Incorporating the prevention paradigm into administrative psychiatry

This overview describes the application of primary, secondary, and tertiary prevention-as well as universal, selective, and indicated preventive interventions-to psychiatric and substance use disorders. Ways in which the psychiatrist with a clearly defined administrative role, such as the medical director of a program, service, agency, or organization, or a psychiatrist in some other directorial role (eg, director of education or clinical program director), can apply the prevention paradigm are described. Specifically, a prevention orientation is relevant to administrative psychiatry in the domains of service delivery, education and training, research, and community consultation and advocacy.

A statewide Crisis Intervention Team (CIT) initiative: evolution of the Georgia CIT program

In late 2004, Georgia began implementation of a statewide Crisis Intervention Team (CIT) program to train a portion of its law enforcement officers to respond safely and effectively to individuals with mental illnesses who are in crisis. This overview provides a description of the evolution of the Georgia CIT, including discussions of the historical context in which the program developed; the program's vision, mission, and objectives; the importance of the multidisciplinary Georgia CIT Advisory Board; the training curriculum; the role played by state and local coordinators; the value of stakeholders' meetings; practical operations of the program; the importance of considering the adequacy of community-based and hospital-based psychiatric services; costs and funding; the program's expansion plan; and evaluation, research, and academic collaborations. These detailed descriptions of the Georgia CIT program may be useful for professionals involved in local, regional, or state CIT program planning and may provide a practical synopsis of one example of this collaborative model that is being rapidly disseminated across the U.S.

A comprehensive review of extant research on Crisis Intervention Team (CIT) programs

The Memphis model of the Crisis Intervention Team (CIT) program has established itself as a prototype of law enforcement-mental health collaboration for a large number of municipalities across the country, and several states are implementing statewide training programs that seek to train approximately 20 percent of their police forces. Given the enthusiasm of advocates, law enforcement/public safety personnel, and mental health professionals for the CIT program, and in light of the increasing pace of implementation of this complex collaboration in a multitude of localities across the country, we seek in this review to provide a systematic summary of the very limited available research that has been conducted on CIT to date and to comment on future avenues for research.

Alcohol and cannabis use in Urban, African American, first-episode schizophrenia-spectrum patients: associations with positive and negative symptoms

OBJECTIVE

On the basis of limited prior research on associations between symptoms and substance use in first-episode psychosis, a retrospective chart review was conducted to test 2 hypotheses: (1) the presence of positive symptoms is associated with alcohol use prior to admission and (2) the absence of prominent negative symptoms is associated with cannabis use prior to admission.

METHOD

Eligible patients included those admitted for a first episode of psychosis in a public-sector, university-affiliated hospital that serves a predominantly African American, socially disadvantaged, urban population. The 72 patients included in the analysis were 18 to 40 years of age, and all were African American. Using a structured data collection instrument, discharge summaries of consecutively admitted patients from January 2002 to March 2005 were reviewed to extract data on basic demographic and clinical characteristics, the presence of 11 symptoms, and alcohol and cannabis use within 6 months prior to hospitalization.

RESULTS

Alcohol use in the 6 months prior to hospitalization was associated with a higher frequency of positive psychotic symptoms among first-episode patients. Cannabis use was associated with a lower likelihood of having prominent negative symptoms. These associations remained even after controlling for relevant covariates in logistic regression models.

CONCLUSION

Although the direction of causality cannot be established, the association between positive psychotic symptoms and alcohol use may represent a self-medication effect, whereas the association between lesser negative symptoms and cannabis use may result from the fact that interpersonal deficits and reduced hedonic capacity minimize drug-seeking activities.

Nicotine consumption and schizotypy in first-degree relatives of individuals with schizophrenia and non-psychiatric controls

Individuals with schizophrenia have very high rates of cigarette smoking, and much has been discovered about the influence of nicotine on brain functioning in schizophrenia. However, less is understood about the relationship between nicotine consumption and milder phenotypes related to schizophrenia, specifically schizotypy. This study examined the relationship between nicotine consumption and schizotypy in two unmedicated samples that included first-degree relatives and non-psychiatric controls. Forty-two first-degree relatives and 50 control participants were administered a self-report questionnaire on schizotypal features as well as a self-report questionnaire on smoking behavior. A positive relationship was found between smoking status and level of schizotypy, and higher levels of schizotypy significantly predicted the odds of being a smoker after controlling for gender and group status. Interestingly, group status was a significant moderator in the relationship between level of schizotypy and smoking status, such that the relationship between these two variables was only significant in the first-degree relatives. This is the first study to investigate the relationship between these variables in a sample of first-degree relatives of individuals with schizophrenia. Those individuals with more schizotypal features are presumably at greater risk for schizophrenia-spectrum disorders and thus may be more likely to smoke cigarettes given the known biochemical effects of nicotine on overt positive and negative symptoms of schizophrenia. Although relatives did not differ from controls in their level of self-reported schizotypy, the significant relationship between smoking status and schizotypy in the former group is likely explained by their genetic vulnerability to schizophrenia-spectrum disorders.

Lack of support for the inability to taste phenylthiocarbamide as an endophenotypic marker in patients with schizophrenia and their first-degree relatives

OBJECTIVE

This study sought to replicate recent findings that both patients and relatives are significantly more likely to be phenylthiocarbamide (PTC) nontasters than healthy controls, and that within the patient group, nontasters have more severe positive and/or negative symptoms than tasters. Associations between PTC-tasting status and olfactory identification scores also were examined.

METHOD

PTC perception and olfactory identification were assessed in 48 patients with schizophrenia or schizoaffective disorder, 28 first-degree relatives, and 32 healthy volunteers.

RESULTS

The three groups did not differ in PTC taste sensitivity. Findings did not change after: a sensitivity analysis that re-categorized participants who "possibly" tasted PTC, excluding Caucasian participants, or restricting the sample of patients to only those with schizophrenia. Among the patients, tasters and nontasters did not differ with regard to positive, negative, or general psychopathology symptoms. In the combined sample and the three groups separately, there were no associations between PTC-tasting status and olfactory identification scores.

CONCLUSIONS

This study, conducted specifically as an attempt to replicate previously reported findings, failed to provide support for PTC perception as an endophenotypic marker for schizophrenia. Further research is warranted.

Neurological soft signs and minor physical anomalies in patients with schizophrenia and related disorders, their first-degree biological relatives, and non-psychiatric controls

BACKGROUND

Subtle neurological impairments and inconsequential minor anomalies of the face and limbs are manifestations of neurodevelopmental and ontogenic abnormalities that are consistently found at higher rates in individuals with schizophrenia compared to healthy controls. Limited research has been conducted on these traits among biological relatives of patients with schizophrenia. This study hypothesized that the mean NSS score and the mean MPA score would be greater in patients than controls and that first-degree relatives would have intermediate scores. Furthermore, it was hypothesized that NSS scores and MPA scores would not be correlated. This study also explored correlations between patients' NSS and MPA scores and their relatives' respective scores and sought to replicate the finding that NSS are associated with negative and disorganized symptoms of schizophrenia, whereas MPAs are not.

METHODS

Patients with schizophrenia and related psychotic disorders (n=73), first-degree relatives (n=44), and non-psychiatric controls (n=54) were assessed. Measures included the Neurological Evaluation Scale, a structured examination for MPAs, and the Positive and Negative Syndrome Scale in patients. Analyses accounted for clustering within families.

RESULTS

Both NSS and MPAs were greater in patients than controls, and first-degree relatives had intermediate scores. Furthermore, NSS and MPA scores were independent in all three groups. Correlations were found between patients' and their relatives' scores on one NES subscale (sensory integration) and total MPA score and several MPA regions (eyes, ears, and hands). This study replicated previous findings that in patients with schizophrenia, NSS are associated with negative, disorganized, and other domains of symptoms. Associations between MPAs and symptoms were sparse and inconsistent.

CONCLUSION

These findings suggest that NSS and MPAs represent two quite distinct markers of risk for schizophrenia that may stem from genetic factors, as well as from environmental/developmental influences. Future research on multivariable risk prediction models may benefit from the use of somewhat independent risk markers or endophenotypes.

Facial measurement differences between patients with schizophrenia and non-psychiatric controls

OBJECTIVE

Several previous reports suggest that facial measurements in patients with schizophrenia differ from those of non-psychiatric controls. Because the face and brain develop in concert from the same ectodermal tissue, the study of quantitative craniofacial abnormalities may give clues to genetic and/or environmental factors predisposing to schizophrenia. Using a predominantly African American sample, the present research question was two-fold: (1) Do patients differ from controls in terms of a number of specific facial measurements?, and (2) Does cluster analysis based on these facial measurements reveal distinct facial morphologies that significantly discriminate patients from controls?

METHOD

Facial dimensions were measured in 73 patients with schizophrenia and related psychotic disorders (42 males and 31 females) and 69 non-psychiatric controls (35 males and 34 females) using a 25-cm head and neck caliper. Due to differences in facial dimensions by gender, separate independent samples Student's t-tests and logistic regression analyses were employed to discern differences in facial measures between the patient and control groups in women and men. Findings were further explored using cluster analysis. Given an association between age and some facial dimensions, the effect of age was controlled.

RESULTS

In unadjusted bivariate tests, female patients differed from female controls on several facial dimensions, though male patients did not differ significantly from male controls for any facial measure. Controlling for age using logistic regression, female patients had a greater mid-facial depth (tragus-subnasale) compared to female controls; male patients had lesser upper facial (trichion-glabella) and lower facial (subnasale-gnathion) heights compared to male controls. Among females, cluster analysis revealed two facial morphologies that significantly discriminated patients from controls, though this finding was not evident when employing further cluster analyses using secondary distance measures. When the sample was restricted to African Americans, results were similar and consistent.

CONCLUSIONS

These findings indicate that, in a predominantly African American sample, some facial measurements differ between patients with schizophrenia and non-psychiatric controls, and these differences appear to be gender-specific. Further research on gender-specific quantitative craniofacial measurement differences between cases and controls could suggest gender-specific differences in embryologic/fetal neurodevelopmental processes underpinning schizophrenia.

Assessing knowledge of schizophrenia: development and psychometric properties of a brief, multiple-choice knowledge test for use across various samples

Psychosocial research on schizophrenia would benefit from reliable and valid measures of knowledge about schizophrenia. Although a variety of instruments have been developed to assess the effects of specific family psychoeducational programs, little research has been conducted on the psychometric properties of scales measuring knowledge about schizophrenia. This study assessed reliability and validity of a brief, easily administered, multiple-choice knowledge test completed by 441 participants from several samples: 144 lay community members, 77 family members of inpatients with schizophrenia, 170 police officers involved in a training program on mental illnesses, and 50 mental health professionals. After item analysis, good internal consistency reliability and construct validity were demonstrated for an 18-item version of this test. The findings demonstrate that knowledge about schizophrenia - a construct with potentially broad applicability in psychosocially oriented schizophrenia research - can be assessed with brief, self-administered, multiple-choice knowledge tests.

Associations between schizotypal features and indicators of neurological and morphological abnormalities

OBJECTIVE

Limited research suggests that subtle neurological and morphological abnormalities that have been documented in patients with schizophrenia also may be associated with schizotypal traits in non-psychiatric samples. Based on the notion that neurological soft signs (NSS) may mark a genetic diathesis, this study hypothesized that NSS scores would be related to the level of schizotypy in relatives of schizophrenia patients and in controls. Additionally, associations between MPA scores and schizotypy were explored in these two groups.

METHOD

Twenty-six first-degree relatives of schizophrenia patients and 38 controls with no personal or family history of psychosis were assessed for schizotypy using the Structured Clinical Interview for DSM-IV Axis II Disorders schizotypal personality disorder module, as well as the self-administered Schizotypal Personality Questionnaire. The Neurological Evaluation Scale and a structured examination for MPAs also were administered.

RESULTS

Mean schizotypy scores did not differ between relatives and controls. Both NSS and MPAs were associated with the level of interviewer-assessed schizotypal features in controls but not in relatives of patients with schizophrenia. NSS and MPAs were not associated with self-reported schizotypy in either group.

CONCLUSIONS

These findings demonstrate that both NSS and MPAs are associated with interview-based schizotypal traits, at least in non-psychiatric participants. Future research should seek to replicate these results in other samples of relatives and controls.

Medical outreach following a remote disaster: lessons learned from Hurricane Katrina

In the aftermath of Hurricane Katrina, many individuals were evacuated to the Atlanta area (1,306 medical evacuees, over 100,000 self-evacuees), placing considerable strain on an already overburdened healthcare system. With the aim of improving future disaster responsiveness, we designed this in-depth case study to identify systemic vulnerabilities and gaps in community responsiveness to an influx of evacuees from a remote disaster. Qualitative methods were used to interview key informants both individually and in focus groups. Coding and content analysis of transcribed interview data were used to identify shared observations and common themes. Twenty-three individuals in leadership roles at the Woodruff Health Sciences Center of Emory University or the Grady Health System completed individual interviews; an additional 24 healthcare providers participated in focus groups. A strategy-based data-coding scheme for interview data was used to identify key foci, including services that met needs of evacuees, unmet needs, service provision that was successful/unsuccessful, underlying reasons for success or failure, and future needs for disaster planning and responsiveness. Analysis of interview data revealed important accomplishments and deficits in the medical community's response in specific domains of community disaster planning and evaluation. For each key component of community disaster planning and evaluation, there are considerations at the institutional, regional, state, and federal levels. In the current study, these considerations were identified as instrumental in effectively meeting the healthcare needs of the evacuated population.

Psychometric properties of the Brief Version of the Schizotypal Personality Questionnaire in relatives of patients with schizophrenia-spectrum disorders and non-psychiatric controls

The Schizotypal Personality Questionnaire-Brief Version (SPQ-B), which includes cognitive-perceptual, interpersonal, and disorganized domains, was developed as a concise, self-report measure of schizotypy. This analysis was conducted to: (1) determine the internal consistency reliability of SPQ-B total and subscale scores, (2) use confirmatory factor analysis to assess the three-factor model as well as a single-factor solution, and (3) examine a measure of concurrent criterion validity of SPQ-B scores. The study was conducted at a large, urban, university-affiliated, public-sector health system in the southeastern United States. Data were obtained from 118 participants, including 61 biological relatives of patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder, and 57 non-psychiatric controls. Relatives and controls did not differ significantly on SPQ-B total or subscale scores (or on the full 74-item SPQ total or subscale scores). Internal consistency reliability was adequate for the total SPQ-B score and the interpersonal subscale but was less than ideal for the cognitive-perceptual and disorganized subscales. Regarding the confirmatory factor analysis, though the three-factor solution yielded reasonably good fit to the data, the single-factor solution provided equal fit. Correlations between the three subscales ranged from .63 to .74. With regard to criterion validity, correlations between the SPQ-B total and subscale scores and schizotypy scores derived from a semi-structured, interview-based assessment revealed correlations generally ranging from .40 to .60. The SPQ-B may be a useful brief screening measure of schizotypy, though some limitations in its psychometric properties were evident in this sample. It may be advisable to use total SPQ-B scores rather than subscale scores in some situations, or to use factor analytic techniques to study the instrument's latent structure in specific samples.

Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients

BACKGROUND

The objective of this analysis was to determine the ways in which patients' legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables. This study specifically investigated differences between patients who were voluntary during both admission and discharge, patients who were involuntary on admission but voluntary on discharge (having converted to voluntary status during hospitalization), and patients who were involuntary during both admission and discharge.

METHOD

Data were collected from the charts and treating clinicians of 227 consecutively discharged patients from two psychiatric units in a large, urban, county hospital in the southeastern United States. Based on results of bivariate tests, sociodemographic and clinical factors were entered into a polytomous logistic regression model to determine effect estimates (adjusted odds ratios).

RESULTS

In the bivariate analyses, 15 variables were significantly associated with the trichotomous legal status. In the model, three factors were independently significantly associated with legal status, while controlling for four potential confounders: (1) whether or not the patient was experiencing psychotic symptoms at discharge, (2) whether or not the patient had documented medical problems requiring medication at discharge, and (3) the number of psychiatric medications.

CONCLUSIONS

A generalized lack of treatment engagement and adherence among involuntary patients likely underlies significant differences between the groups in terms of psychotic symptoms, diagnosed medical problems requiring medications, and number of psychiatric medications at discharge. Studying legal status (and the process of legal status conversion from involuntary to voluntary) and its correlates is an important topic for further research.

Associations between olfactory identification and verbal memory in patients with schizophrenia, first-degree relatives, and non-psychiatric controls

OBJECTIVE

Olfactory identification deficits and verbal memory impairments may represent trait markers for schizophrenia. The aims of this study were to: (1) assess olfactory identification in patients, first-degree relatives, and non-psychiatric controls, (2) determine differences in verbal memory functioning in these three groups, and (3) study correlations between olfactory identification and three specific verbal memory domains.

METHOD

A total of 106 participants-41 patients with schizophrenia or related disorders, 27 relatives, and 38 controls-were assessed with the University of Pennsylvania Smell Identification Test (UPSIT) and the Wechsler Memory Scale-Third Edition. Linear mixed models, accounting for clustering within families and relevant covariates, were used to compare scores across groups and to examine associations between olfactory identification ability and the three verbal memory domains.

RESULTS

A group effect was apparent for all four measures, and relatives scored midway between patients and controls on all three memory domains. UPSIT scores were significantly correlated with all three forms of verbal memory. Age, verbal working memory, and auditory recognition delayed memory were independently predictive of UPSIT scores.

CONCLUSIONS

Impairments in olfactory identification and verbal memory appear to represent two correlated risk markers for schizophrenia, and frontal-temporal deficits likely account for both impairments.

Brief reports: crisis intervention team training: changes in knowledge, attitudes, and stigma related to schizophrenia

OBJECTIVE

Crisis intervention team (CIT) training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses. This study determined changes in knowledge, attitudes, and social distance related to schizophrenia among police officers after CIT training.

METHODS

A survey was administered to 159 officers immediately before and after a 40-hour CIT training program in Georgia. Pre- and posttest data were gathered from surveys taken between December 2004 and July 2005.

RESULTS

After the training, officers reported improved attitudes regarding aggressiveness among individuals with schizophrenia, became more supportive of treatment programs for schizophrenia, evidenced greater knowledge about schizophrenia, and reported less social distance toward individuals with schizophrenia.

CONCLUSIONS

This study supports the hypothesis that an educational program for law enforcement officers may reduce stigmatizing attitudes toward persons with schizophrenia.

A descriptive study of pathways to care among hospitalized urban African American first-episode schizophrenia-spectrum patients

BACKGROUND

Studying pathways to care, or contacts made during the period of time from the onset of illness until the first initiation of treatment, is critical for understanding how to improve the early recognition and treatment of mental disorders. However, little is known about pathways to care among patients with first-episode psychosis in the United States. The objectives of this study were to examine the pathways to care and number of help contacts prior to hospitalization in first-episode patients, and to ascertain the frequency of contact with primary care providers and police.

METHOD

Pathways to care, including all contacts for help from the onset of prodromal symptoms until first hospital admission, were assessed in 25 urban African American patients. Other measures were obtained as part of an ongoing study of predictors of the duration of untreated psychosis.

RESULTS

The median durations from the onset of illness to hospital admission and from the emergence of positive psychotic symptoms to hospital admission were 128.0 weeks (range 0.6-476.9) and 32.9 weeks (range 0.4-337.7), respectively. Of the 83 total contacts, 17 were with police, whereas only four were with primary care providers. While the number of contacts per patient ranged from one to eight, 16 of the 25 patients were admitted within 1 week of their first contact for help.

CONCLUSIONS

The findings indicate that pathways to care in this population are highly variable, and there is a need for additional research to better understand the nature and determinants of these pathways. Such investigations may provide insights into service enhancements that can promote early detection and intervention, thus improving illness outcomes.

Cigarette smoking and overweight/obesity among individuals with serious mental illnesses: a preventive perspective

BACKGROUND

Cigarette smoking and lifestyle factors underlying overweight/obesity (such as unhealthy diet and physical inactivity) appear to play a major role in the excess medical morbidity and mortality among persons with serious mental illnesses. The literature on the prevalence, etiology, prevention, and treatment of these two risk factors, in the context of serious mental illnesses, are reviewed following a preventive approach.

METHODS

The review relied upon searches of the MEDLINE database, from 1996 through April 2006, restricted to the English language. Original research, review articles, and clinical guidelines relevant to the topics of cigarette smoking, unhealthy diet, physical inactivity, and overweight/obesity among individuals with serious mental illnesses were identified.

RESULTS

Compared to those without a mental illness, individuals with a current mental illness are more than twice as likely to smoke cigarettes and more than 50% more likely to be overweight/obese, presumably the product of unhealthy diet and physical inactivity. Various biological, iatrogenic, and social factors place psychiatric patients at risk for these and other adverse health behaviors. Studies suggest that many of the same preventive approaches developed for general medical populations are likely to be effective in persons with serious mental disorders, though specialized approaches also are needed. Domains of prevention include primary prevention (population-based strategies to reduce the incidence of these adverse health behaviors), secondary prevention (early detection and treatment), and tertiary prevention (pharmacological and psychosocial treatments to reduce the burden of illness among those with the behaviors in question). However, mental health clinicians commonly lack the training or expertise to provide these services.

CONCLUSIONS

The high prevalence, adverse effects, and efficaciousness of treatments for smoking and obesity in persons with serious mental illnesses suggest the importance of addressing these problems in this population. Both further research and dissemination efforts are needed to ensure that patients with serious mental illnesses receive the appropriate preventive and clinical services for these two adverse health conditions.

Factor structure of the Neurological Evaluation Scale in a predominantly African American sample of patients with schizophrenia, unaffected relatives, and non-psychiatric controls

OBJECTIVE

This study aimed to identify latent factors of the most widely used scale to measure neurological soft signs, the Neurological Evaluation Scale (NES), in a sample of schizophrenia patients, their relatives, and non-psychiatric controls.

METHOD

The NES was administered following the format and instructions of the original scale [Buchanan, R.W., Heinrichs, D.W., 1989. The Neurological Evaluation Scale (NES): a structured instrument for the assessment of neurological signs in schizophrenia. Psychiatry Res. 27, 335-350]. Three factor analyses were conducted using: (1) 23 items of the scale, (2) these 23 items in a sample restricted to African American participants, and (3) 12 items previously recommended based on adequate inter-rater reliability [Sanders, R.D., Forman, S.D., Pierri, J.N., Baker, R.W., Kelley, M.E., van Kammen, D.P., Keshavan, M.S., 1998. Inter-rater reliability of the neurological examination in schizophrenia. Schizophr. Res. 29, 287-292].

RESULTS

Exploratory factor analysis in the overall sample (n = 110) revealed three factors of interest: a "coordination/Romberg" factor (which included the fist-edge-palm test, finger-thumb opposition, rapid alternating movements, and the Romberg test), a "sensory integration" factor (which included synkinesis, extinction, stereognosis, and audio-visual integration), and an "eye movements/tandem walk/overflow movements" factor (which included convergence, gaze impersistence, tandem walk, and adventitious overflow). Minimal differences were apparent when comparing these results with those obtained from an analysis including only African American participants (n = 99). Restricting the analysis to only 12 items resulted in two factors (with poor discriminant validity and internal consistency), which showed few similarities with previously reported exploratory factor analysis results.

CONCLUSIONS

This study shows that results of empirically-derived factors of the NES vary substantially across study samples and research groups, though there appear to be at least two consistent latent variables, one related to the repetition of motor tasks and another tapping the processing of sensory stimuli. The factors demonstrated in the present study are more consistent with the original conceptually-derived subscales than prior factor analyses. Thus, until further research replicates consistent subscales of subtle neurological impairment in a variety of settings and samples, the total NES score may be more useful when comparing results across studies. Further research on latent neurological factors is needed.

Causes of schizophrenia reported by family members of urban African American hospitalized patients with schizophrenia

Family members often provide psychosocial support and assistance in seeking treatment for individuals with schizophrenia. It is crucial to understand what family members believe to be the causes of schizophrenia, as this likely influences the family's help-seeking decisions. The aim of this descriptive study was to investigate the causes of schizophrenia reported by family members of African Americans hospitalized with schizophrenia. Sixty-one family members of 38 patients with a first episode or an acute exacerbation of persistent illness were administered a survey containing 30 possible causes of schizophrenia from 5 categories. The sample endorsed predominantly biologic causes. Many family members also endorsed personality and societal causes, as well as family and esoteric causes. Compared with family members in the persistent group, family members in the first-episode group were more likely to select personality or societal causes in addition to biologic causes. These results provide insight into the etiologic beliefs of a sample of African American family members. Further research is needed to assess the potential influence of these beliefs on treatment seeking on the part of the family.

Determinants of health plan membership among patients in routine U.S. psychiatric practice

This study utilized a large clinical dataset of patients representative of those in routine U.S. psychiatric practice to assess the influence of sociodemographic variables and diagnostic class on health plan membership (public or private). Data on patients with schizophrenia or other psychotic disorders (n=288) and patients with mood or anxiety disorders (n=1304) were obtained from a cross-sectional practice-based survey conducted by the American Psychiatric Institute for Research and Education. The likelihood of health plan membership was lower among males and among those from a minority race/ethnicity. Health plan membership was also affected by educational attainment and employment status. Even after controlling for these sociodemographic determinants of health plan membership, individuals with schizophrenia/other psychotic disorders were significantly less likely to belong to a health plan than those with mood/anxiety disorders.

Predictors of missed first appointments at community mental health centers after psychiatric hospitalization

OBJECTIVE

This study was conducted to determine the practical, readily accessible predictors of missed first outpatient appointments in a community mental health setting after psychiatric hospitalization.

METHODS

Data were collected from treatment team members and from charts of 234 consecutively discharged patients from two inpatient units in a large, urban, county hospital. Data on whether the patient attended the first scheduled outpatient community mental health appointment were gathered by telephone contact with outpatient clinics. Outcome data were available for 221 patients. Bivariate tests examined a variety of demographic, psychosocial, and clinical characteristics that may be associated with nonadherence. Significant predictors were entered into a logistic regression model to determine effect estimates (adjusted odds ratios).

RESULTS

In bivariate tests, a number of variables were predictive of nonadherence with the first scheduled outpatient appointment. In the logistic regression model, the four characteristics that were independently significant predictors included involuntary legal status at discharge or leaving against medical advice, not having an established outpatient clinician, axis IV problems related to the primary support group (for example, death of a family member or health problems in the family), and number of days from hospital discharge to the follow-up appointment.

CONCLUSIONS

Clinical, policy, and programmatic implications may be elaborated by studying risk factors for nonadherence in a community mental health setting. Given the multitude of problems associated with nonadherence, interventions should be tailored around specific characteristics that elevate the risk of nonadherence, especially nonadherence in the form of failure to attend the first appointment after psychiatric hospitalization.

Prolonged duration of untreated psychosis in nonaffective first-episode psychotic disorders compared to other psychoses

Introduction. While the consequences of the duration of untreated psychosis (DUP) represent an active area of research, less attention has been focused on the determinants of the DUP. This analysis assessed several potential determinants of the DUP from a practice-based survey. Method. Data on selected patients in their first treatment episode for psychotic symptoms were obtained from 104 practicing physicians. Patients with a long DUP (n=31), defined as >4 weeks, were compared to patients with a short DUP (≤4 weeks, n=28). Results. The long-DUP group had a higher percentage of patients with nonaffective psychotic disorders (58%) compared to the short-DUP group (29%). The median DUP among those with nonaffective psychotic disorders was 8 weeks, compared to 3 weeks among those with other psychotic disorders. The long-DUP group had a higher percentage of patients rated as uncertain about or denying a mental illness (55% compared to 25% in the short-DUP group). The presence of negative symptoms approached significance in terms of differentiating between the two groups, with 66% of the long-DUP group having negative symptoms compared to 39% of the short-DUP group. When three variables (nonaffective psychotic disorder versus other psychoses, insight, and negative symptoms) were entered into a logistic regression model, only diagnostic category remained an independently significant predictor. Conclusion. In this practice-based sample, patients with nonaffective psychotic disorders were more likely to have a longer DUP than patients who developed psychotic symptoms in the context of mood disorders, substance use disorders, or other disorders.

Determinants of inpatient psychiatric length of stay in an urban county hospital

This study investigated predictors of length of stay (LOS) for two inpatient psychiatric units (a crisis stabilization unit and a longer-stay milieu unit) in a large, urban, university-affiliated, county hospital. It was hypothesized that three variables would be independently associated with shorter LOS: (1) higher Global Assessment of Functioning (GAF) scale scores, (2) not requiring the use of seclusion or restraints, and (3) the presence of a comorbid substance use disorder. Data were collected on consecutive discharges (n=234) from the two inpatient units. Bivariate tests were conducted, and multiple linear regression models assessed the independent effects of potential determinants of LOS. The presence of a comorbid personality disorder or substance use disorder was predictive of shorter LOS on the crisis stabilization unit (n=88). Several variables were found to be predictive of shorter LOS on the longer-stay milieu unit (n=146), including: involuntary legal status on discharge, not requiring seclusion or restraints, higher admission GAF scale score, female gender, and the presence of a comorbid substance use disorder. Findings indicate that a substantial portion of the variance in LOS in this setting can be predicted from basic sociodemographic and clinical factors available in hospital medical charts.

Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health

Following a brief introduction to response planning for terrorism and other disasters, the authors present their experiences in developing a grassroots, interdisciplinary group charged with incorporating a mental health response component into the bioterrorism response plan for the metropolitan Atlanta area. This group was organized and supported by the Center for Public Health Preparedness at the DeKalb County Board of Health. Various viewpoints of key participating agencies are presented. Recommendations are provided for other localities and stakeholders who plan to incorporate a community mental health component into local disaster response plans.