Recidivism and mental illness: the role of communities

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature

BACKGROUND

Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.

METHODS

Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.

RESULTS

Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.

CONCLUSION

This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

REDUCED REHOSPITALIZATIONS AND REINTEGRATION OF PERSONS WITH MENTAL ILLNESS INTO COMMUNITY LIVING: A HOLISTIC APPROACH

The goal of inpatient rehabilitation services should be directed towards returning persons with mental illness to the community by producing measurable gains in functioning that promote increased personal independence, self-direction, and care to prepare the patient to live in the least restrictive environment. Aftercare compliance was increased and the recidivism rate was cut in half when the aftercare nurse saw the person with mental illness before discharge and a specific appointment was scheduled with the aftercare nurse. The scope of community outpatient services that can be authorized is determined by the outcome of negotiating and communicating between the clinician and case manager.

The relationship between supply and hospitalization rates for mental illness and substance use disorders

This study investigated the extent to which mental illness and substance use hospitalization rates were related to the supply of psychiatric treatment services. Supply variables, notably the per capita rate of psychiatrists, primary care physicians, and specialty units, were strongly related to mental illness and substance use hospitalization rates to acute care hospitals across 114 small geographic areas in Iowa. The supply of outpatient services was not related to hospitalization rates. The need to study the reliability of patient assessment processes, refine guidelines and admissions criteria, and understand the contributions of supply variables to hospitalization rates are indicated by these results. A conceptual model is offered within which the dynamic cycle from patient functioning to service delivery may be framed.

Environmental context of caregiving for severely mentally ill adults: an African American experience

Most people with severe mental illness depend on family to provide care. Although an increasing amount of research has examined caregiving, there is much to be discovered about the caregiving experience of African American families. This ethnographic study reports findings from 16 African American caregivers, presenting a picture of how they navigate through their environment to meet the needs of caregiving. Formal resource selection and use, and perceived barriers to and facilitators of care within an urban environment, are discussed. The impact of the African American community's perception of mental illness on caregiving and involvement in policy change also is discussed.

[Elements for changing a prevailing psychiatric care model]

This study presents the results of research done at the Pedro II Psychiatric Center in 1995, as part of a partnership between the Center and the Universidade do Estado do Rio de Janeiro. Research includes the development of a profile for inpatients based on clinical and socioeconomic data from patient files, emergency ward assessment of the group's interactive abilities based on WHO parameters, and a critical analysis of the psychiatric care model employed in the Psychiatric Center. With the psychiatric reform pursued by major sectors of Brazilian society we intend not only to respond to the economic/administrative irrationality created by 'hospital-centrism', but especially to meet the needs of patients, health professionals, and society in general in moving away from a psychiatric care model dominated by the reference patterns of psychiatry and to de-institutionalize mental health. The results of this study criticize the biomedical model and open the door to a care model engaged in psychosocial rehabilitation. The critical analysis based upon the data from the investigation done at the Psychiatric Center should be applicable to other psychiatric hospitals in Brazil's public and private sectors.

Clients with schizophrenia and their caregivers' perceptions of frequent psychiatric rehospitalizations

The purpose of this phenomenological study was to achieve an understanding of the lived experience of the event of rehospitalization as seen by the schizophrenic patient and his or her designated caregiver. Five schizophrenic clients who met criteria and their designated caregivers were located using purposeful intensity sampling. A standardized open-ended interview was conducted with each informant using a dialogical approach. After redundancy was reached, data were analyzed using the constant comparative method. Five themes reflecting the meaning of recidivism evolved from the data. These included rehospitalization as an event that: provided a safe place, provided stabilization of medication, produced a renewal of hope, reinforced frustration with the mental health care system, and produced decreased individual control. Findings can be used to develop a more comprehensive model of care for intervention with patients and caregivers.

Small area variation in the utilization of mental health services: implications for health planning and allocation of resources

OBJECTIVE

To determine the variables associated with utilization of mental health services and to develop a planning model to predict service utilization that incorporates these factors.

METHOD

A regression analysis of service utilization and demographic characteristics was used to assess the relative importance of alternative service, supply of psychiatrists and demographics in explaining variations of services use. A model using socioeconomic factors was applied to the population to predict need.

RESULTS

The percentage of divorced males was the only factor significantly and positively correlated with the utilization of hospital inpatient and provincial psychiatric beds. Predicted need exceeds utilization in 7 out of 10 areas for all services.

CONCLUSIONS

Small area variations in inpatient psychiatric utilization is correlated with community characteristics, not supply of psychiatrists or utilization of alternative services. A model has been developed using census data to allocate resources according to need.

A proposed vision for psychiatry at the turn of the century

Throughout the 20th century, a series of rapidly changing emphases have been prominent within psychiatry, each one dominating a period spanning two or more decades. This pattern, along with other historical trends, has contributed to both a diffusion and a confusion about what psychiatry is and what it stands for, affecting the credibility of the profession. As psychiatry approaches the turn of the century, it is critical that psychiatrists and organized psychiatry define and agree upon a coherent vision that will serve as a foundation for a shared understanding with others regarding what the profession represents. Five principal themes are discussed here, emanating from both past and recent history, that can provide this definition to all concerned. The adoption of a biopsychosocial model by all psychiatrists regardless of personal areas of interest or emphasis is the first building block and needs to be coupled with strong support for the continuing evolution of a scientific base and the scientists who are pursuing it. Healthcare reform and the pressures from other nonmedical professions that have reshaped psychiatry's "marketplace" require that a third theme revolve around a reshaping of psychiatry's relationship with the rest of medicine and psychiatrists' interactions with their medical colleagues. Finally, a new set of liaisons with our patients must be built through a redefinition of professional values and an enhanced emphasis on patient rights and responsibilities that will empower our patients to act as our strongest supporters.

A small area analysis of psychiatric hospitalizations to general hospitals. Effects of community mental health centers

Population-based psychiatric admission rates vary across geographic areas, but reasons for this variation are unknown. Insofar as Community Mental Health Centers (CMHCs) provide outpatient services that may deter the need for hospitalization, the presence and structural characteristics of CMHCs may have an impact on a population's psychiatric admission rates. This study uses small area analysis to examine how general hospital psychiatric admission rates are associated with CMHC characteristics. Based on a survey of all CMHCs in Iowa and corresponding small area variation data, it was found that population admission rates were higher in areas closer to the CMHC and lower in outlying catchment areas, adjusting for age, sex, and urban/rural differences in populations. There was little evidence that differences in staffing and service variables influenced admission rates, although greater CMHC staff coverage by social workers and psychiatric residents was associated with lower admission rates. The results suggest that CMHCs do not lower an area's hospitalization rate, and in fact, the presence of CMHCs may promote a "supplier-induced demand" phenomenon of higher admissions.