Who became revolving door patients? Findings from a nation-wide cohort of first time admitted psychiatric patients

A cohort representing all first-time admissions to Danish psychiatric institutions during the period April 1, 1970 to March 31, 1971 was followed for 10 years in the psychiatric register. The cohort comprised 5,881 males and 6,856 females aged 15 years or above. The revolving door population was delineated as (1) patients with minimum four admissions and no admission or discharge period lasting for more than one fourth of the observation period or (2) patients with minimum four admissions during the first one fourth of the observation period. The incidence rate was 3.14 males and 3.55 females per 1,000. Revolving door patients were younger than others, single or divorced, and lived in larger cities. They were more frequently referred to out-patient aftercare and discharged to their own home. A male diagnostic profile of schizophrenia, demential or organic psychoses, personality disorders and abuse emerged together with a female profile of manic depressive and psychogenic psychosis and neurosis. Twenty-one point nine percent of males and 13.0% of females had more than 10 admissions and 4.5% of males and 3.7% of females spent more than 5 years in hospital. High risk groups were 15-24 years old as 21% and 13% of young males respectively females became revolving door patients, and schizophrenics, as 46% of male and 30% of female schizophrenics became revolving door patients.

Prediction and profile of the long-stay population. A nation-wide cohort of first time admitted patients

A nation-wide cohort of 12,737 first admitted patients aged 15 years or more to Danish psychiatric institutions was followed in the Danish Case Register for a 10-year period. Long stay patients were delineated as: 1) patients whose first admission lasted for more than 1 year (new long-stay); or 2) patients who later had an admission lasting for more than 1 year (late long-stay). Together they comprised 420 males and 527 females with an incidence rate of 0.22 males and 0.27 females per 1,000. Up to age 65 males dominated, after 65 females dominated. Thirty-three percent of demential disordered and 24 of schizophrenics became long-stay patients. A multiple contingency analysis showed that the variables "age group", "main diagnosis", "size of municipality of residence" and "marital status" were independently associated with the outcome "long-stay". The two long-stay groups differed. New long-stay patients tended to be females, older, suffering from demential disorders and with a total hospital stay shorter than that of the long-stay population. In a multiple contingency analysis the variables "age group" and "main diagnosis" were independently associated with the outcome "new long-stay" and the variables "age groups", "main diagnosis" and "size of municipality of residence" with the outcome "late long-stay".

An integration of the DSM-III and ICD-8 by global severity assessments for measuring multidimensional outcomes in general hospital psychiatry

A multiaxial classification system has been developed in which three ICD-8 derived axes of psychiatric syndromes, personality disorders and somatic syndromes, and two DSM-III axes of psychosocial stressors and social functioning have been included. Global assessment scales were annexed the three ICD-8 axes. This DSM-III/ICD-8 system was used for registration of 880 consequetively admitted psychiatric patients in a general hospital setting. The results showed that six psychiatric syndromes (substance use disorders, schizophrenia, manic-depressive psychosis, reactive psychosis, neurosis, and adjustment reactions) were responsible for 80% of the diagnostic variance. Of these syndromes, manic-depressive psychosis had the highest improvement rate both concerning symptoms and social functioning. Manic-depressive psychosis had also the lowest coefficient of variation in the stay in hospital indicating a high degree of homogeneity in accordance to the diagnose-related group system. However, patients within the categories of reactive psychosis and neurosis who received antidepressants also had a low coefficient of variation, although the neurotics were significantly more depressed than the manic-depressives at discharge from hospital.

Integration of DSM-III and ICD-8 to be used in a consultation-liaison psychiatric service. Preliminary experiences

In 1983 a total of 405 patients received psychiatric supervision in somatic departments in the general hospital. At this supervision, these patients were registered by means of a five-axial diagnostic coding according to the DMS III principle, and this was combined with a quantitative global assessment of the severity of the condition. Reliability testing was undertaken by five supervising physicians with a total of 15 patients. The total number of supervisions constituted one supervision per somatic bed per annum. Women were overrepresented, and medical departments made the greatest use of psychiatric supervision. Reactive conditions dominated parallel with a high relative incidence of alcohol-related conditions. In patients with diagnoses of psychoses, only slight to moderate psychiatric symptoms were encountered. This held true also for personality deviations. 50% of the patients had experienced significant psychosocial stress, but 10% of these were diagnosed as having non-reactive psychoses, 52% of the patients had moderate to pronounced disturbances of social function. Half of the patients supervised in this manner could be investigated or treated in the referring departments. Approximately half of the patients in whom referral to private psychiatric specialists was made did not keep these appointments. Reliability testing in the material shows the employability of the diagnostic armamentarium. All in all, the investigation suggests that extension of the liaison psychiatric service in somatic departments would result in a relative increase in the number of patients who could be treated in the referring department and an increase in the number of psychiatric conditions diagnosed. Establishment of a psychiatric outpatient clinic in the somatic environment appears to be indicated.

Sex differences in the utilization of mental health services: a nation-wide register study

A nation-wide investigation of a cohort of first admissions during the period April 1, 1970 to March 31, 1971 to psychiatric institutions was followed in the Danish Psychiatric Register for a 10 year period. The cohort comprised 5,881 males and 6,856 females with an annual incidence rate of 3.14 males and 3.55 females per 1,000. Males were significantly younger than females and more frequently involuntarily admitted. Males predominated among schizophrenics and addictive disorders, females among neurotics and manic-depressive psychotics. Young males required longer hospital stays and more admissions than young females. The opposite was the case among patients over 65 years. Three outcome groups were delineated and the incidence rate calculated to: the "short term" group comprising 1.64 males and 1.90 females per 1,000, the "long-stay" group comprising 0.22 males and 0.27 females per 1,000 and the "revolving door" group comprising 0.42 males and 0.32 females. Multiple contingency analyses showed that only the outcome "revolving door" was independently associated with the sex of the patients with males being a high risk group.

Rating scales for states for anxiety, depression, mania and schizophrenia. A multiaxial approach

Rating scales are considered to be an efficient instrument in the assessment of treatment effect, and during the last 25 years a number of rating scales has been constructed for measuring states of anxiety, depression, mania and schizophrenia. The paper describes some of the most frequently used scales. Time has come to coordinate the existing rating scales and to agree upon common operational definitions in the judgement of psychopathological symptoms. Basic practical guidelines to be used in both clinical practice and research are given.

Working conditions of male and female psychiatrists

The percentage of females among Danish medical graduates has increased from 1% in 1900-10 to 33% in 1980-84. In 1980 women doctors comprised 21% of all Danish medical doctors; the percentage among psychiatrists was 29. The purpose of the study has been to analyse the job-profiles of male and female psychiatrists, and their activities in research, teaching, committees, etc. The job-profiles of males and females differ, females more likely being in less influential positions. Based on an investigation among members of the Danish Psychiatric Association, the working conditions and professional activity of 307 male and female psychiatrists were analysed. Male psychiatrists were found to complete their training at a younger age than females. Among those aged 25-44, 29% of males and 6% of females had reached a position as chief consultant. Males report greater activity in all areas of research, and 35% of females and 17% of males do not research at all. In all age groups and all fields investigated more males take part in organisational activities, while 48% of females and 25% of males report no such activity. No difference was found regarding teaching experience, but men were relatively more often involved in teaching professional groups and women, nursing staff. A significant preponderance of males had their main interest in biological psychiatry, females in psychotherapy.

Use of headache rating scales: a multiaxial approach

The basic principles of the rating scale procedure have been outlined, including the Likert scale, the Guilford criteria for item definitions, and the Guttman and Rasch criteria for item combinations. With these criteria, headache rates among the core symptoms of anxiety and depression. Next, we have discussed one of the prevailing scales for headache, the Waters Headache Questionnaire (WHQ), with a multiaxial approach. The WHQ thus contains a severity axis, a diagnostic axis, and a personality axis. Previous studies on the validity of the WHQ, including factor analysis, have shown that migraine and muscular headaches are not mutually exclusive categories. Studies to validate a two-dimensional diagnostic system of migraine and non-migraine headache by Rasch models are discussed. In the field of personality it was suggested, when using questionnaires like the WHQ, to focus on the concepts of acquiescence and dissimulation. Supplemental axes such as "severity of psychosocial stressors" and "social functioning" or "quality of life" should be considered in future research.

Characteristics of a nationwide cohort of psychiatric patients--with special reference to the elderly and the chronically admitted

The pattern of psychiatric care has changed over the last decades with an extension of outpatient facilities, a decrease in the number of chronically admitted and an increase in the number of shortlasting admissions. A cohort of first time admitted psychiatric patients to Danish institutions in 1970 was followed for 10 years with the purpose to describe the characteristics of the population with multiple admissions. The cohort comprised 12737 patients with 35497 admissions. It was divided into 3 groups, one - 6470 patients - consisting of those with 1 admission, one - 744 - consisting of those continuously admitted to the termination of the study period or their death, and one - 5523 - consisting of those with several admissions. Patients chronically admitted tended to be older, and among them the senile and cerebrovascular disorders were dominating with the non-organic disorders in total comprising less than 10% of the patients. Significantly more females than males were admitted for more than 5 years. Patients with multiple admissions had in total shorter admission periods than the chronically admitted. Males had significantly more admissions than females and 8.2% compared with 3.9% of females had 10 admissions or more.

The Melancholia Scale and the Newcastle Scales. Item-combinations and inter-observer reliability

The reliability of the total scores on three rating scales (Melancholia Scale and the two Newcastle Scales) and the algorithms leading to the Feighner, Research Diagnostic Criteria, and the DSM-III subtypes of depression have been compared. The degree of inter-observer agreements for the various item-combinations was significantly higher than would be expected by chance. The average agreement for each assessment system ranged from 80 to 93 per cent. This 7 to 20 per cent lack of total agreement probably reflects the limitation of clinical assessments including the influence of halo effects.

Long-stay patients in Danish psychiatric hospitals

The numbers of long-stay patients in Danish psychiatric hospitals were studied, based on information from the Danish cumulative psychiatric register and from the census studies of patients in Danish psychiatric hospitals, performed at 5-year intervals since 1957. In 1977, 2079 (20%) of the in-patient population which had been admitted before 1957 were still in hospitals. This 'old long-stay' group has diminished exponentially, with an annual reduction of 7%. During the period 1972--6, the number of patients who, on any given day, had been in-patients or attending as day-patients for more than 1 but less than 2 years (the 'new long-stay') varied between 847 and 1089: an average of 20 per 100 000 total population. The ratio of in-patients to day-patients was approximately 4:1. Based on the decline of the 1972 cohort during the period 1972--7, and assuming a constant 'influx' of new long-stay patients and a constant exponential decline of the cohorts, the number of new long-stay patients, including day-patients, at equilibrium was estimated to be about 4300 or 85 per 100 000 total population. About 31% will be schizophrenics and about 43% will be patients with organic disorders. Ninety-four per cent of the number at equilibrium will be reached after 16 years for the diagnostic group with the slowest decline, schizophrenia. On 1 April 1976, 3106 long-stay patients were present, accumulated since 1 April 1972. Nineteen per cent of these patients were in day-hospitals. This type of institution was used especially for younger patients with schizophrenia and reactive disorders.

Traffic accidents involving psychiatric patients. Characteristics of accidents involving drivers who have been admitted to Danish psychiatric departments

A nationwide study of psychiatric in-patients driving motor vehicles and involved in accidents causing bodily injury in the years 1972--74 was undertaken. Compared with drivers in general involved in accidents causing bodily injury, drivers with a psychiatric record were characterized by an over-representation of women. A preponderance of psychiatric drivers in the age group 25--54 was observed. About 3% of drivers with a psychiatric record were involved in two or more accidents during the period studied. A greater proportion of the psychiatrically diseased group drove stolen vehicles, without valid licences, and were found not to have used safety belts at the time of the accident. Occurrence of injury was more frequent among the diseased drivers. They were more frequently alcohol intoxicated and with a higher blood alcohol level. The most commonly encountered diagnostic groups were personality disorder and transitory reactions.

Traffic accidents involving psychiatric patients. Description of the material and general results

The present investigation analyzes the characteristics of traffic accidents involving psychiatric patients and comprises all persons who during the period 1970-74 have been admitted to a psychiatric in-patient institution and who during the period 1972-74 have been involved in a traffic accident causing bodily injury. Accidents with psychiatric patients involved constitute about 5.7% of all traffic accidents reported in Denmark. Compared with the total group of accidents, they are characterized by an over-representation of women and of persons in the age group 25-54 years. Accidents with psychiatric patients are over-represented during the period July-September, and in areas densely built up. The accidents tend to be more complicated, and the psychiatric patients are more likely to get injured and be hopitalized due to the accident. The investigation is based exclusively on routinely collected data. The limitations with which the results are encumbered and the problems concerning methodology and comparison of different studies are discussed.

Psychic disorders among pre-school children in a geographically delimited area of Aarhus county, Denmark

A study was undertaken concerning prevalence of psychic disorders among 175-5 to 6-year-old, pre-school children randomly selected from the general population in the municipality of Aarhus and the island Samsø of Aarhus County, Denmark. Deviant behaviour was arbitrarily defined, with a symptom considered aberrant if it occurred in 10% or less of the children studied. Mental health of the children was assessed by (a) the number of deviant symptoms, (b) opinions of the parents and (c) the personal assessment of the author, who interviewed all the families. Thirty-five probands (20%) showed good adjustment, 113 (65%) were coping well with only minor symptoms, and 27 children (15%) were poorly adjusted. A high prevalence of psychosomatic, behavioural, and emotional symptoms was observed, some of them more frequently among boys than girls. No significant difference was found between urban and rural children. The need for psychiatric help even among supposedly normal, pre-school children is discussed and emphasized.

Psychiatric treatment in a delimited population-with particular reference to outpatients. A demographic study

The present investigation analyses the psychiatric service available to and utilized by a population in a geogrphically delimited area, namely the Randers area with a population of 108.928. During the period 1970-74, the average yearly rate of patients admitted to the three psychiatric institutions covering this area was per 1,000: 7.9 males and 9.1 females. During 1970-71, 1.2 males and 1.8 females per 1,000 were treated as outpatients in a psychiatric clinic affiliated to a psychiatric hospital, and a psychiatric outpatient clinic in a general hospital discharged 4.1 males and 7.7 females per 1,000. It seems probable that despite outpatient treatment the number of admissions increases slightly rather than decreases, and consequently, outpatient treatment cannot replace psychiatric admission.