Literature Review

Readmission rates of mental health patients have soared in the recent past. This trend is an inherent source of frustration to patients, families and the respective treatment teams. Indeed, the rapid deterioration of patients that culminates in readmission can be distressing to the patients as well as their supporters. The complex process of discharge and re hospitalization that happens within a very short period of time requires lengthy hours of multidisciplinary efforts and input that is always rendered redundant at the end of the process. In their nationwide study regarding the occupation of psychiatric wards,

Glazer and Ereshefsky (2006) ascertain that over 50 of the beds are occupied by re hospitalization cases. A notable pattern of patient illness in psychiatric wards is based along recurring of illnesses. Thus once the mental health patients leave the hospitals, the probability that they would return in future is seemingly high.

The differences in the readmission of psychiatric patients are based on different factors of the institution milieu. The severity of the illness, indulgence in risky behaviors, substance use and abuse, fragmented care pathways and other modifiable factors have increasingly being associated with patient return in mental health institutions. Of great importance are the economic factors that have been identified as the main contributory factors to rapid readmissions. Generally, current statistics are a major cause of concern for most mental heath institutions. Efforts have been mounted through consistent research to identify intrinsic gaps that contribute to this scenario. This literature review underscores the previous findings in this regard.

Trends in Mental Health Policy
National statistics indicate that close to forty four million Americans suffer from mental health illness. In his study, Prince (2009) ascertained that the mental health department in America is presently experiencing a shortage in human resources. As a result, the quality of services being provided by the sector greatly compromises the recovery and holistic wellbeing of mental health patients.

Nationally, mental health has been identified as a neglected realm of the public health sector according to Delaney and Fogg (2007) who analyze the National health report based on the survey carried out in 2007. The information regarding the mental policy is also fragmented as exemplified by the World Heath Organization report of 2008. Essentially, it seeks to address the underlying goals of mental health but only mentions the reduction of suicide.

A report presented by Prince (2009) draws particular attention on the increasing rates of mortality for schizophrenia. In addition, it cites vital surveys that highlight a significant 28 of the population believed to consult mental health services annually. Furthermore, he notes that social deprivation indicators like unemployment are elemental in psychiatric morbidity and highlights the urgent need for collaboration between different sectors. He concludes by stating that mental health services are critical for this segment of the national population whose incapacitation is likely to lead to increased poverty and marginalization.

As highlighted above, mental health is relegated and is not identified as one of the public health priorities in America. Notably, psychiatric patients comprise of the poor in this nation. It is therefore imperative to enhance equitable distribution of mental health services in order to ensure that the psychiatric patients benefit from the same. Giffords (2006) has proposed the matrix model to be the most ideal approach to addressing the emergent concerns regarding healthcare. This presents various interventions with regard to mental health treatment, prevention, promotion and sustainable rehabilitation of the affected population. He argues that in order to attain optimal results, an all inclusive approach that incorporates both public and individual concerns needs to be adopted.

Burns and Fim (2002) affirm this contention by indicating that effective treatment of psychotic disorders requires input from all segments of the society. In particular, they show that while pharmacological treatment controls severe symptoms, social interventions and psychological support are instrumental in enhancing the quality of life of the patients and preventing physical deterioration and malfunctioning. Further, a multivariate analysis revealed the inherent relationship between substance abuse and criminal victimization of the psychiatric patients.

Burns and Fim (2002) also indicate that the sector has in the recent past received particular attention from consumer organizations. Fundamentally, these play a critical role in evaluating the performance of the sector. In particular, they publicize the extent of the department in addressing its goals of providing sufficient services to the mental health population, addressing stigmatization, providing integrated and comprehensive health services, reducing costs associated with mental health and increasing the workforce. A recent study indicates that the department has dismally failed in all these areas. By bringing these concerns to the fore, consumer organizations have played a critical role in encouraging formulation of sustainable policies by the federal government.

Implications of Deinstitutionalization
Various controversies have emerged over the process of deinstitutionalization that was carried out in the last quarter of the previous century. Shadish, Lurigio and Lewis (1995) decry this process and argue that mental health patients need long-term institutionalization in order to recover fully. He highlights the ineffectiveness of rehabilitation programs in dealing with violent behavior, impulsive suicide and substance abuse that is exhibited by the patients. However, Easterbrook, Berlin, Gopalan and Mathews (1991) point out that community programs have made it possible for the economically weak within the society to access these vital services. In response, Shadish et al (1995) ascertain that effective community care is more expensive than institutionalization. Further, he shows that long term rehabilitation that greatly benefits the patient is also an added expense.

Also, Gopalan and Mathews (1991) indicate that deinstitutionalization provides an ideal environment for the mental health patients to recover easily. In this regard, they argue that community based care provides a more humane environment that enables the mental health patients to access outpatient care. In addition, Geller (2000) posits that deinstitutionalization has been effective in shortening the period of time that the mental health patients stay in hospitals. According to him, the hospital environment is restrictive and does not provide the patients with a chance to socialize with the entire public. In other words, the environment provided therein is not viable and psychologically, this undermines the recovery process. However, Shadish et al (1995) contests this by indicating that this can only be achieved if the community based facilities are equipped with sufficient infrastructure including human resources. Notably, this has not been achieved in the US and as a result, mental patients continue to suffer.

In his review, Dowdall (1999) describes deinstitutionalization a s an adjustment process that provides mental heath patients with a chance to recover without having to experience the effects of the life provided in institutions. This was based upon the realization that mental health patients that are institutionalized tend to become accustomed to the environment in the institutions and find it difficult to adjust to the conditions outside the institution. Dowdall (1999) asserts that deinstitutionalization allows that patients to be empowered and regain their freedom. This then enables them to assume responsibility for their action and therefore recover faster. Unlike in the mental institutions that have their distinct rules, the community environment allows the patients to adapt to the normal environment and co-exist with the rest of the population with ease.

In his study, Scull (1991) argues that deinstitutionalization gives hope to the mental patients. According to him, it provides a viable environment that enables the patients to be appreciated and be cared for by the entire community. This gives hope to the patients and hastens their recovery as they are perceived as normal individuals in a communal environment.  Nonetheless, Shardish et al (1995) indicates that such an ideal scenario is yet to be achieved in the current US society as the patients face a high degree of stigmatization from the society. He further proposes that psycho education and other viable measures would be instrumental in altering the present demeaning perception that mental health is accorded by the public. According to him, only then would deinstitutionalization yield desirable outcomes.

Nonetheless, Shardish et al (1995) indicates that deinstitutionalization has resulted in incidences of homelessness. This is due to the fact that it results in to premature discharge of the mental health patients from the hospitals. However, the community based mental health institutions lack the vital infrastructure and resources to provide quality services to the discharged patients. In the long run, the patients lack vital care and fall victims of homelessness.

Burns and Fim (2002) pertaining to USA health services reviewed the transfer of mental health patients for hospitals to community care programs. Findings indicated that community based models were more effective in shortening the duration of the patients in hospitals, reducing incidences of readmission, and enhancing community integration. However, a parallel review undertaken by Foster (2002) indicated an increase in mortality rates, homelessness and frequent readmissions for patients whose conditions were severe. In order to counter the later scenario, Foster (2002) proposed that there is need to ensure that the community programs and given sufficient resources and are well planned for. In particular, he cites that that planning of community programs need to be attuned to the specific needs of the psychiatric patients.

Modifiable Risk Factors for Rapid Readmission in Mental Health Hospitals
Frequent Hospitalization
In their research, Weiden and Glazer (1997) found out that a history of consistent hospitalization in mental health hospitals is a predictor of rapid readmissions. According to this study, patients that had a pattern of seeking inpatient treatment tended to repeat the treatment-seeking behavior. In this regard, Carmel (2002) affirms that psychiatric patients that are accustomed to the mental health institutions or felt comfortable and relieved during their previous admissions often prefer readmissions as a viable mode of adjustment to their painful experiences during a relapse. He refers to this tendency as hospitalphilia.  This is characterized by a short interval between admissions that lasts for a relatively shorter duration and often ends against the medical advice. Such patients according to him prefer short and frequent admissions to extended periods of admission.

Although previous studies indicated that such admissions are influenced by violence, this study found out that the admissions are self initiated and the characteristic aggression does not influence re hospitalization. Notably, the patients did not exhibit any form of violence after admission, perhaps a strategy aimed at restraining the hospital staff from interfering with the self initiated admission schedule. The limitation of this study was that it reviewed only documented and published information about the patients. At this point, it should be acknowledged that unpublished studies are likely to contain more factual information that would conflict with these findings. However, the study was very comprehensive and various documentaries from a diverse cultural background were reviewed. Therefore, it can be applicable to other countries outside USA.

In a bit to explain the relationship between system variables and rapid re hospitalizations, Carmel (2002) found out that the attitude that the mental health workers accorded patients also influenced rapid readmissions. The study employed a sample of sixty one mental patients with revolving door syndrome in a psychiatric unit in North Carolina. The results indicated that patients that were perceived regulars by the nurses were in some instances overlooked when admitted or handled superficially. As a result, the emergent issues in their medical status were not handled effectively because particular attention was given to major symptoms. Lack of timely interventions regarding emergent infections of these patients influenced their rapid readmission. In order to address this, the study recommended a change in the attitude towards frequently admitted mental health patents by the mental health providers.

Notably this study was restricted to one facility and one state. In this regard, it should be appreciated that the professional experiences of mental health individuals vary across the nation. These variations are influenced by the different economic resources that the states have. In addition, Huff (2000) notes that state policies also influence the quality of mental services offered in different states. It can therefore be argued that the findings do not have a nationwide application. However, the implications of these findings to policy formulators are desirable.

Non Compliance to Treatment and Medical Appointments
In his study, Green (1998) analyzed the causes and patterns of acute admissions in a psychiatric unit in New York for patients with revolving door syndrome. He employed 63 inpatients that were suffering from schizophrenia. This study was aimed at making efforts to improve treatment options and enhance sustainability upon discharge from the hospital. The leading cause was identified to be lack of compliance to medication.

Lack of response to the treatment was cited as the second most common cause of acute readmissions in the institution. The treatment that was currently available for use at the time of study was oral conventional antipsychotic, atypical antipsychotic and depot conventional antipsychotic. The decision to employ either atypical or depot treatment was based on the identification of whether the relapse was caused by non response or non compliance. This study recommended that medication for such patients need to be determined during acute admission.

Notably, the study relied solely on the data collected from in patient. In his review Easterbrook et al (1991) argues that inpatients tend to have different characteristics from outpatients. In particular, he ascertains that the attention and management that the two groups of patients are accorded differs significantly. This has various implications on the policies undertaken at various stages. At this juncture, it can be argued that the data employed for this study was not presentation of the psychiatric population. However, it can be contended that the first hand information got from the study is very instrumental in making viable decisions regarding treatment of inpatients suffering from mental disorders.

A previous study undertaken by Weiden and Glazer (1997) that employed a pharmaco-economic decision analysis model evaluated the implications of changing treatment from traditional oral neuroleptics to modern atypical oral treatments and depot neuroleptics for revolving door patients. The study employed one hundred and fifty patients that were randomly picked from various psychiatric state institutions across US. The rationale for this was to capture the inherent economic disparities and analyze how the same contributed to rapid readmission of mental health patients. Shifting of treatment was perceived as a viable means of management of schizophrenic out patients. This study found out that patients with limited resources were more likely to be rapidly readmitted than their counterparts. This was attributed to the low quality of previous medication that such patients were previously accorded. It was further compounded by lack of quality after care services at the community level. The study affirmed that these conditions worsened the symptoms after discharge and prompted rapid readmission.

In his study that sought to determine the relation between non compliance to outpatient admissions and rapid re hospitalization in psychiatric wards, Geller (2000) found out that patients who did not comply with outpatient appointments after being discharged from the hospitals were three times more likely to be readmitted. He employed a sample of 241 revolving door patients in three south eastern states. Findings indicated that out of the entire sample, almost sixty percent did not comply with the outpatient appointments regardless of the fact that they had been scheduled accordingly by respective institutions. These segment of the sample experienced more rapid readmission rates than their counterparts. The study recommended that patients utilizing outpatient services need to comply with the medical instructions in order to avoid rapid readmission. According to this study, lack of compliance complicated the recovery process and made it difficult for the health providers to monitor the status of the illness and intervene accordingly. The limitation of this study was that it was restricted to female patients only.

Notably, non compliance to medical appointments has been associated with non compliance to treatment. In his research regarding the relationship between non compliance and rapid readmission, Bech (2005) found out that psychiatric patients who personally discontinued their medication found it difficult to disclose this to the medical providers. As such, they preferred to discontinue with the appointments altogether. Conversely, the psychiatric patients that missed important appointments tended to make misinformed decisions regarding their after care. This led to complications that ultimately culminated in rapid readmission. Further, Bech (2005) shows that non compliance to appointments and treatment undermines the quality of services that the patients are given by the medical staff. In particular, this tendency compromises communication between the patients and health providers, decreases the degree of health provider empathy and increases the level of provider frustration. In order to avoid this, Bech (2005) proposed that the patients should be given sufficient information regarding medical schedules.

Severity of Illness
In his consultative review, Blader (2004) explored factors that determined rapid readmission in psychiatric institutions for adolescents and reported that severe early diagnosis especially that of affective psychoses and schizophrenia contributed significantly to rapid relapse that characterizes the revolving door syndrome. Despite the fact that this study entirely focused on adolescents, it can be argued that this applies to children as well as adults. Also, the deductions can be ascertained to have been based on credible data due to the fact that the study was conducted within a period of ten years. Conventional studies have cited severity of the illness to be a contributory factor to frequent readmission. These are represented by Lyons, Uziel-Miller and Reyes (2000) that employed psychometric screening procedures in identifying psychiatric patients that were at a high risk of rapid readmission.

In this, they ascertained that factors relating to frequent readmission in hospitals had been studied intensely in the recent past in a bit to curb the expenses involved as well as improve the outcomes of the disease. In this respect, they referred to the recent dramatic increases in readmissions in mental hospitals that involved revolving door patients. Notably, this led to an increase in deinstitutionalization. Their study employed 130 patients and lasted for a period of three months. They concluded that identification of the patients that were at a higher risk of readmission would be useful. In particular, it would give mental health personnel a chance to plan for their management in a timely manner and make viable interventions accordingly. Such measures according to them would include discharging patients to community based institutions.

The limitation of this study was that it was undertaken within a very short period of time. Considering the fact that it was using observation as an important tool of collecting data, this study should have taken more time in order to come up with viable conclusions. In this respect, Boardman, Hodgson, Lewis and Allen (1997) point out that severity of illness in mental patients is contributed to by various factors that are both environmental and economic in nature. It is therefore imperative to take sufficient time to identify deserving patients and take intervention measures accordingly. Nevertheless, the study was credible as it utilized factual first hand information from the mental health practitioners.

Substance Abuse
In his study in mental hospitals in the State of Mississippi Prince (2009) found out that coupled with treatment non compliance, substance abuse contributed significantly to rapid re hospitalization for revolving door patients. His study was based on a sample of seventy patients that were randomly picked from a psychiatric institution.  He concluded that sustainable intervention measures such as patient education could be instrumental in reducing such incidences. Like wise, Haywood, Kravitz, Grossman and Lewis (2008) carried out a comparative evaluation of mental health inpatients without and with co morbid substance-related complications. They found out that instances of readmissions were more rapid for the psychiatric patients with co morbid substance-related complications. However, they indicated that this was only for a short period of time.

Further, Gastal, Andreoli and Quintama (2000) carried out a four year prospective review after relapse in schizophrenia for one hundred patients. Their findings indicated that non compliant patients that had been previously diagnosed of substance assumed a significant 64 of the institutional rapid readmissions. They also found out that the duration before re hospitalization was relatively shorter for non compliant patients that had dual diagnosis for substance use and abuse than for non compliant patients that had not been previously diagnosed for substance abuse. Further, they indicated that patients that were medication compliant had a relatively longer period before readmission than their counterparts that had been diagnosed of substance abuse. Basing on this analysis, they concluded that sustainable treatment programs in this respect need to address substance abuse and non compliance in order to attain optimal results.

A relative research was carried out by Levine (1998) who sought to identify factors that contributed to substance use and abuse by schizophrenic patients and the relationship of the same with rapid readmissions. This study was motivated by the recognition that substance abuse was one of the reasons behind rapid re hospitalization of mental health patients in the state of Arizona. The findings indicated that the relatives, family and community members of the patients contributed to their substance abuse by selling alcohol and drugs to them. In addition, this study revealed that use of alcohol and drugs by the patients was aimed at containing severe side effects that are related to the use of anti-psychotic drugs, avoiding drowsiness and suppressing hunger as a result of shortage of food. However, this led to severe side effects and undermined the effectiveness of the medication. As such, affected patients were readmitted in hospitals within a very short period f time.

The key areas of intervention in this regard were identified as enhancing psycho education amongst patients and the community at large, raising community awareness with regard to substance use and abuse, strengthening the abilities of law enforcers and care takers to curb substance use and abuse and initiating community based campaigns that target the protection and care of the mental health patients. The limitation of this study was that the data that was used was derived from clinical records. However, the implications can be applied to a large geographical area.

Violence
Violence and criminal behavior have also been implicated for contributing significantly to rapid readmission. A study conducted in North Carolina by Appleby, Desai and Luchins (2001) using a sample of 330 involuntary out patients suffering from psychotic and major mood disorders analyzed the specific characteristics and environments of violent mental patients. They found out that violent behavior was exhibited by half of the sample and contributed significantly to rapid readmission. The main limitation of this study was that the data employed was derived from a single facility.

Further, a study conducted by Casper and Regan (1996) in Canada indicated that violence was one of the main reasons that contributed to frequent and rapid readmissions. This viewpoint was brought forth by the care giving relatives who ascertained that severe relapse of mental health disorder in psychiatric patients culminated in a situation where the safety of the relatives was jeopardized, their property destroyed and in severe instances, their lives threatened as a result of violence. A study conducted by Gastal et al (2000) in Mexico indicated that such a situation became even more disheartening in cases where the law enforcement agencies failed to respond in a timely manner. Further, the fact that the patients were unlikely to be held criminally responsible for their activities made the relatives to request for rapid readmissions. In his study regarding the relationship between violence, substance abuse, criminal victimization and rapid readmission, Boardman et al (1997) found out multiple actors that discouraged the care giving relatives from taking up criminal proceedings in such instances.

To begin with, it was indicated that relatives feared that their patient was likely to lead a devastating life in prison while she is awaiting trial. Further, the fact that the patient was likely to receive long term hospitalization in instances where she was found mentally unfit to stand trial made the relatives reluctant to pursue criminal proceedings. Finally, Burns and Fim (2002) found out that the police were always reluctant to press criminal charges in such instances and therefore the efforts could be fruitless. In his study undertaken in New York about the reasons for frequent readmissions, Gifford (2006) found out that five of the 60 patients with revolving door syndrome had spend close to five months in the institution because of violence. Haywood et al (2008) explains this by indicating that the care giving relatives often take hasty measures in incidences where the patient has previously portrayed violent behavior. In particular, they arrange for readmission as soon as the patient goes in to a relapse.

In order to address this Casper and Regan (1996) suggest that the public and especially the relative care givers need to liaise with community mental health providers. This would ensure that they are well acquainted with vital information regarding violence and mental health. In particular, they would be informed of timely and effective measures to manage such relapse and avoid readmission. In addition, they note that the criminal justice system also needs to be well informed about the implications of violence in this regard. Policy changes with respect to long term stay in mental institutions are likely to have a positive impact on the perception of the public about violence and mental health.

This study was limited by the involuntary nature of the respondents. In this regard, Gifford (2006) indicates that seeking the consent of the patient is important as it ensures that the information is given out of free will. Notably, this enhances the credibility of such information. With regard to the above study, it can be argued that the data collected was subjective in nature. Nevertheless, the fact that a significant number of respondents were employed implies that such mishaps were screened accordingly.

Implications of High Risk Behavior
Rapid readmission in mental health hospitals is also occasioned by manifestation of high risk behavior. This is all inclusive and it includes drug use and abuse and inappropriate sexual behavior that expose individuals to infections such as HIV. This then makes the mental health patients susceptible to readmissions. In his study in New York, Casper and Donaldson (2000) ascertained that high risk behavior has far reaching implications on the mental health patients with the profound being probability of frequent readmission in mental hospitals. The limitations of this study were that it was not gender representative as the researcher placed undue emphasis on the female segment of the society. Nevertheless Gifford (2006) indicates that the implications are transgender and therefore are applicable to all segments of the society.

With regard to vulnerability and susceptibility, Green (1998) points out that the vulnerable segment of the society is usually comprised of the elderly, women and persons that are intellectually and physically fragile. It is posited that they are frequently admitted because they are considered to be at risk and therefore require a considerable degree of protection from the society that they belong to. According to Carmel (2002), their vulnerability loading undermines their ability to protect themselves against societal ills and violence. Thus in most cases, they are victimized and suffer dire consequences.

Suicide attempts as a result of high risk behavior have also been identified as a major contributory factor to rapid readmissions in mental hospitals. In this regard, Fontanella, Bridge and Campo (2009) indicate that suicidal thoughts stem from the understanding and experience of the grave implications that are associated with high risk behaviors. In particular they ascertain that use and abuse of drugs causes suicidal thoughts in mental heath patients. In their survey in thirty three mental institutions across US, Fontanella et al (2009) found out that fifty two percent of the mental health patients were readmitted rapidly because of suicidal attempts. While some were associated with economic vulnerability, a significant 63 were attributed to risky behavior after discharge from hospital.

These presumptions were also affirmed by Geller (2000) who undertook a similar study in UK. His findings indicated that while a great percentage of the population believed that suicidal attempts by mental health patients were associated with their vulnerable status and the stigmatization from the society, some of them (54) were caused by the implications of high risk behavior. In particular, he indicated that the implications of the female patients being sexually andor physically assaulted because of their unstable mental status made them feel dejected and resort to suicide. In addition, this study affirmed that use and abuse of drugs was responsible for triggering suicidal thoughts in mental health patients and therefore prompting readmissions.

In order to counter this, Geller (2000) asserted that the stakeholders in community mental health need to complement their efforts towards enhancing care and protection of the mental health patients in the community. To achieve this, he indicated that the community needs to be educated about mental health. In addition patients need to spend sufficient time in institutions so that they can be informed about their vulnerability and how to manage the same. This according to Geller (2000) can only be attained if patients recover well before being discharged to mental health institutions. Notably, complete recovery also enables them to understand their status and avoid resistance.

Social Deprivation
Numerous studies of whom Hawthorne, Green and Lohr (1999) are represented ascertain that social indicators of deprivation contribute to an increase in readmission in mental institutions. They demonstrate that composite measures of social deprivation such as unemployment rates, Jarman Underprivileged Area Score and various other complex statistical models have successfully and accurately been employed in the past to determine the rate of readmission in psychiatric hospitals. Of great importance is the fact that this study ascertains that social deprivation influences re hospitalization in psychiatric institutions. This contention is also affirmed by Roy (1996) who asserts that particular indicators such as lack of a car as well as unemployment are predictive of readmission. Further, social derivation also contributes to relative disorders such as personality disorders, psychotic disorders and substance use and abuse. Notably, these compromise treatment and compliance to medication.

In this regard, Roy (1996) indicates that lack of sufficient economic resources makes individuals susceptible to mental illness. However, mental illness also contributes to economic deprivation. This according to him is well exemplified by schizophrenia patients that have been proved to be liable to downward social rift phenomenon. This twin relationship makes it difficult to identify specific causal factors that are responsible for increased readmissions. He employed a sample size of sixty psychiatric patients that were drawn from three different mental institutions. His findings indicated that almost half of the patients were unemployed. Of the thirty two male patients, twenty six were not married. In addition, the study found out that eighteen of the patients were homeless and did not leave any address for follow up. However, this study failed to provide a clear differentiation between first admissions and readmissions.

Further, Walling and Bishop (1996) attribute rapid readmissions to multiple intricate and augmenting factors. They used clinical information and records to ascertain that the nature of diagnosis, occupational status, previous episodes, multiple agency use and the number of previous re hospitalizations can be used to analyze the frequency of readmissions.  In order to attain optimal results, they asserted that they need to be prioritized in order of relevance to a patient and then employed in monitoring patients accordingly.

Care Pathways
In their review, Mahendran, Mythily and Chong (2005) ascertained that the rapid readmission of patients in psychiatric hospitals in the state of Georgia was attributed to poor coordination of vital services with regard to referral pathways between secondary specialists and primary healthcare. This study employed a sample population of three psychiatric institutions and was carried out over a period of two years. The results ascertained that in order to enhance quality services, the referral system between specialists and health care provides needs to be clarified. In particular, the study recommended that there is an urgent need to increase the specific referral systems to facilitate and increase the accessibility of psychiatric patients to an integrated and comprehensive system as well as to community- based healthcare provision.

This study was limited by its over reliance on informal reports provided by the patients and their relatives. Thus the accuracy of its conclusions can not be accredited. However, the fact that it employed more than one mental institution during its study shows that it captured the diversity required. In this regard, it is worth acknowledging that the contextual conditions of various mental institutions differ. As such, the quality of the services provided by such institutions also differs considerably. Notably, the study captured these differences and therefore, it can be ascertained that the conclusions are representative of the mental health institutions in Gorgia.

In his review, Kastrup (1997) contends that the mental health care givers as well as their clients are in most instances confused with regard to the correct and effective healthcare path way. In his partially qualitative review undertaken in rural Virginia, he indicated that most patients and care givers fail to understand the best approaches that can be used to treat the mental health disorder effectively. This according to this study is attributed to various factors that range from complexity of the disease to the equally complex mental health system in the country. The limitation of this study was that it employed a rural population. Thus its findings can not be applied in the urban context that comprises a host of mental health patients.

Further, a study conducted by Goodpastor and Hare (2002) in New York ascertains that the multicultural and relatively complex emergent economic factors make it difficult for the mental health care givers to figure out the specific cause of the disease and take timely and effective intervention measures. They employed a sample of fifty mental health patients that were drawn from a diverse background with respect to social, racial, cultural and economic wellbeing.

Apart from the economic and environmental factors, this study found out that cultural indifference and in particular language highly compromised the quality of mental heath services. In this regard, they showed that differences in language made it difficult for minority patients to follow the Doctors instructions and prescriptions accordingly. Thus they failed to adhere to the medication instructions which led to rapid readmission. This was further compounded by the complex nature of the mental health system in the country. To counter this they suggest that there is need to ensure that the health care pathways are well defined.

Lack of insight, knowledge and Acceptance of the Psychiatric Condition
Prince (2009) indicates that insight, knowledge and acceptance of the mental situation of the patient need to occur at a macro level. In particular, the patient, household and general neighborhood should understand and appreciate the situation. In their study that sought to underscore the implications of stigmatization to mental patients in Illinois and the relationship of the same with rapid readmission, Mueller, Carlos and Wulf (2005) found out that stigmatization contributed significantly to denial of the mental illness by the patient and resistance to medication. This was further compounded by the adverse effects of mental illness to the wellbeing of the patients. In this respect, it is indicated that the judgment of such patients is often impaired and this makes it difficult for them to understand and accept their status. This undermines the treatment and rehabilitation efforts.

Further, Mueller et al (2005) noted that stigmatization was more pronounced amongst the members of the public than amongst patients. This according to him made it difficult for the patients to cope with ease after being discharged from mental hospitals. Of great importance to this study is the indication that stigmatization contributes to social seclusion and compromises the process of recovery.
In a follow up study by Dalrymple and Fata (2003) in New York concerning the effectiveness of community based care, findings showed that most mental health patients cease taking their medication once they leave the hospital. Basically, they believe that they have recovered fully and the illness is unlikely to recur. This then culminates in noncompliance to medication and frequent readmission. This study was qualitative in nature and it employed ten revolving door patients in the psychiatric unit. The nurse of this institution contended that the period of hospitalization is short as the patient leaves as soon as she starts stabilizing.

At this point, the patient may not have recovered enough to participate actively in the treatment plan and she may be unreceptive of any knowledge or insight. Also, the relatively short period of hospitalization does not provide sufficient time to explain to the patients the implications and management of the mental illness. The limitation of this stud was that it focused on one mental facility.

Psychiatric Disorders
In their study about the predictors of readmission amongst children and youths, Lyons, Uziel-Miller and Reyes (2000) cited psychiatric disorders to be one of the strongest predictors of rapid readmission in mental health hospitals. He observed that children that are frequently readmitted suffer from depressive disorders. Notably, these findings complemented Bladers observations that indicated the youth with depressive disorders were more likely to be rapidly readmitted in mental hospitals than their counterparts (Blader, 2004). In addition, the study found out that mental health youths who exhibited oppositional deviant behavior were frequently admitted. This study was compromised by different factors. To begin with, it entirely focused on a Caucasian sample. Then, it also relied on informal information from the relatives of the children. Accuracy of such information was not assured. However, it presented useful insights regarding the contribution of psychiatric disorders to frequent re hospitalization. It recommended that in order to yield optimal results, mental treatment in children and adolescents needs to treat the related behavioral disorders too.

Another study conducted by Anderson and Estle (1999) regarding factors influencing rapid readmission in psychiatric hospitals amongst the elderly indicated that secondary medical conditions have limited influence on re hospitalization. It employed a sample population of one hundred and fifty elderly patients that had been identified to have revolving door syndrome. In particular, the study analyzed the influence of cardiac diseases and diabetes on rapid re hospitalization. This study had a limitation of primarily depending on clinical records for data. Thus the credibility was undermined by its employment of secondary, rather than primary data. However, the fact that the data captured differences in racial and economic status of the patients enhanced its applicability to a diverse population.

Challenges Facing Community Based Institutions
The ineffectiveness of community healthcare has been blamed by Foster (2002) for the increasing incidences of rapid readmissions. Usually, patients that do not find sustainable care in the community institutions tend to deteriorate with time. He shows that in order to provide sustainable services to the affected population, community mental health institutions need to be expanded. It is because the number of mental health patients being discharged from the hospitals has increased in the recent past. At this juncture, it is worth noting that deinstitutionalization sought to transfer the resources from a central point to community services. As such, they need to be utilized accordingly.

In his study that sought to determine the quality of resources in mental health institutions, Foster (2002), noted that insufficient bed capacity contributed to frequent re hospitalization of mental health patients. This study found out that this situation led to early discharge of mental patients before they attained stability. This was influenced by the increased number of mental health patients. In addition, he found out that lack of vital resources in community health institutions contributed to a large turnover in the same. This study ascertained that the quality of the infrastructure that is found in secondary healthcare institutions is far much better than that employed at primary level. It recommended that in order to enhance service delivery, there is need to provide sufficient resources in mental health institutions. The main limitation of this study was that it was conducted in a single state. Nationwide application was therefore undermined in this respect.

Lack of sufficient staff was also identified to be a contributory factor to frequent and rapid readmission. In this regard, Foster (2002) found out that limited hospital staff does not allow that patients to undergo effective treatment. In Particular, he noted that the level of counseling, community support to the families and relatives and quality of psycho education was very low. In this respect, Carmel (2002) indicates that according counseling and psycho education sufficient time was instrumental in avoiding readmissions. In order to counter this situation and provide quality mental services to the population, Foster (2002) suggested that there is need for the government to reconsider distribution of resources and ensure that all mental services are equipped with sufficient resources.

Diathesis-stress Model
This denotes that every individual has a certain level of vulnerability and susceptibility (diathesis) that makes the same liable to developing a mental disorder (Scher, Rick  Zindel, 2005). Nevertheless, this model presumes that persons have their own individual points at which they develop the disorder. This is entirely influenced by the interaction between the level of stress being experienced by the individual and the degree of the risk factors.

In their review of related theories, Scott and Anne (1991) cite the model to be instrumental in determining the persons that are likely to develop disorders because it solely addresses the interaction between situational stressors and pre morbid risk factors. The risk factors that have been widely studied entail mental illness or family history of drug use and abuse, personal psychological factors like impulsivity or hostility, environmental characteristics like low socioeconomic status and biological factors. Stress in this regard refers to experiences and events that trigger psychological distress (Scher et al., 2005). It has negative implications on the vital body mechanisms that enhance the cognitive, physical and emotional stability of an individual.

As indicated earlier, this model implies that if a person is highly susceptible, a relatively low degree of stress is required for the person to fall ill and vice versa. It shows that determination of a persons stress and vulnerability is fundamental in ascertaining the probability of the person falling ill or the illness reoccurring. Thus the model is imperative for preventing the occurrence of illness. It is because timely intervention measures that target individuals that have the highest risk of developing negative health implications can be undertaken accordingly. A classic example in this regard would include psychological interventions that are taken to ensure that an individual at risk responds to stressful situations with ease.

The model is perceived important in explaining the occurrences of mental and behavioral disorders. In this respect, Scott and Anne (1991) indicate that previously, it has been employed in underscoring the relationship between environmental and hereditary factors that contribute to mental illnesses such as schizophrenia. Further, it has been beneficial in stimulating relevant research in mental health. In particular, it is indicated that it has enhanced research and treatment of mental disorders. Most importantly, it has been employed in mitigating stress and therefore preventing the pronunciation of diathesis through development of viable protective factors. The most common protective factors that have been put forth by Scott and Anne (1991) include skill building, rigorous psychopharmacology and development of effective support systems for the affected individuals.

The model has also been beneficial to the care takers and families of mental health patients. In this respect, Scott and Anne (1991) indicate that it enables the close associates of these individuals to determine periods when the patients are vulnerable, examine the stressors leading to such experiences and employ protective factors in helping the person cope with the experience effectively. Utilization of this profile has enhanced humane, efficient and effective treatment interventions.

Current Thinking on Modifiable Risk Factors
From the preceding analysis, it is certain that modifiable risk factors inhibit treatment and prevention of mental health illnesses. In deed, the implication of these factors to effective prevention, intervention and treatment of mental illness can not be overlooked. While Carmel (2002) points out that frequent readmission are effective in enhancing the treatment and ultimate recovery of mental heath patients, it is worth acknowledging that modifiable risk factors compromise the overall quality of mental health service.

In their review, Stanley, Kutcher and Magdalena (2005) indicate that not only do these factors undermine recovery, but they also lead to waste of resources that could have otherwise been employed for other purposes. This is even more important at this time when there is increased pressure on the mental health resources. For instance, it can not be disputed that preventing readmission of one patient in this respect would enable new patients to access the same. This according to Stanley et al (2005) is vital in enhancing early interventions and ensuring that appropriate measures are undertaken to prevent severity of the disease.

Further, Delaney and Fogg (2007), cite that addressing modifiable risk factors would be instrumental in reducing the risk of the persons suffering from mental health illness. This presumption is deduced from the Diathesis-stress model conception. Notably, modifiable risk factors are stressors. As such, they increase the vulnerability of persons at risk. Considering that this school of thought believes that biological factors can not be detrimental and are relatively manageable without the stress, it therefore follows that elimination of such stress would reduce the vulnerability of individuals of suffering from mental illness.

Further, Fontanella et al (2009) indicates that modifiable risk factors can not be effectively addressed without the intervention measures from the mental health providers. Generally, mental health practitioners are very resourceful and their knowledge is very instrumental in providing the right direction for the any action. In this regard, Foster (2002) argues that the information provided by these personnel is based upon factual analysis of the mental health status of the patients. As such, he recommends that they should not be eliminated from the cycle at all costs.

At this point in time, it should be acknowledged that the efforts of every stakeholder are imperative in addressing the modifiable risk factors. Major stakeholders in this respect entail the patients, mental health providers and the government (Nelson, Maruish  Axler, 2000). Patients are charged with the responsibility of abstaining from activities that are likely to have adverse implications on their health and cooperating with the mental health providers by following medical instructions accordingly.
The mental health providers on the other hand provide technical support to the patients. In particular, they are responsible for providing vital information regarding the management of the disease to the patients. This is achieved through clear instructions and effective counseling. Further, they provide timely preventive and curative interventions to the patients. Of great importance is their role of making follow up to ensure strict adherence to medical instructions by the patients.

Finally, the government and relevant policy makers are expected to avail vital resources to the mental health department. These range from sufficient infrastructure in both primary and secondary mental health institutions to adequate human resource and facilities. In addition, Roy (1996) indicates that there is need to ensure that the mental health facilities are distributed equally across the nation. This would enable all segments of the population to have access to these vital services. Notably, failure of each one of the stakeholders to play his or her role is likely to compromise the quality of services and compromise the effort towards addressing modifiable risk factors.

In his viewpoint, Geller (2000) notes that the scientific effectiveness of the interventions that seek to address the modifiable risk factors is yet to be established. In this respect, he indicates that a great percentage of the research undertaken has been compounded by complexities that are related to the short duration of analysis, non randomization of interventions, use of inadequate sample sizes and employment of surrogate outcome measures. Thus to ascertain the effectiveness of the intervention measures, there is need to undertake consistent and credible research in this regard.

Furthermore, Kastrup (1997) shows that the ineffectiveness of the intervention measures is exemplified through the increase in the mental health patients in the recent past. This trend has continued irrespective of the fact that the intervention measures have been implemented in the past. To counter this, Geller (2000) recommends that prevention strategies need to be delivered based on available evidence of their effectiveness Otherwise, parents, educators, health providers and politicians are likely to continue investing in these programs that are either ineffective or harmful to the general public.

Conclusion
From the review, it is certain that the US mental health department has continuously failed to cater for the emergent needs of the mental health patients. This has been ascertained by the present trends that indicate that the sector is accorded minimal attention. Conventionally, deinstitutionalization was aimed at providing the mental health patients with a viable environment for recovery. Notably, this has not been achieved because of lack of sufficient resources and social stigmatization. Of great reference are the modifiable risk factors that undermine the effectiveness of the entire system.

At this juncture, it is important to acknowledge that modifiable risk factors remain a major setback in enhancing the provision of mental health to the US population. Severity of the illness, a history of hospitalization, substance use and abuse, fragmented pathways and lack of sufficient resources amongst others have been cited to undermine the quality of mental heath services in various ways. This is further compounded by the existence of a fragmented institutional framework and policies that are sectoral in nature. In addition, the complex nature of the mental health system makes it difficult for the minority patients to access quality care. Essentially, modifiable risk factors are a source of stress that increases the vulnerability of the population to mental illness. As such, sustainable measures need to ensure that preventive and effective intervention measures are used to prevent the occurrence of the mental illnesses.

In this regard, consistent, comprehensive and credible research needs to be undertaken. This is because of the fact that previous researches have had numerous inadequacies. This explains why previous intervention measures have been fruitless. Seemingly, the problem is not insurmountable. The challenge to attaining a sustainable solution is in mobilizing and marshalling the necessary will, political or otherwise to address the issues accordingly. As the current thinking about the modifiable risk factors ascertains, this can be achieved through partnerships and relevant collaborations between major stakeholders in the mental health sector. Efforts by individual stakeholders need to complement each other in order to come up with viable and lasting solutions to addressing modifiable risk actors and enhancing the quality of life of mental health patients.

Leadership Styles

The paper seeks to identify the writers predominant leadership style. The Situational Leadership theory is discussed. The paper evaluates the situations, in which the dominant leadership style works to the best of the leader and the organization. The recommendations for maximizing the benefits of the leadership style are provided.

Leadership style is the critical component of any organizations success, and it is important that leaders are able to identify and apply their leadership style to maximize their efforts and to improve the quality of interactions between followers. The current leadership theory differentiates between the four different styles  delegating, participating, selling and telling. Although they are never or rarely represented in pure form, it is easy and even desirable to identify the dominating leadership style to which a leader keeps in his daily performance. In the discussed case, participating style was identified as the basic way of taking leadership decisions  the style, which implies that in the major, if not all decisions, the leader engages team members in the discussion of what should be done but takes the final decision himself. However, that participating style promotes participation and empowers team members does not mean that it is equally applicable and useful in all business situations.

To make sure that this leadership style works to the best of the organization, leaders should know the situations when this style is the most appropriate. The Situational Leadership Theory identifies the situations, which are the best for each particular leadership style. In terms of participation, leaders will increase the overall efficiency of their decisions if applied to the situations with low level task behavior and high levels of relationship and support between team members and between them and their leader. In such situations, participating leadership style will work the best because it promotes open discussion and knowledge sharing, and enhances team members desire to perform.

It should be noted, that participating leadership style alone cannot promote the quality and efficiency of all organizational decisions. I would advice that participating leaders are able to balance their desire for participation with the desire to be directive and even selling telling, whenever each particular situation requires being this way. The extent, to which a participating leader is able to maximize his effort, depends on whether he is able to identify the situations when participation is necessary, and to restrain from participation when it goes against the major organizations objectives.

Topic Effective Leadership

Effective leadership is the process of successfully guiding organizational goals by utilizing available resources. This paper analyses the characteristics of my leader and explains the approach used in this case.

I work in a childrens welfare and a leader in my organization would be my supervisor because she has been with the company for 25 years and she is very smart. My supervisor has helped greatly in the achievement of organizational goals through guiding the marketing She has achieved this through a combination her individual characteristics. Enhanced organizational abilities are one of the characteristics identifiable with my supervisor (Martin, 2007). This supervisor has managed to steer the management team by ensuring that all assignments pertaining to children affairs are completed in time by matching each team members individual strengths to the task. Besides the supervisor guiding the team, she has also succeeded in integrating the team to the top leadership in the children welfare organization hence enhancing efficiency. The supervisor has strong decision-making skills. She uses this ability quite often in successfully help in achieving team goals. She motivates the team members by giving rewards for good work while discouraging poor performance (Theodore, 2002). This has led to an improvement in performance for the all team leading to achievement of targets. This approach of analyzing effectiveness is the best to use in this case. It is an approach based on personal traits and individual characteristics. The reason for using this approach is due to the nature of effective leadership, which is a social art and science that maximizes the utilization of organizational resources to achieve set goal.

Conclusion
Effective leadership plays a big role in enabling organizations to achieve their objectives. Leadership is a social skill and therefore the analysis of individual characteristics can provide a basis for the measurement of effectiveness. Employers should therefore use this approach in determining the effectiveness of their staff in achieving organizational goals.

Verbal learning

Verbal learning is a field or discipline in experimental psychology that involves the study of particular verbal associations as well as acquisition of the associations. It is getting hold of verbal information and retaining it. It can be referred to as memorization in daily terms. There have been studies about how people acquire knowledge through connecting or associating things that are repeatedly occurring closely together in a given time. Verbal learning consists of primarily two undertakings which are serial learning and paired-associate learning. Serial learning is learning to reproduce the articles or items in a certain list in their original and exact order such as learning the letters of an alphabet. On the other hand, paired-associate learning involves learning in order to make or create a verbal response upon the presence of a particular stimulus like learning a unfamiliar language vocabulary wherein the stimulus would be the foreign term and the response is the English word. Associations are ultimately formed by means of conditioning. Both serial and paired-associate learning go hand in hand and is simply like memorizing a password or mnemonics.

Mnemonics are techniques or devices, such as a rhyme or an image, that serve to enhance the storage and the recall of information contained in memory (Solso, 1995). Mnemonics may be visual or verbal in nature. There are different kinds of verbal mnemonics coding, first-letter, and story method. Coding mnemonics are best for memorizing figures or numbers while first-letter mnemonics are best effective when learning an order of learned information. Story method on the other hand is best used in learning lists effectively. Some of the most well-known verbal mnemonics include the SOHCAHTOA which stands for Sine, Cosine, Tangent, the three trigonometric functions.

Adolescence and Adulthood Developmental Stages Worksheet

Adolescence is a stage in a persons life between puberty and adulthood. The stage usually falls between the ages of 10 to the early 20s. The children become young adults. It involves maturity in both social and physical aspects of an individual thus making them to become sexually mature and socially independent. This stage also involves them starting to develop a sense of who they are and they tend to learn more from people outside their families.

Major milestones related to the physical development in adolescence
The physical growth and development during adolescence includes both an increase in body size and also sexual maturation which is usually referred to as puberty. How fast these changes occur to a person varies from one person to another and is usually affected by both the environment and heredity factors. During the adolescence, the boys and girls reach their average adult weight and height. In the boys, the growth spurt usually occurs between the ages of 12 to 17 years. They also grow about 4 inches (ten centimeters) during the year of maximum growth.

The growth spurt in girls usually occurs faster and early which is usually between the ages of 912 and 1412. They on the other hand grow to around 9 centimeters in height during their maximum growth year. In other words, the boys tend to become taller and heavier than girls. By the age of 18, the boys usually have two centimeters of growth left while the girls having slightly less. The specific physical milestone for the boys includes  the changes in voice meaning that the voice becomes deeper and husky, this occurs between the age of 1012 and 18 years growth of the scrotum and testes between the ages of 1012 and 18 years this is followed by the lengthening of the penis between 11 and 15 years public hair growth then follows between 11 and 14 years. At this point in time, the adolescent has reached his peak growth spurt. It is then followed by minor changes in body shape and finally the growth in facial hair between the ages of 13 to 18 years.

In the adolescence, girls milestones includes breast budding between 8-13 years growth of pubic hair between 8-14 years which signifies the peak of their growth spurt other changes are that they start to experience their first period (menarche) between 10-16 years then the growth of underarm hair between 912- 1612 followed by changes in body shape at around 1512 years and they finally develop adult size breasts between 16-17 years.

Major milestones related to the cognitive development in adolescence
Cognitive development is sometimes referred to as mental or intellectual development. Cognitive activities include perception, thinking, and reasoning, problem solving ability, concept development and abstract thinking. One of the most important and complicated cognitive activities is language development. During adolescence the precursors to formal operational thinking develops well and includes a limited ability to think hypothetically and also making multiple perspectives. During the middle and late years in the adolescent stage, the formal operational thinking becomes well developed and it is integrated in a significant and major percentage of their lives. The adolescents long-term knowledge base continues to expand they also develop more complex rules for solving problems and become less self-conscious and focused in addition, they become better in their day to day lives in terms of planning and decision making they are also able to evaluate vocational options in terms of their interests, values and abilities.

During the late adolescence stage, they develop the ability to narrow their vocational options and settle on specific careers.

Major milestones related to the physical development in early, middle, and late adulthood
Early adulthood ranges from 20 years to early 40 years. In these ages, there are several physical milestones that are usually visible. They include some gain in height and body muscle and fat which is the peak of their strength, energy and endurance the brain also grows in size during this stage although there are no new neurons that are formed at this stage by the mid 20s, the body functions are usually fully developed including the sharpest senses.

In the middle adulthood the physical developmental milestones depicts much decline compared to other early stages some of it attributes include the ability to focus declines and in some cases they loose their near vision abilities and hence need more brightness. Their sensory and motor functioning reduces with a loss in the ability to hear high pitched sounds. Their reaction time slows, especially for motor responses. Their general physical strengths also start to decline.

The physical changes during late adulthood include mostly more problems for people in this stage some of the milestones include an almost total decline in taste, vision and even smell they also lose their ability to detect pain or even notice temperature change. These declines usually develop gradually and become more pronounced in late 70s plus. Other physical attributes include rising blood pressure, neural loss, declining lung capacity and a change is sexuality is also evident. Most of these changes are inevitable though they vary according to individuals.

Major milestones related to the cognitive development in early, middle, and late adulthood
The cognitive development in young adults involves many things that tend to make people in this stage to have high mental and intellectual abilities. In this stage, these young adults are able to apply their intelligence in situations that have profound consequences in the process of achieving long-term goals like the ones that involve careers. This stage also includes the mastering of cognitive skills that one needs to monitor hisher own behavior. They will also acquire a considerable amount of independence in this stage.

Cognitive development in middle adulthood is usually multidirectional, meaning that there are gains in some areas and losses in others. On the declining side are the ability to apply mental powers to new problems there is also a decline in the way people perceive formal concepts, relationships, and drawing inferences. These declines in mental activity are usually attributed to changes in the brain. These changes also affect the ability to remember and use information acquired over a lifetime. On the gaining part is that they are able to reconcile or choose among conflicting views, thesis and antithesis.

In the late adulthood, one tends to experience a decline in all the primary mental abilities. For instance, in the sensory register, they experience a small decline in ones brain power and sensitivity though this varies with individuals. The working memory whose main role is to store unconscious information is noticeably decreased as this makes processing of information to take a longer time.

Socio- emotional development in adolescence
The brain regions that control emotions tend to develop and mature during adolescence. This period that is characterized by emotional outbursts can prove to be quite challenging for the parents and also teachers. Adolescents however learn how to suppress inappropriate thoughts and actions and replace them with goal-oriented ones.

In this stage, the adolescent also develops a sense of self in relationships to other people and their own internal thoughts and desires. Though opposite sex interactions are frequent in late-childhood, they usually increase during the adolescence stage. This is mainly due to the coming out of romantic attraction, which is both a biological as well as societal standards product. Adolescence dating can be a source of intimacy, heightened self esteem, expanded social competency and also peer status. On the negative side, it can be a source of abuse, jealousy and damage to self esteem if not monitored accordingly. Adolescents also desire autonomy meaning separation from parents and becoming independent adults. Such desires can lead to plenty of family conflicts and defiant characteristics leading to what psychologists refer to as psychological storm.

Major milestones related to the socio-emotional development in early, middle, and late adulthood
Socio-emotional milestones related to early adulthood include the ability to give and receive love a person begins to make long-term commitments to relationships. People in this stage also discover the importance of romantic relationships and individuation since this is what leads to marriage. Their relationships in this stage are mostly influenced on how their parent and peers interacted with one another. For instance, securely attached children are most likely to become securely attached with their spouses in this stage. In addition to that, past experiences also influence their parental behavior.
In the middle and old adulthood stage, the individuals tend to develop interest in guiding the development of the next generation. In the late adulthood, an individual develops a sense of acceptance of life as it was lived and the importance of the people and relationships that individuals develop over a lifespan.

In the Erikssons Stage of Generativity versus Stagnation theory, Eriksson insists that if one has a strong sense of creativity, success and having to leave a mark in life, one needs to develop the act of generativity, meaning that they need to concentrate on the next generation by caring about them and acting as a link for the generations to come and give love without any expectation of a specific return. On the other hand, adults who develop a sense of stagnation, become self absorbed and hence feel little connection to others as they generally offer little or none to the society. It is important to note that too much stagnation can lead people developing a sense of rejectivity and  too much generativity can lead to overextension which means people have no time for themselves simply because they are too busy dealing with other peoples issues.

What is language and lexicon

Language can be defined as a particular and a more specific system of decoding and encoding information. It can also be defined as a means of communicating which entails the use of conventional symbols and sounds. The term language has also been used severally to denote or refer to the natural languages which characterize the most common means of communication which is highly considered peculiar among human beings. Language is thus defined as the process of communicating feelings and thoughts through an arbitrary system of making signals such as gestures, voice, sounds and the use of written symbols (Hattiangagi, 1997).  On the other hand lexicon can be defined as the connection between a language and the knowledge expressed in that language. Different languages have different vocabularies and lexicon gives a way of combining this collection of words to express an unrestricted range of concepts.

Every kind of language has its own unique set of vocabularies and yet it has a full set of grammatical mechanisms which are used in combining its varied stock of words in various ways to express a broad spectrum of an open ended range of ideas and concepts.

The study of language, its features and structure can and has been addressed in different numerous disciplines such as in education, anthropology, neurolinguistics and philosophy (Brian, 1999).

However, the very fundamental and highly influential studies in the study of language originate from psycholinguistics and linguistics. Human beings are believed to be one among the very most supreme creatures with an exemplary capability of developing and acquiring language, an aspect which is highly necessitated by the existence of high levels of intelligence and reasoning and most probably well developed structure of the vocal tract and voice box.

It is therefore very evident that animals also have their very own unique ways of communicating. For example, whales communicate by singing while bees on the other hand tail wag. However, there are very divergent and diverse differences which characterize and distinguish human communication from other creatures (Robinson, 2001). Numerous features do exist which appear to be common and characterize all human languages which have been proposed. Some of these unique features of language include

Displacement  is a common feature of language which refers to the ability of an individual to speak not only about what is happening at that given period of time  and place but  also the ability to refer to other situations either past or future unreal or real. Displacement refers to the ability to mentally reflect on issues either of the past or future and talk about them even without watching or observing them at present.

Arbitrariness  This is another common feature of language which denotes that there exist no natural connection among sound, word and the thing it denotes.  This is to say, in general language or communication it is difficult to tell the real meaning of a word by simply just looking at it (Wettstein, 2004). Thus, in order to be in a position to understand arbitrary words in a given language one must have mastery of a specific language. However, in various languages there exist several iconic symbols which can be understood or mastered without entirely having to master the entire language.
Productivity  Productivity is a common language feature which is also referred to as creativity or open endedness. Productivity explains that the existence of a potential number of utterances, words as well as the meanings in human language is definitely infinite. For example, human beings can create words such as property in Cyprus, my space codes and the like but the number of these particular terms may have no limit in any given communication. In all animal communication all signal produced have fixed references which explain that one signal can only stand for one idea at time and its meaning cannot by any chance be broadened.

Cultural transmission  Although each and every individual is born with a fixed set of genetic predispositions for language use, that is the nature and shape of our vocal tracts, cultural transmissions explains that this virtue does not rule out and determine the kind of language we are going to acquire or achieve as our mother tongue. For example, a British child brought up in china and raised up by a Chinese family is bound to speak Chinese and not English (Collinge, 1990). Cultural orientations greatly influence and shape language acquisition patterns in human beings especially during the formative early childhood years.

The process of language comprehension and more so language processing is enormously a complicated task usually characterized by quite unique features.  Psycholinguistic studies do recognize four unique levels of language structures and processing. That is sound, syntax, pragmatics and meaning. First and foremost psycholinguistic studies put much emphasis on the importance and significance of sound or rather phonetics and phonology as the central most points of focus in language processing (Romaine, 2001). Sound production and especially articulation of phonetics and the perception of the so called acoustic phonetics is usually the vocal point in language processing and acquisition process.

Thus, phonology which forms the very first level of language structure and processing is mainly concerned with describing the process used in combining sounds to form or create permissible sequences. The most important reason for acquiring congruent knowledge of phonological rules is basically vested towards creating help or assistance in the process of segmenting spoken language.
Meaning or rather semantics and morphology form the second most important level of language structure and processing. Semantics in this case is concerned with the relationships which exist between the meanings in the lexicon, commonly known as lexical semantics. Therefore, in this case the most import focus and area of study is centered at the sentence level which entails studying and describing the meaning of different relationships commonly expressed in the entire sentence through examining the relationship between its own words (Stone, et al, 2004). Morphology on the extreme contrast puts much emphasis on the study of structure of words. Morphemes thus form the smallest units of word structure in any given sentence.

Syntax and the study of syntax form another very import level in language structure and processing. This is the third most crucial level which is concerned with the process of explaining and defining the structure of grammatically acceptable and correct sentences. Linguistics strongly believe that different native speakers of different languages possess tacit knowledge and competences in language which they might not always be aware of (Michael, 2001). In an attempt towards defining and describing phrases and phrase structure, experts and researchers have devised a set of rule system which involves the organization of noun phrases, prepositions and verbs known as phrase structure and this forms the very last crucial level of language structure and processing known as pragmatics, which is concerned with rules and principles in language acquisition and articulation.

Cognitive psychology is defined as the scientific investigation of cognition in human beings which encompasses all our diverse mental capabilities such as learning, perceiving, remembering, reasoning, thinking and understanding. Language processing in cognitive psychology plays a very significant role which helps in coding of information, decoding, interpretation and retrieval of information from memory (Moats, Foorman, 2003). Language processing is entirely significant in interpretation of signals as information is coded in memory. Thus, internal mental process can highly be understood and described in terms of the algorithms and rules as those observed in the information processing model. This makes it easier to even understand the basic functions of the mind.

Drugs and Neurotransmitters

Neurotransmitters are chemicals that permit the signal transmission from a neuron across a synapse. The neurotransmitters can also be found in the axon endings of the motor neurons and they stimulate the effects of the fibers of the muscles. There are also certain neurotransmitters that are produced by glands, such as the adrenal and the pituitary glands. The neurotransmitters are stored in the bulbous end of the nerve cell which is also called the axon and when an electric impulse that is traveling along those nerves gets to the axon, the neurotransmitter is released making it to travel across synapse and in the process, it may prompt or inhibit the continuation of electrical impulses along the nerves. Their main work is to transmit information within the brain and from it to all the body parts. This paper will look at the effects of drugs on neurotransmitters and it will look at scholarly articles in science journals and the way they have tackled the topic.

Neurotransmitters are chemicals that permit the signal transmission from a neuron across a synapse. The neurotransmitters can also be found in the axon endings of the motor neurons and they stimulate the effects of the fibers of the muscles. There are also some that are produced by glands like the adrenal and the pituitary glands. The neurotransmitters are stored in the bulbous end of the nerve cell which is also called the axon, and when an electric impulse that is traveling along those nerves gets to the axon, the neurotransmitter is released making it to travel across synapse and in the process, it may prompt or inhibit the continuation of electrical impulses along the nerves. Their main work is to transmit information within the brain and from it to all the body parts. There are almost three hundred neurotransmitters in the human body. The first neurotransmitter to be discovered was the acetylcholine which is responsible for muscle stimulation, especially, in the gastrointestinal system. It is also found in the neurons whose work is to sense and the autonomic nervous system. It plays a part in the sleep and dreaming. 

The other major neurotransmitter is the Norepinephrine that is commonly known as noradrenalin and is very much associated with alertness of the nervous system. It is commonly found in the sympathetic nervous system and it normally increases the heart rate and the blood pressure. It is also an important part of the formation of memory. Related to the aforementioned neurotransmitters is the dopamine which is the main inhibitory neurotransmitter in the brain. It works by finding its way to the neuroreceptor and blocks the firing tendencies of the neurons. The other common neurotransmitter is the GABA (Gamma Amino butyric Acid) which is also an inhibitory neurotransmitter acting like a brake to the excited neurotransmitters that cause anxiety. The most common neurotransmitter in the CNS is called glutamate and it is of great importance to the memory functions of the brain. It is somehow toxic to neurons and when it is in excess proportions, it tends to kill them. The most important inhibitory neurotransmitter is the serotonin and it is involved in various emotions like mood and aggression. The last of the chief neurotransmitters in the body is the endorphin which has the structure of drugs like opium, morphine and heroine and its inhibitory functions involve reduction of pain and creation of pleasure.  It is also the neurotransmitter that allows animals to hibernate by slowing the heart rate, respiration and metabolism rates. 

Article 1
Drug and neurotransmitter receptors in the brain by SH Snyder 
(in the Science magazine copyrighted by Association for the Advancement of Science
Identification of the Topic in the article)
This article is about the biochemical investigation of the neurotransmitters and the use of drugs and the impact on the brain which has been one of the most studied arenas of the molecular neuroscience in the last ten years. The article looks at how the binding of the neurotransmitters to their receptors is affected by the use of drugs which in most cases inhibits or excites the firing of neurons or changes the process of cellular metabolism. In the article, there is an emphasis on how each category or type of drugs affects a particular neurotransmitter and the health effects that are accompanied by the impacts of the drugs on the performance of the neurotransmitters. Finally, the article looks at the process of measuring receptors in a way that distinguishes between the antagonists and agonists which the article proposes that it can be used to provide useful probes that can be placed on the programs for drug discovery. 

Findings of the article
The article is focused on the impact of drugs on the selected neurotransmitters and on health. To start with, drugs that are absorbed by human beings from plants, which are normally referred to as plan poisons block the functions of the acetylcholine site receptors of the muscle cells and this is one of the major causes of paralysis (Snyder, 2009). One of the drug poisons is called botulin which prevents the axon vesicles endings from discharging the acetylcholine which makes people to become paralyzed. Related to botulin is a derivative called botox that is a drug used by people to eliminate wrinkles. This leads to massive loss of this neurotransmitter in the nervous system and this loss of acetylcholine is the major cause of the Alzheimers disease and hence, senility. 

The second finding documented by the article is the role of dopamine and the reward mechanism in the brain and it was found out that drugs like alcohol, cocaine, opium and heroin increases the levels of dopamine in the brain creating a feel good complex. The continued use of these drugs increases the production of dopamine whose extremely excess levels in the body causes schizophrenia especially when the dopamine is concentrated in the frontal lobes. Schizophrenics are treated with medical drugs that block the production of dopamine but on the flipside, the over consumption of this drugs can lead to severe reduction of dopamine and this will lead to Parkinsons disease.  The third finding that the article made is that alcohol and the drugs that fall under barbiturates influence the neurotransmitter called GABA by blocking its production. Little amounts of GABA in the brain leads to anxiety disorders because GABA is an inhibitor that breaks the action of the excitatory neurotransmitters that influence anxiety. Consumption of drugs like valium may affect the production of glutamate and this can cause stroke. Valium influences the glutamate receptors which cause brain damage due to the death of brain cells and this is one of the major causes of stroke. Other drugs that are responsible for influencing or inhibiting the production of glutamate include nicotine, alcohol and opium. On the other hand, over consumption of medical drugs that are supposed to help in the production of glutamate may cause excessive glutamate production in the body which on the flipside may cause the Lou Gehrigs disease and many other diseases that affect the CNS. 

There are many drugs that affect the production of serotonin. If there is too little serotonin in the body, a person may become emotionally unstable leading to depressions, temperament, aggression, ADHD, obsession compulsive disorders and even suicide. According to the article, lack of serotonin or too little of it leads to increases craving for carbohydrates and this causes emotional disorders, migraines, irritability of the bowel and a deadly condition called fibromyalgia. Alcohol, heroin and nicotine are some of the drugs that cause low secretion of serotonin while Prozac and caffeine increase the level of serotonin. Interestingly, milk especially when warm also increases levels of serotonin and that is why milk has been used even in the past to cool down people with emotional disorders. According to the article, serotonin is a derivative of one component of milk called tryotophan. Hallucinogens such as ecstasy, LSD, psilocybin and mescaline attach serotonin to sites of reception and may block perceptual pathways transmissions because serotonin also plays a big role in perception in animals.

Knowledge, Insights and Skills gained from the article
There are many things that were gained from this article, especially, about the consumption of drugs and their effects on neurotransmitters. One insight is that consumption of alcohol affects almost all of the chief neurotransmitters in the brain in an adverse way meaning that alcohol can be one of the major causes of the diseases that affect the central nervous system. This is because it either inhibits the work of neurotransmitters or excites others whose excess quantities may be disastrous. The other skill gained is that neurotransmitters work when they are in moderate quantities. Low production of neurotransmitters due to inhibition by drugs can cause serious diseases and the same applies to overproduction. This means that consumption of drugs may lead to overproduction of neurotransmitters and to bring the levels of those neurotransmitters down, one has to take medical drugs, which if they are consumed can bring the levels down to dangerous proportions.

Article 2
Effect of nicotine on behavior mediated via monoamine neurotransmitters and Modulation of neurotransmitters in mice brains by an anticonvulsant principle from cuttle bone from the Indian journal of pharmacology.

Description of the article
This article is a research report after a study was conducted to determine the effect of nicotine on mannerisms on behavior that was mediated through a monoamine neurotransmitter and the modulation of neurotransmitters in brains where mice were used as subjects. This followed an anticonvulsant principle from the bone of the cuttle. The research method used studied the effects of nicotine after intraperitoneal administration was conducted.

There was an observation of the effect of dopamine on the mediated behavior and also the effect of the amphetamine on stereotyped behavior and the sensitivity of alcohol withdrawn subject to some inhibitory compounds that induce catalepsy. The effect of lithium that was induced on the subjects was also studied together with the effect on the noradrenalin. In the second part of the research article, there was the investigation of the effect of acetone and petroleum extracts on memory, behavior and anxiety.

Findings of the article
The article reported that symptoms of alcohol withdrawal are a result of the effects of the alcohol on a variety of neurotransmitters after the research on both chronic and acute administration in rats. The induction of lithium leads to the diminishing of the noradrenalin neurotransmitters and this led to the reduction of mediated and stereotypical behavior. The other finding is that nicotine would potentate the ability of amitriptyline in its antidepressant activity.
Knowledge and insights gained from the article

One of the insights gained from this article is that most drugs affect the nootorpic activity of the monoamine neurotransmitters and they have a potential for causing an imbalance in the nootorpic principle. This is after the observation of the mice that had been induced with the soluble fraction of acetone and the ether that was induced in the head twitches of the rodents to ascertain the effects of drugs on neurotransmitters, where in this case, noradrenalin was used. This research was just a representative of a wide scope of the effects of drugs on the neurotransmitters and the skills employed in the research can be transferred to the investigation of the impacts of many other drugs in human beings. Just as the drugs would control behavioral reaction in the rodents, the pattern is similar in human beings the only problem is that there is no way human being could have been used as subject in such a study due to ethical considerations. For example, drugs such as cocaine affect the production and the storage of dopamine in the brain and initially they produce feelings of power and confidence due to its antidepressant activity. 

However, extreme or continuous intake of the drug often leads to a crash where the opposite of the initial feelings creeps in. Similar to the effect of the acetone on rodents, drugs such as opium and opiates have the tendency of mimicking peptides that occur naturally in the brain by creating an opiate activity that affect the endorphins. The real endorphins of the brain act as painkillers, causes pleasure sensations and the rush experience especially in athletes but these endorphins that mimic the real ones produce that effect for a short time before they backfire. One of the drugs that cause this scenario is alcohol which is believed to counteract the action of the GABA receptor, causing reduced muscle control and delayed time for reaction.

Response to the articles
The two articles were much related to the topic at hand which is the effects of the drugs on the neurotransmitters. The first article offered an above average description of the particular drugs to certain neurotransmitter and the disease that accompanies that effect, while the second article is more of research studies that use subjects in a way that will help generalize the effects of the drugs on neurotransmitters. The first article gives comprehensive, undiluted first hand information though it tends to look at the effects of drugs on just a few of the chief neurotransmitters meaning that a lot of information has been left out on all the other hundreds of neurotransmitters. 

All in all, the articles are professionally written with a careful analysis of the subject done and the reader is left satisfied because of the simplicity of the delivery of the topic and the tackling of each neurotransmitter on its own. The first article opens a new area of  learning  because in the process of reading and analyzing it, a new dimension comes out that some drugs may not be as harmful as the article portrays because some of them can be used to boost the production of the neurotransmitters especially where there is a shortage and vice versa. This means that if alcohol inhibits the production of serotonin, then it can be used to counter overproduction of the same.

COPING WITH CHANGING ROLES IN ADULTHOOD

One of the fundamental characteristics of life is the fact that change is inevitable as age advances. A primary change occurs in the duties and responsibilities that individuals have to contend with as they grow. For people getting into adulthood, they are faced with social compulsory roles of forming families, caring for their aging parents, catering for their children as well as strategizing for an imminent retirement. As one grows, change occurs in all the facets of the individuals life including the physical, emotional, cognitive and social facets.  Some of the changes that occur to the physical being include the decline in the functional ability of body organs as age advances. For an average person, there is a 0.8 to 1 decline in the biological cells function ability per year once a person reaches age 30. Although a great percentage of the decline is normal, a good percentage of the decline is associated with life factors such as diseases, stress, nutritional factors, environmental factors and other socio-environmental issues.  Some of the physical changes that are evident in the physique of average persons going through adulthood include graying hair, wrinkled skin, change in body posture as well as an aging skin.  Some of the internal changes that accompany the growth to adulthood include changes in the gastro-intestinal system, respiratory system, central nervous system and the cardiovascular systems. Growing into adulthood is also associated with a biological loss of the sensory and cognitive abilities.

The concern in this study is to analyze some of the ways through which individuals respond to the changes that accompanies their transition and general life in adulthood.   There is general evidence to show that the coping mechanisms among different genders and social classes may significantly be different especially considering the resources available at an individuals disposal during this period of adulthood. Most of the coping mechanisms adopted by individuals involvers the application of physical resources and materials to relieve life pressures in the different faculties of a person. For instance, the adoption of sports as a recreation tool by most adults is a response to physical fatigue or it can be a conscious effort to avert fatigue accumulated through lifes multiple struggles. An important feature that accompanies the different changes in growth is the accumulation and change in the roles that individuals are expected to participate in. According to Burr (1972) individuals accumulate diverse roles at every stage in their development process.  Individuals moves and transfers into different roles, leaving some and keeping others and beginning new roles that are demanded by their biological, economic and social lives.  For instance, it is socially expected that young people joining adulthood should form families in almost all the societies of the world. Biologically, a young man joining adulthood is under biological pressure to find a partner who would fulfill his sexual needs that are fully developed following adolescence.

Rodgers and White (1993) assert that role transitions are not always smooth and that they are affected by social context and the timing of transitions.  It is also noted that movement into different roles may produce direct effect on concurrent transitions in other important aspects of life. For instance, it is observed that women in European countries, especially Germany delays entry into motherhood due to educational responsibilities. Their stage in student hood directly affects their entry into adulthood (Blosfeld  Huinik, 1991).At each stage of life, an individual holds different roles. In most cases, individuals hold multiple social roles that are expected by the society and that are equivalent to an individuals social status. For instance, when a girl goes into marriage, she eventually takes the role of being a wife, a mother while at the same time continues playing he role of a daughter and daughter in law. All the roles that she acquires are accompanied by conscious and unconscious social, behavioral and economic expectations by the social circles that every role places her (Merton, 1957).It is to be noted here that the different roles that accompanies an individual automatically due to growth requires distinct skills and attention which is expected of the individual. For instance, a mans role in the house is crucial and different from the roles that is expected of him in the workplace either as a worker, a manager etc. As such, one crucial coping mechanism by adults is in the acquisition of skills that enables them play their roles effectively. The skills can be acquired formally in structured learning or informally through interactions with other peers faced with similar challenges.  According to Lopata (1991) the different roles an individual finds himself in the process of growth forms the persons role cluster and all roles in the cluster are interconnected considering that all of them are dependent on the individual.

Due to an increasing number of roles as a person goes into adulthood, individuals consciously or unconsciously develop coping mechanisms that enable them to handle the increased responsibilities that they are not familiar with. Some of the theories that are used to explain the transition to adulthood in regard to roles include the role conflict theory and role overload theory. Role conflict refers to an incongruity between expectations demanded by one role as compared to the other. In role conflict, the roles an individual is supposed to attend to normally conflict and results to strain on the part of the individual. Role overload on the other hand refers to an overload of roles on an individual who does not have all the necessary resources required to meet the expectations required by the role.  According to Goode (1960) both role overload and conflict results to a situation where the individual is unable to satisfy the demands of each role. The result is what is described as role strain where an individual generally struggles to satisfy conditions imposed upon him by the roles.

Due to the strain, there is a great likelihood for individuals to develop physical, emotional and social problems as a direct reflection of the strain they are going through. Women in many cultures such as Japan and China experience burnout, distress and stress as a result of combining family roles and work responsibilities.  How individuals respond to the strains and challenges presented by different roles in great way affects the psycho-social development that accompanies their life development. According to Marks and MacDermid (1996) individuals who manage to participate actively in a variety of roles are able to reduce strain associated with their expected roles and this helps them to foster high self esteem in their lives and reduce chances of depression and the associated health and medical consequences. Individuals who participate in multiple roles are in a great way active and time occupied and this helps them to cope with the social and emotional strains associated with adulthood roles. Women with multiple roles such as that of a mother, paid worker and a wife manages better health than women who have fewer or no roles.

It is important to point out here that there are no universally expected coping mechanisms for individuals who take up adult roles, but that there are general mechanisms that are developed either consciously or unconsciously by individuals as a response to the roles expected of them. Some individuals develop a flexibility attitude that allows them to handle the pressures that comes along with roles. Most young people especially in the developing countries enter adulthood with little or no formal knowledge of the challenges that abides in such age. As such, their response to challenges is based on flexibility and efforts to handle every challenge that emerge. For many people in developed countries, a great percentage is consciously aware of some of the challenges associated with adulthood and as such, they engage in information seeking and participation of activities that assists them to effectively handle their adult responsibilities.  Such includes participation in formal adulthood classes, counseling sessions, physical exercises etc.

According to Hanan (2000) the transition of young people into adulthood is often marked with an identity crisis in regard to the role they are expected to play in their society. The role normally rotates around their sexuality and gender identity. From their peer influence in their teenage, young people are able to isolate some of the roles expected in regard to their sexes. For instance, boys in most societies grow up with a psychological orientation towards being fathers and in most cases being breadwinners. Crisis normally revolves around their gender expectations considering that sexuality is not necessarily the same as gender. (p. 2). In regard to their gender orientations, young people graduating to adulthood cope with adult roles through role sharing.  In role sharing, the growing young men and women unconsciously shares out roles that they play in their social units such as the family. For instance, a man in the house is expected to cater for specific roles and the woman is expected to cater for other roles. When these roles are shared, they induce a feeling of cooperation between partners that reduces the build up of stress associated with individualism and isolation.

According to Drew, Emerek and Mahon (1998) role sharing is common across all stratas of the society and it cuts across the class divides.  In both the high and low classes, men and women share common roles implying that there is a similarity in coping mechanism irrespective of socio-economic status. For instance, the roles of fathers in China and Europe are primarily that of a disciplinarian, teacher and breadwinner while that of the mother is primarily that of a caregiver to the children. In a situation where these roles are clearly cut among partner adults, there is limited likelihood of too much role strain and therefore acts as a coping mechanism. A more recent trend among a good number of older adults especially in the western societies is the adoption of simple lifestyles such as adopting pets which serves to fantasize them during their lonely moments. In conclusion, the pressures in life demands for a mechanism that can reduce their effects and this can successfully be acquired through personal activities as well as involvement in social active duties.