Identifying multiple recidivists in a state hospital population

Of 195 patients admitted to a state hospital over a four-month period, 74 were multiple recidivists. Nearly half of the 195 patients could be assigned to one of six profile subgroups of recidivists described in a previous study. Because of the high rate of medication noncompliance in this state hospital sample (65 percent), noncompliance alone was not an adequate predictor of multiple recidivism. The study found that membership in a profile subgroup coupled with factors related to gender, medication noncompliance, homelessness, and arrest history may be a more useful way of predicting multiple recidivism in samples of newly admitted patients.

Use of restraint and seclusion in psychiatric settings in New York State

OBJECTIVE

The authors examined rates of use restraint and seclusion during September 1992 in 125 psychiatric settings in New York State.

METHODS

Psychiatric centers and general hospitals with psychiatric services were surveyed by mail about use of restraint and seclusion during a one-month period and about facility characteristics. Four measures of use of restraint and seclusion were calculated: percentage of patients restrained, percentage of patients secluded, rate of seclusion orders, and rate of restraint orders.

RESULTS

Use of restraint and seclusion varied dramatically among the psychiatric settings studied. Use of restraint was not related to use of seclusion. Of the 112 tested relationships between facility and patient characteristics and variations in the restraint and seclusion measures, only 12 proved to be significant. None of the variables correlated significantly with variations in more than two of the four measures of restraint or seclusion, and only three correlated with at least two of the four measures.

CONCLUSIONS

Variations in use of restraint and seclusion in psychiatric settings in New York State are dramatic and difficult to correlate with differences in the patient populations. The authors suggest that such variations prevail because of the disparate clinical perspectives on the advisability of restraint and seclusion and the limited comparative monitoring of restraint and seclusion practices in psychiatric settings.

Multiple personality disorder among female inpatients in a state hospital

OBJECTIVE

Professional skepticism and concerns regarding diagnostic reliability hinder research in dissociative disorders and multiple personality disorder. The reported frequency of multiple personality disorder in different psychiatric settings ranges from 2.4% to 35%. The authors conducted a replication study of multiple personality disorder ascertainment in women admitted to a state hospital over a 5.5-month period.

METHOD

Responses to the Dissociative Experiences Scale and to the Dissociative Disorders Interview Schedule were obtained, along with data on length of stay, county of admission referral, admission commitment status, and discharge diagnoses, for 176 female inpatients in a state hospital. Of 421 women representing 483 consecutive admissions, 121 were discharged before they could be assessed for study, 64 were excluded, 60 declined to participate, 176 enrolled in the study, and 175 completed the research procedures.

RESULTS

Twenty-one women (12%) met criteria for multiple personality disorder based on the Dissociative Disorders Interview Schedule; these women were significantly younger than the women without multiple personality disorder. Scores on the Dissociative Experiences Scale of the women with multiple personality disorder (mean = 59.5, SD = 19.6) were significantly higher than the scores of women without multiple personality disorder (mean = 22.5, SD = 20.1), but considerable overlap occurred. There was no significant difference between groups in length of stay or admission status.

CONCLUSIONS

The authors conclude that 1) the wide variability in multiple personality disorder detection is partially due to site-specific ascertainment biases and 2) despite its apparent usefulness for screening purposes, the Dissociative Experiences Scale requires more comprehensive evaluation before it can be applied broadly.

Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders

OBJECTIVE

A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals.

METHOD

Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations.

RESULTS

Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations.

CONCLUSIONS

Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Symptom severity and number of previous psychiatric admissions as predictors of readmission

OBJECTIVE

The study examined factors predicting early readmission (within 30 days of discharge) to a state hospital.

METHODS

A total of 189 patients with acute symptoms who were admitted to a state hospital were evaluated at discharge using the Brief Psychiatric Rating Scale (BPRS) and the Nurses Observation Scale for Inpatient Evaluation (NOSIE). Patients who were readmitted within 30 days were compared with those who were not on BPRS and NOSIE ratings and on other variables, including length of stay, number of previous admissions, demographic characteristics, and diagnosis.

RESULTS

Scores on the thought disorder factor and self-neglect question on the BPRS and the number of previous admissions were significantly higher among patients who where readmitted within 30 days of discharge. The variables correctly predicted readmission for 86 percent of cases in the study.

CONCLUSIONS

The characteristics of high scores at discharge on the BPRS thought disorder factor and the BPRS item on self-neglect, along with a high number of previous admission, may be helpful in identifying patients at risk for readmission to inpatient psychiatric settings.

Use of lithium, carbamazepine, and valproic acid in a state-operated psychiatric hospital

OBJECTIVE

To examine the prescribing of mood stabilizers (lithium, carbamazepine, and valproic acid) in a 500-bed state-operated psychiatric hospital in New York.

METHODS

All 129 inpatients receiving mood stabilizers were identified and their medical records reviewed using a standardized drug use evaluation form. Diagnosis, other indications, and prior experience with mood stabilizers were examined, as well as outcome and adverse effects.

RESULTS

Approximately one-quarter of the inpatient population received a mood stabilizer. The frequency of carbamazepine use exceeded the use of lithium, with 72 patients receiving carbamazepine and only 62 receiving lithium. Twenty-eight patients received valproic acid. Indications found most frequently for carbamazepine use included assaultive or aggressive behavior (70% for those receiving carbamazepine as the only mood stabilizer). Of those patients with bipolar or schizoaffective disorder and receiving either lithium, carbamazepine, or valproic acid, 36% were prescribed carbamazepine (10% as a first-line agent) and 50% lithium (26% as a first-line agent). None of these indications for carbamazepine has been approved by the Food and Drug Administration. In general, positive outcomes were documented but without supporting objective measures. Significant adverse effects were documented in the medical record in one-quarter of the patients.

CONCLUSIONS

There was widespread use of the three mood stabilizers examined, singly and in combination, for a variety of indications. Lithium and valproic acid remain more frequently prescribed for the treatment of bipolar and schizoaffective disorders. Monotherapy with carbamazepine or valproic acid results in statistically significantly fewer adverse effects than lithium or combination therapy (p values between p = 0.00038 and p = 0.006). Current clinical practice has endorsed the use of carbamazepine for aggressive or assaultive behavior, although there does not appear to be sufficient proof of effectiveness in the literature. Formal studies of carbamazepine's antiagressive effects should be conducted.

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. IV. The reduction of unnatural death rates during 1988-1992 in three facilities as a result of planned changes

This paper documents the most recent five-year (1988-1992) analysis of unnatural deaths in Oregon's state mental and correctional institutions. The current findings are compared with those of the preceding five years (1983-1987) within the context of the long term trend in unnatural death rates for the previous 25 years. The unnatural death rates for the institutional clients are also compared with those for the noninstitutionalized citizens of Marion County, Oregon. There are two major findings in these 1988-1992 data: (a) There have been highly significant reductions in unnatural death rates in Oregon State Hospital and in the Forensic Psychiatric Program, which the authors believe are largely due to the implementation of planned changes to reduce the previously very high suicide rates in these two facilities; and (b) There was a dramatic reduction (to zero) of unnatural deaths at the Fairview Training Center. The authors also believe that this was attainable mostly because of large-scale improvements made at that facility, by the Department of Human Resources and the Oregon Legislature, just before and during the present study time frame. Changes in these three facilities which led to the improvement in unnatural death rates of clients are discussed.

Assaults by patients on psychiatric residents at three training sites

OBJECTIVE

This study attempted to determine how often psychiatric residents are exposed to violence, the types of violence they encounter, and what institutional changes might increase their safety.

METHODS

Safety conditions at two private general hospitals and one state hospital that served as training sites for a psychiatric residency program were assessed through a survey of psychiatric residents and site visits to the hospitals. The survey asked residents to quantify violent incidents occurring in the emergency rooms, wards, and clinics at each site. The site visits focused on safety issues related to staff training, physical layout, staffing patterns, current policies, and compliance with policies.

RESULTS

All 47 residents in the training program responded to the survey. None reported serious injury, although as many as 56 percent had been physically assaulted on the wards of one hospital, and 54 percent of residents had encountered a weapon in one emergency room. Almost all residents had been verbally threatened or had witnessed violence to others. A paradoxical finding of the survey was that the residents felt safest in the hospital that had the highest rate of violence. The site visits revealed that deficiencies in the safety procedures were allowing weapons to be brought into patient care areas.

CONCLUSIONS

Psychiatric residents are often exposed to dangerous situations, although serious injury is rare. Residents' beliefs about their level of safety seem to be influenced more by how competent they perceive the staff to be than by the frequency of violence. The findings from the site visits pointed to two steps to increase safety: creating a weapon-free environment by searching all patients and finding ways to improve compliance with existing safety measures.

Savings in hospital bed-days related to treatment with clozapine

OBJECTIVE

The authors' aim was to determine whether clozapine was associated with a decrease in state hospital bed-days for patients with chronic schizophrenia.

METHODS

Patients were started on clozapine in a state facility and were followed while taking the medication for 1.5 years (N = 172), two years (N = 86), and 2.5 years (N = 53). Patients' number of bed-days before starting clozapine was compared with those during the follow-up period.

RESULTS

Bed-days were reduced by an average of 132 days per year after 1.5 years, 166 days per year after two years, and 201 days per year after 2.5 years (p < .001). During the final 180 days of each follow-up period, only 23 to 30 percent of patients were continuously hospitalized, compared with 56 to 64 percent before clozapine. Forty to 57 percent of patients had no hospital days at all during the last 180 days of follow-up.

CONCLUSIONS

Based on hospital costs of $250 per patient per day, this reduction in bed-days could result in gross savings of about $33,000 per patient per year at 1.5 years, $41,500 per patient per year at two years, and $50,250 per patient per year at 2.5 years. Hospital patients are conspicuous targets for clozapine funding, since bed-days represent an easily measured expense. Nevertheless, community treatment should be an even higher priority, since most chronic mentally ill persons are outpatients.

[Analysis of 1,000 hysterectomies. Technical simplifications and reflections. ISSSTE hospitals]

1,000 hysterectomies are reported by the author in a space of 20 years in four hospitals of ISSSTE. Some clinic-pathological parameters were analyzed, morbi-mortality, etc. The obtained results are informed using a simplification on the surgical techniques. The most frequent symptoms were menstrual disorders, and the most frequent diagnosis was myomatosis with (61.2%) average age between 35-45 years old. All were total hysterectomies, intrafascial 92.6% and abdominal 74.8%. Attention is called upon the fact that 7.2% of the patients presented pelvic congestion post tubaric occlusion and the association of adenomyosis. The overall morbidity was 12.2% being urosepsis the most frequent. Mortality was in one case of giant interligamentary myoma and DIC. Blood transfusion was needed just in 4.2%. We think that the surgical simplification here announced offer more safety, less morbidity, less bleeding and brief surgical time. More over, a critical analysis was made about use and abuse of this kind of surgical intervention.

Finding alternatives to the streets for the homeless mentally ill: efficacy at a state hospital intensive placement unit

The authors describe a sample of homeless mentally ill patients receiving extended psychiatric care on an intensive placement unit. Summaries of 246 discharges were reviewed to examine demographic and clinical factors associated with extended psychiatric care and postdischarge placement. It was found that homeless patients requiring extended care were often medically ill and substance abusing. Residential placements were accepted by most patients on discharge. It was determined that homeless psychiatric patients benefited from extended care on an inpatient unit designed to alleviate anxieties regarding living arrangements and psychiatric treatment systems historically rejected by this population.

[The costs of operating psychiatric hospitals of the Ministry of Health in the Federal District]

The hospitals of the Ministry of Health in Mexico City, particularly psychiatric hospitals, have been confronting operational problems due to a scarce budget and lack of informational on their operation and costs. The present study intends to begin to solve some of those problems through an initial diagnosis. A form was designed for data harvesting, which enables to sort costs by class (direct and indirect). This information was projected in a worksheet and analyzed by service, day-bed and unity as a whole. The results show an inequitable distribution of the budget among hospitals.

When there are almost no state hospital beds left

The number of state hospital beds nationwide has been reduced to 40 per 100,000 population; in California, nonforensic state hospital beds have decreased to 8.3 per 100,000. The main effects of this reduction are becoming more evident. Most seriously affected have been the new generation of chronically and severely mentally ill persons who have reached adulthood since deinstitutionalization. Those who need intermediate or long-term hospitalization and cannot receive it may become even more desperate and psychotic; may avoid treatment entirely; and may turn to drug abuse and become homeless or incarcerated in jail. Moreover, the small number of long-stay beds can lead to a breakdown in the public mental health system and attempts to avoid responsibility for persons who need both acute and long-term hospitalization. This avoidance can be manifested by raising admission criteria for acute treatment or shifting responsibility to other systems. The authors recommend providing intermediate and long-stay hospitalization to the extent needed.

Hispanic Americans and the state mental hospitals in Texas: ethnic parity as a latent function of a fiscal incentive policy

This paper examines patterns of utilization of the state mental hospitals in Texas by Hispanics compared to Anglos over a 5-year period from FY 1984 to FY 1988. Historically, Hispanics have been underrepresented in public mental health client populations in the United States. In the mid-1980s in Texas, the ethnic gap in use of psychiatric facilities was expected to widen as Hispanic population growth outpaced the capacity of the public system to provide accessible mental health services for persons with serious and persistent psychiatric illnesses. But in the inpatient sector, the gap narrowed significantly in the second half of the decade, due to a policy-driven sharp reduction in the overall census of the state mental hospitals. A fiscal incentive program to stimulate the development of community-based mental health services had a markedly different effect on subsequent inpatient utilization by Anglos compared to Hispanics, most notably in counties that were less urban and less affluent and counties with a relatively high proportion of Hispanic residents. The context and mixed implications of these developments are explored.

Crisis stabilization services for children and adolescents: a brokerage model to reduce admissions to state psychiatric facilities

There continues to be an increased interest in developing community-based services for children and adolescents as an alternative to inpatient care. However, there has been much more talk than action in creating such alternatives. This paper describes the success of a crisis stabilization program for children and adolescents in a community mental health center which historically over-utilized the State psychiatric facility for youth. The Crisis Stabilization Program consists of three components: (1) a two-person crisis team, (2) a four-person on-call team for after hours crises, and (3) funds which the crisis team utilized to broker for a wider array of community-based services.

A national survey of ethics committees in state mental hospitals

In June 1992, a national mail survey was directed to 204 state inpatient psychiatric institutions. This study was implemented following the 1992 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement that hospitals put in place some means with which to address ethical issues. The goals of the study were: 1. to examine state mental hospital characteristics and their response to the JCAHO requirements; 2. to describe healthcare ethics committee (HEC) composition, function, and role; 3. to study patient and family access to a HEC; and 4. to discover ethical issues most frequently addressed. The survey response rate was 71%. Of the 145 responders, 62 had HECs in place, and 53 were in the process of implementing HECs. There were no differences between JCAHO accredited institutions and non-accredited facilities with regard to having HECs. Physicians accounted for 22% of HEC membership, followed by nurses (15%), and administrators (12%). Twenty-six percent of facilities systematically notified patients about existence of the HEC; 71% of facilities had no patient request for HEC services in the last year. A patient's danger to others, and resuscitation policy were issues most frequently (23%) heard by HECs.

Total hip and knee replacements: a survey of 261 hospitals in England

A survey of all 261 National Health Service hospitals in the 14 regions of England performing joint replacement surgery was carried out to determine inter-regional variations in the surgeon's choice of hip and knee replacements. There are over 30 types of cemented, 35 types of uncemented hip replacements, and more than 35 types of knee prostheses for the surgeon to choose from. The Charnley low friction arthroplasty is the market leader in hip surgery and is used in 193 hospitals (74%). There is a marked North-South divide in the use of this prosthesis. The Kinematic and Insall Burstein prostheses are the most popular knee replacements. At present, there is a huge choice of joint replacement on the market and many implants have yet to prove that they offer any real advantages over established and often cheaper alternatives. It is suggested that special centres for joint replacement surgery within each region should run clinical trials to determine which prostheses have the best long-term results. The resulting standardization of implants within each hospital would enable Regional Health Authorities to reduce costs in the short-term by cutting stock levels, and should reduce costs in the long-term by reducing the revision rate of failed joint replacements.

Use of clozapine in Texas state mental health facilities

Clozapine-use patterns in facilities operated by the Texas Department of Mental Health and Mental Retardation are reported. Data collected by manual and automated tracking systems from January 1990 through July 1992 were analyzed to determine patient demographics, the number of patients started on clozapine and the number who stopped taking the drug, the reasons for discontinuation, and other variables. Of 852 clozapine recipients still in the departmental system by the end of the study period, 134 (16%) had discontinued the drug by that date. There were no significant differences in gender, age, or race between the patients who discontinued the therapy and those who did not. Almost one fourth of the patients who discontinued clozapine therapy did so within the first month, and more than 90% did so within the first year. The most common reasons for discontinuing the medication were lack of clinical response, patient refusal or request, and adverse effects, including agranulocytosis. More women than men discontinued the drug because of adverse effects. Although relatively few patients discontinued clozapine during the study period, many had only recently begun taking the drug, and some of these may discontinue it in the near future. Of 852 clozapine-treated patients served by the Texas Department of Mental Health and Mental Retardation between January 1990 and July 1992, 16% discontinued the therapy. One fourth of these did so within the first month of treatment.

Long-term high-dose neuroleptic treatment: who gets it and why?

OBJECTIVE

High doses of neuroleptic medication are still administered to many patients, although many studies have shown the effectiveness of low-dose strategies. The purposes of the study were to determine whether and in what ways high-dose patients differed from patients on regular dosages and whether the higher dosages were more effective.

METHODS

In a case-control study at two large state hospitals, 38 high-dose patients were compared with 29 regular-dose patients.

RESULTS

The high-dose patients had a persistent course of illness, with severe chronic symptoms resulting in hospitalizations of much longer duration than those of the regular-dose patients. The high-dose patients evidenced more regressed functioning and were more violent. To control these behaviors, clinicians increased neuroleptic dosages.

CONCLUSIONS

The high-dose patients represented a subgroup of chronic regressed and violent patients. Clinicians prescribed high dosages and continued to use them despite a lack of clear evidence that such treatment is effective.

Impact of clozapine on medication use in a state hospital

Medical records of 90 consecutive patients who started clozapine were reviewed to see how this drug is being used with other psychotropic medications and to evaluate what impact it has had on the drug regimens of these patients. Data from up to 6 months before to 12 months after clozapine's initiation was included. The percent of patients receiving medications for antipsychotic side effects decreased from 86% 6 months prior to clozapine to 13% 12 months after. The use of benzodiazepines decreased from 43% to 23% during this time period as did lithium use from 57% to 17%. While 28% of the patients were receiving carbamazepine prior to starting clozapine, no patients remained on this drug concurrently with clozapine. The average number of psychiatric medications per patient decreased from 3.39 +/- 1.37 6 months prior to clozapine to 1.61 +/- .83 at month 12. Concern for drug interactions along with clozapine's reduced incidence of extrapyramidal side effects and increased efficacy contributed to the reduction in medication use observed.

Changing characteristics of schizophrenic patients admitted to state hospitals

OBJECTIVE

Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period.

METHODS

Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health.

RESULTS

Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients.

CONCLUSIONS

Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.