profit and economic viability in inpatient psychiatric facilities

16.    Community roles of the inpatient psychiatric facility

17.    Treatment: art or science? First point, art and science are not exclusive. Second, common notions of science as excluding art and as commonly taught are not how science advances; it is only after conceptual advance which requires ‘art’ that ‘science’ can follow the model of deductive logic [read ‘algorithm’ or ‘evidence based practice.’] Main point: ‘Everyday treatment: art or science?’ Again, art and science are not exclusive. However, they may be treated as exclusive. Roles of personality, economics, power, and belief (myth)

18.    Ethics and allocation of resources to treatment. An ideal of treatment is that all who seek or present should receive adequate and proper treatment for the presenting problem. However, two issues, frequently suppressed by the idealist, arise. The first issue is general and concerns medicine vs. other social needs. Treatment requires resources. A resource applied to treatment may and usually does mean less resources available for other needs. The ideal case is possible only in a world of infinite resources. It is in the nature of a large complex society that resource realism is hidden from common view. However, once one becomes aware that resources are finite to continue to hold the ethical ideal to the exclusion of all other concerns is to be blind. One would like to treat every presenting problem with all the resources available. However, this is simply not possible. One approach to the issue favored by some who would like to maintain the ideal and serve economic realism is to attempt to deploy all resources available and let ‘reality’ choose. Given limited rationality and the potential for abuse, there is merit to this approach. On the other hand, ‘blind ethics’ may result in greater harm. What is the proper response? Obviously, in addition to idealism, any response other that ‘blind ethics’ requires courage, intelligence and self-criticism. The second issue is within mental health treatment. Some diagnoses by their nature require huge amounts of resources that take away from the treatment of lower profile problems. Sometimes, in order to keep one person alive, numerous others receive diminished treatment. And its not just ‘life’ vs. ‘quality.’ Diminished treatment translates in to greater mortality. Again, where is the balance? There is a metaphor for rationality and science that are appropriate here – the searchlight metaphor. Objects in the beam of the searchlight are seen with great clarity; objects outside the beam are not seen – thus science, rationality and even intuition never capture the whole picture. This is point is only a criticism when it is ignored. The relevance of the metaphor is that there is a tendency to treat the most spectacular problems –a cure for cancer­– even when this may result in a lesser quality of life, greater net mortality. Contra: at least in this society, ‘search for a cure for cancer’ offers hope for the ill, security for others

19.    Importance of correct diagnosis of personality disorders. Borderline Personality Disorder is over-diagnosed [frequently informally by non-medical staff.] Differential diagnosis of Axis I and personality disorders e.g. in mania personality traits are exaggerated and may present as personality disorders. Differential diagnosis among personality disorders e.g. narcissistic versus borderline personality disorder

20.    Significance of Axis II traits or disorders in Axis I profiles. Consequent significance of Axis II in treatment of primary Axis I disorders

21.    ‘Depressive personality disorder’

22.    Effect of belief and culture on: concept of personality, personality formation and flexibility, personality disorders – definition, diagnosis, treatment and outcome

23.    Recreational drug use and ‘first break’ psychiatric patients

24.    ‘First break’ and drug induced psychosis; differential diagnosis and implication for treatment planning

25.    PTSD and eating disorders in psychiatric programs

26.    Seasonal Affective Disorder and dysthymia

27.    Role of insurance in therapeutic outcome – medical necessity and ‘revolving door’ admissions. Economic effect may be beneficial for agencies and insurance companies but not for society. Proposed solution: state monitoring and rewarding of counties with sound therapeutic policies may result in improved therapy and economics. Such monitoring should account for special needs of the individual counties and distinctions among small and large, urban, rural and mixed counties

28.    Introduce a dynamic though non-theoretical framework for DSM as in JOURNEY IN BEING: FOUNDATION. Review DSM IV TR discussions of personality disorders, Abnormalities of Personality, Michael H. Stone 1993 etc.