Recidivism and mental illness: the role of communities

This study examined the impact of community characteristics on rehospitalization of chronically mentally ill (CMI) clients from public psychiatric hospitals in Virginia. The relationship between rehospitalization, often termed recidivism, and community attributes was explained within the theoretical context of community ecology (Hawley 1950). A small area analysis approach that employed path analysis was used to assess the relationship between rehospitalization and selected community variables including: available health care resources, socioeconomic factors, race, presence of psychopathology, and household composition. The path model was estimated and validated using a linear structural relations computer program (LISREL VI). Results reveal female-headed households and socioeconomic status to be significant predictors of rehospitalization. A discussion of implications of the findings for community mental health services delivery and research is provided.

A comparison of the effects of hard rock and easy listening on the frequency of observed inappropriate behaviors: control of environmental antecedents in a large public area

Observation of clients at a state mental health hospital by direct care staff indicated that they appeared to act in more inappropriate ways when "hard rock" or "rap" music was played in an open courtyard than when "easy listening" or "country" music was played. A study was conducted to compare the inappropriate behavior of clients when hard rock and rap music were played (21 days), followed by easy listening and country and western music (21 days). This comparison was followed by a reversal phase in which hard rock and rap music were again played (18 days). The behaviors of the clients were observed and recorded via a controlled methodology. The results demonstrated that more inappropriate behavior was observed under conditions in which hard rock and rap music were played than when easy listening and country western music were played. The implications of these findings are discussed.

A historical perspective on the role of state hospitals viewed from the era of the "revolving door"

OBJECTIVE

By focusing on the functioning of a state hospital throughout its existence, the author provides a historical perspective on the nature and causes of "revolving door" admissions.

METHOD

Northampton State Hospital was chosen as a prototype, and data on characteristics of patients and patterns of hospital utilization were analyzed from three 10-year periods: 1880-1889, 1930-1939, and 1980-1989. The data for the first two time periods came from the hospital's admission and discharge logbooks and its annual reports; the material for the most recent decade was obtained from unpublished yearly reports generated by the hospital's medical records department.

RESULTS

The hospital operated very differently in each of the decades analyzed, but only in the 1980s was recidivism a major finding. This was not, as has often been thought, due to problems or populations unique to the state hospital in the 1980s nor to the fact that in earlier eras the state hospital rarely discharged patients. The once-large asylum has been replaced by a facility rapidly admitting and discharging patients, many of whom have accumulated more than 10 lifetime admissions, in a pattern of care not previously noted.

CONCLUSIONS

State hospitals have functioned in different yet questionable ways throughout their history. Their current role of providing a revolving-door pattern of care to a considerable population is rooted in a contemporary shift in ideology. This role for state hospitals appears to make no more sense than did their earlier role as neglected and neglectful asylums, and it should be reevaluated.

Need-for-treatment criteria for involuntary civil commitment: impact in practice

There has been considerable discussion in the literature on the differences between criteria for involuntary commitment that are based on dangerousness and criteria based on need for treatment. A number of states have adopted clinical criteria, and other state legislatures are actively considering them. Some libertarians argue that dangerousness is constitutionally required if a person is to undergo the loss of liberty involved in commitment. Citing widely publicized data from the state of Washington, they predict that a return to clinical criteria would result in a deluge of inappropriate commitments. Some clinicians counter that use of clinical criteria would result in selection of a much more appropriate clinical population and point to research indicating that strict observation of the need-for-treatment provisions of the APA model commitment statute would actually decrease the number of commitments. The author examines state hospital admission and census data from eight states that added need-for-treatment criteria to their commitment codes between 1975 and 1990 and argues that the data indicate that there is little reason to believe that such changes would result in the deluge of admissions predicted by the critics.

A report on the "worst" state hospital recidivists in the U.S

A total of 196 nonspecialty state hospitals in the U.S. each identified one patient--referred to as the hospital's "worst" recidivist--admitted to the hospital in 1987 who had the most lifetime admissions to that hospital. Persons admitted for mental retardation or substance abuse detoxification were excluded. The mean age of the recidivists was 42.2 years; their mean age at first admission was 24.7. The number of admissions per patient ranged from five to 121, with a mean of 31. Compared with the national population of state hospital admissions, significantly larger proportions of recidivists had diagnoses of schizophrenia, bipolar disorder, and personality disorder. More research is needed to determine actual community tenure of patients who receive revolving-door care and whether alternative approaches would be more effective.

Pulmonary tuberculosis in diabetics

Pulmonary tuberculosis is found predominantly in the lung apices. In diabetics it has been suggested that tuberculosis tended to occur predominantly in the lower lobes. A retrospective chart review was performed of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to a health care facility to determine the presenting chest roentgenographic location of tuberculosis. Multiple lobe involvement was the predominant chest roentgenographic finding in both diabetics and nondiabetics with pulmonary tuberculosis. Since tuberculosis and diabetes frequently coexist in the population at risk for tuberculosis, clinicians should suspect tuberculosis in the diabetic with an abnormality on chest roentgenogram. Aggressive diagnostic measures and specific chemotherapy should be given and monitored to treat pulmonary tuberculosis.

A needs survey among patients in Leros asylum

The recent exposure of the plight of inmates living in poor conditions at the state asylum on the Greek island of Leros has caused public and professional outrage. If Greece is to avoid mistakes made by other countries, the plans for rehabilitating the patients and closing the hospital should from the outset include identification of the precise needs of patients for support and care. The survey of the patients' characteristics and needs for care found that most patients had no outside friends or relatives, and most were unable to perform basic daily skills. They shared many basic characteristics, however, with a large sample of the long-stay population in the UK, and 25% were thought to be able to live independently.

Effects of exposure to aggressive behavior on job satisfaction of health care staff

This study examined the effects of exposure to the aggressive and disruptive behavior of institutionalized elderly patients on health care staff's job satisfaction. Aggressive behavior was defined as physical, verbal, or general disruptive behavior. Health care staff from a geriatric long-term care hospital were interviewed about their exposure to these types of aggressive behavior and the effect of this exposure on job satisfaction. Job satisfaction was significantly correlated with overall exposure to aggressive behavior. Although physical aggression was reported more frequently, exposure to verbal aggression correlated higher with job satisfaction. Exposure to aggressive behavior was the best predictor of job satisfaction, followed by level of education. These findings indicate that job satisfaction is negatively affected by exposure to aggressive behavior but positively affected by educational level. The role of educational programs in moderating the impact of exposure to aggressive behavior on job satisfaction is discussed.

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. II. Analysis of the incidence rate and its many variations

We have analyzed suicide data of the Forensic Psychiatric Program of the Oregon State Hospital in terms of the various ways of expressing occurrence rates that are found in the literature. All of these rates are ultimately based upon either (a) the average daily population, computed from occupancy rates of institutional beds, or (b) a measure of the total number of individuals at risk (that is, all who were in the study population during the time frame of the study). We discuss reasons for the use of these different rates. We have also calculated the risk of suicide for each of two factors: (a) the primary psychiatric diagnosis and (b) the type of legal commitment under which these patients were admitted to the Forensic Psychiatric Program. We discovered that virtually the entire risk of suicide in this program was borne by patients whose primary diagnosis was that of chronic schizophrenia and who were committed there because of diminished criminal responsibility for a crime of which they were found guilty in a court of law.

Prosthetics and orthotics: a survey of centres in the Kingdom of Saudi Arabia

This paper reports the results of a survey carried out to evaluate existing prosthetic and orthotic facilities and programmes of education, training, and research and development in the Kingdom of Saudi Arabia. One hundred and twenty hospitals and medical rehabilitation centres were each circularised with a questionnaire requesting information that mainly concerned (i) types of prostheses/orthoses, (ii) area of facility, (iii) personnel number and qualifications, and (iv) problems encountered and suggested solutions. The completed questionnaires revealed that in the final analysis of data there were only ten prosthetic/orthotic facilities. The survey provided useful data on the personnel, equipment, and facilities available in each hospital or medical rehabilitation centre, together with details of the services to prospective referring clinicians. Two centres were found to provide high quality services by qualified personnel. There were no formal prosthetic/orthotic training programmes and there was only one prosthetic/orthotic research and development centre. The respondents generally felt that there were three major problems: (i) lack of qualified personnel, (ii) lack of materials and components, and (iii) lack of continuing education and training programmes. It is hoped that presentation of these results will provide facts for both health-care providers and educators which may be used as a basis for development in this important area of healthcare.

The relationship between community resources and state hospital recidivism

OBJECTIVE

The authors examined the propositions that a revolving state hospital door is an inevitable consequence of deinstitutionalization and that enhancing resources for community-based care can limit this phenomenon.

METHOD

They analyzed the recidivism patterns of state hospital patients in a region of Massachusetts where, because of a federal court consent decree, the level of funding for community programs was more than twice as high as it was in other regions in the state and compared the pattern of recidivism in this region with that observed in the other areas of the state.

RESULTS

Despite the fact that the average daily state hospital census in the resource-rich region was only half that of the other regions, longitudinal data on hospital use showed that the readmission patterns were similar in all state regions.

CONCLUSIONS

The authors suggest that attributes of serious and persistent mental illness may have more effect on hospital readmission patterns than service system variables.

Evaluation of a Maryland fiscal incentive plan for placing state hospital patients in nursing homes

In Maryland a six-month fiscal incentive to promote nursing homes' acceptance of chronic patients discharged from state psychiatric hospitals was evaluated after one year. During the fiscal year of the incentive program, such placements (N = 182) increased an average of 38 percent from previous years. Of 163 patients whose placements were evaluated, 22 were returned to the state hospital during the six-month period that the incentive was in place. Ten of the 22 were returned within 30 days of placement. Contrary to expectation, the return rate did not rise after the incentive was discontinued; four patients were returned during the second six months of the study period. Most returns during the first six months were due to patients' physical and verbal threats. The results supported the use of short-term fiscal incentives and emphasized the importance of intensive supportive interventions with chronic mentally ill patients early in the nursing home placement.

National survey of state psychiatric hospital pharmacies

The results of a winter 1990 nationwide mail survey of pharmaceutical services provided in state psychiatric hospitals are reported and discussed. The survey universe consisted of all 207 state psychiatric hospitals registered by the American Hospital Association. Private and federal and other government-operated psychiatric hospitals were not included. Questionnaires were mailed to the director of pharmacy at each institution. Two questionnaires were not deliverable. There were 117 usable replies, for a net response rate of 57.1%. Compared with community hospitals, state psychiatric hospitals had pharmacy departments that were open fewer hours per week, occupied more floor space, were less likely to have a complete unit dose distribution system and i.v. admixture program, had lower inventory turnover rates, and had fewer full-time positions. About 28% of the respondents employed pharmacists who spent at least two thirds of their time providing clinical services. Differences in the provision of pharmaceutical services between state psychiatric hospitals and community hospitals may be due in part to the fact that most of the former are long-term-care institutions rendering a specific class of therapies.

Geriatric patients and services in state hospitals: data from a national survey

Notwithstanding the large-scale deinstitutionalization of the elderly, psychogeriatric patients continue to make up a significant portion of patients in U.S. state hospitals. This paper reports pilot data from a national survey assessing the current status of geriatric populations in state hospitals. Elderly patients still account for one-fifth of state hospital patients, and two-thirds of state hospitals still have separate geriatric units. The data suggest that, while deinstitutionalization of the elderly may be continuing in many state hospitals, in more than one-third of state hospitals the geriatric census is on the rise. Tentative hypotheses suggesting further research are discussed.

Predictions about new long-stay patients: were they valid?

During 1979-1989, the long-stay population in Massachusetts state psychiatric hospitals declined and then moderately increased, although to far below its initial 1979 level. The increase toward the end of the period was due to a growing number of patients admitted, an increase in the proportion of these new patients who were retained for 1 year or longer, and a decrease in discharges of long-stay patients, especially those hospitalized for 20 or more years. The last factor was particularly important and was due to the fact that the number of these very-long-stay patients had become so small by 1983 that the effect of their continued discharge on the total long-stay population was minimal. The authors point out that more community services, not more hospital beds, may be needed. They recommend that states assess the clinical needs of the long-stay population before determining how to allocate their resources to address this phenomenon.

Characteristics of repeatedly assaultive psychiatric inpatients

Investigations of assaults in psychiatric hospitals have found that a small proportion of inpatients are responsible for a large percentage of the violence that occurs. In a large state hospital patients who were repeatedly violent (recidivists) were compared with patients who were violent only once or twice (nonrecidivists), and the relationships between repeatedly violent behavior and gender, age, and diagnosis were examined. All reports of violent incidents over a six-month period for a population of 1,552 inpatients--a total of 497 incidents involving 313 patients--were reviewed. Seventy patients were involved in three or more incidents each and were responsible for 53 percent of all violence. Recidivist men inflicted serious injuries at a rate ten times higher than that for all the other violent patients. Recidivist women were significantly younger than nonrecidivist assaultive women and were about the same mean age as the assaultive men. Recidivist women were also more likely to have organic brain disorder or personality disorder.