Comparison of self-report and clinician-rated measures of psychiatric symptoms and functioning in predicting 1-year hospital readmission

Readmission of Patients to Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric Readmission Rates

Background: Appropriate and adequate treatment of psychiatric conditions in the community or at first presentation to the hospital may prevent rehospitalization. Information about hospital readmission factors may help to reduce readmission rates. This scoping review sought to examine the readmission of patients to acute psychiatric hospitals to determine predictors and interventions to reduce psychiatric readmission rates. Method: A scoping review was conducted in eleven bibliographic databases to identify the relevant peer-reviewed studies. Two reviewers independently assessed full-text articles, and a screening process was undertaken to identify studies for inclusion in the review. PRISMA checklist was adopted, and with the Covidence software, 75 articles were eligible for review. Data extraction was conducted, collated, summarized, and findings reported. Result: 75 articles were analyzed. The review shows that learning disabilities, developmental delays, alcohol, drug, and substance abuse, were crucial factors that increased the risk of readmission. Greater access to mental health services in residential treatment and improved crisis intervention in congregate care settings were indicated as factors that reduce the risk of readmission. Conclusion: High rates of readmission may adversely impact healthcare spending. This study suggests a need for focused health policies to address readmission factors and improve community-based care.

Evolution of Clinical Outcome During Adolescents’ Psychiatric Inpatient Care: A Prospective Multiple Informant Study

Background:

Examining the effectiveness and adequacy of adolescents’ psychiatric inpatient treatment through multiple perspectives is crucial to provide the best care.

Objectives:

The aims of the current study were to examine the consistencies and discrepancies between patients and clinicians and to understand how each group considered the timing of improvement of symptoms and psychosocial difficulties of adolescents during a psychiatric inpatient stay.

Methods:

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA, assessing symptoms and psychosocial difficulties) was rated on a weekly basis by patients and clinicians during a psychiatric inpatient stay. Data were collected from 297 patients, 58.2% females.

Results:

Both clinicians and patients reported a significant decrease of the HoNOSCA scores from admission to discharge, revealing that inpatient treatment is perceived as helping the adolescents to alleviate their symptoms and psychosocial difficulties. However, the item-by-item analyses indicated that patients and clinicians reported difficulties in different symptoms and psychosocial domains. Moreover, the week-by-week analyses revealed discrepancies in the perception of the time-course of clinical outcome- changes between clinicians and patients, as well as between males and females, and between voluntarily and involuntarily admitted patients.

Conclusions:

By integrating perspectives of patients and clinicians and their respective timelines, as well as by taking into account the mode of admission and the patient’s gender, this study provides a deeper understanding of the evolution of clinical outcome during adolescents’ hospitalizations, which allows to adapt their treatment and therewith, to help patients more efficiently.

Physical Comorbidities are Independently Associated with Higher Rates of Psychiatric Readmission in a Chinese Han Population

BACKGROUND

In people with psychosis, physical comorbidities are highly widespread and leading contributors to the untimely death encountered. Readmission rates in psychiatric patients are very high. Somatic comorbidities could be one of the considerable risk factors for psychiatric rehospitalization. Nevertheless, much less is known about the relation between physical comorbidities and psychiatric readmission. We aimed to investigate the association between physical comorbidities and psychiatric readmission in Han Chinese patients with psychiatric disorders.

METHODS

We used administrative data for January 1, 2009 to December 31, 2018 from the headquarters of the Affiliated Brain Hospital of Guangzhou Medical University to identify adults with schizophrenia, unipolar depression or bipolar disorder discharged from hospital. Data were extracted on sociodemographic and clinical characteristics. The Charlson comorbidity index (CCI) was used to assess the existence of significant physical comorbidity. Cox proportional hazards regression estimated rehospitalization risk after discharge.

RESULTS

A total of 15,620 individuals were included in this study, with the mean age of 35.1 years (SD = 12.8), and readmission occurred for 23.6% of participants. Survival analysis showed that physical comorbidities were statistically and significantly associated with psychiatric readmission, even after the adjustment for the number of psychiatric comorbidities, other sociodemographic and clinical variables.

CONCLUSION

Our results suggest that somatic comorbidities are related with higher rates of psychiatric readmission. Hence, to treat psychosis more effectively and to reduce rehospitalization, it is crucial to treat physical comorbidities promptly and adequately. It is absolutely necessary to bring somatic comorbidities to the forefront of psychiatric treatment and research.

Characteristics of the "young-old" and "old-old" community-dwelling suicidal Ideators: A longitudinal 6-month follow-up study

BACKGROUND

Despite heterogeneity of older people in suicidal behavior, research identifying characteristics by age groups is scarce. We examined baseline features of older community-dwelling suicidal ideators by dichotomized age groups and the 6-month trajectory of their suicidal ideation along with its related psychopathology. Predictors of suicidal ideation within each group were investigated.

METHODS

Older community-dwelling suicidal ideators enrolled in the Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior study were subdivided into the "young-old (65-74 years)" and "old-old (≥75 years)" group. Baseline, 1-, and 6-month assessments were compared. Within each group, multiple regression analysis using rating scales (Patient Health Questionnaire-9, Beck Anxiety Inventory, Alcohol Use Disorders Identification Test, Stress Questionnaire for Korean National Health and Nutrition Examination Survey-Short Form, and Social Relationships Scale) was conducted to identify predictors of suicidal ideation measured with the intensity subscale of the Columbia-Suicide Severity Rating Scale. Two-way repeated-measures analysis of variance (RM-ANOVA) was used to compare changes in suicidal ideation, depression, anxiety between age groups over time, and one-way RM-ANOVA to examine changes within each age group.

RESULTS

Among 29 "young-old" and 53 "old-old" ideators, the latter were less likely to be receiving psychiatric treatment (odds ratio [OR] = 4.065) and make suicide attempts (OR = 2.874), whereas the former revealed greater levels of anxiety and stress. Baseline depression and stress in the "young-old" group and the "old-old" group, respectively, predicted the intensity of suicidal ideation at both baseline and 1-month assessments. No significant age group x time interactions on suicidal ideation and depression were found. However, within each age group, both suicidal ideation and depression significantly decreased only during the first month with no further improvement.

CONCLUSION

We speculate cautiously that more attention may need to be paid to the "old-old" ideators in the evaluation of psychiatric issues and for referral to psychiatrists. To decrease suicidal ideation, tailored approaches involving proactive, timely management of depression in the "young-old" and interventions focusing on stress reduction in the "old-old," would be helpful.

A Cross-Lagged Panel Approach to Understanding Social Support and Chronic Posttraumatic Stress Disorder Symptoms in Veterans: Assessment Modality Matters

Although there is a strong and consistent association between social support and posttraumatic stress disorder (PTSD), the directionality of this association has been debated, with some research indicating that social support protects against PTSD symptoms, whereas other research suggests that PTSD symptoms erode social support. The majority of studies in the literature have been cross-sectional, rendering directionality impossible to determine. Cross-lagged panel models overcome many previous limitations; however, findings from the few studies employing these designs have been mixed, possibly due to methodological differences including self-report versus clinician-administered assessment. The current study used a cross-lagged panel structural equation model to explore the relationship between social support and chronic PTSD symptoms over a 1-year period in a sample of 264 Iraq and Afghanistan veterans assessed several years after trauma exposure. Approximately a third of the sample met criteria for PTSD at the baseline assessment, with veterans' trauma occurring an average of 6 years prior to baseline. Two separate models were run, with one using PTSD symptoms assessed via self-report and the other using clinician-assessed PTSD symptoms. Excellent model fit was found for both models. Results indicated that the relationship between social support and PTSD symptoms was affected by assessment modality. Whereas the self-report model indicated a bidirectional relationship between social support and PTSD symptoms over time, the clinician-assessed model indicated only that baseline PTSD symptoms predicted social support 1 year later. Results highlight that assessment modality is one factor that likely impacts disparate findings across previous studies. Theoretical and clinical implications of these findings are discussed, with suggestions for the growing body of literature utilizing these designs to dismantle this complex association.

Psychiatric readmissions and their association with physical comorbidity: a systematic literature review

BACKGROUND

Comorbidity between mental and physical disorder conditions is the rule rather than the exception. It is estimated that 25% of adult population have mental health condition and 68% of them suffer from comorbid medical condition. Readmission rates in psychiatric patients are high and we still lack understanding potential predictors of recidivism. Physical comorbidity could be one of important risk factors for psychiatric readmission. The aim of the present study was to review the impact of physical comorbidity variables on readmission after discharge from psychiatric or general inpatient care among patients with co-occurring psychiatric and medical conditions.

METHODS

A comprehensive database search from January 1990 to June 2014 was performed in the following bibliographic databases: Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. An integrative research review was conducted on 23 observational studies.

RESULTS

Six studies documented physical comorbidity variables only at admission/discharge and 17 also at readmission. The main body of studies supported the hypothesis that patients with mental disorders are at increased risk of readmission if they had co-occurring medical condition. The impact of physical comorbidity variables on psychiatric readmission was most frequently studied in in patients with affective and substance use disorders (SUD). Most common physical comorbidity variables with higher probability for psychiatric readmission were associated with certain category of psychiatric diagnoses. Chronic lung conditions, hepatitis C virus infection, hypertension and number of medical diagnoses were associated with increased risk of readmission in SUD; Charlson Comorbidity Index, somatic complaints, physical health problems with serious mental illnesses (schizophrenia, schizoaffective disorder, personality disorders); not specified medical illness, somatic complaints, number of medical diagnoses, hyperthyroidism with affective disorders (depression, bipolar disorder). Co-occurring physical and mental disorders can worsen patient's course of illness leading to hospital readmission also due to non-psychiatric reasons.

CONCLUSIONS

The association between physical comorbidity and psychiatric readmission is still poorly understood phenomenon. Nevertheless, that physical comorbid conditions are more common among readmitted patients than single admission patients, their association with readmission can vary according to the nature of mental disorders, characteristics of study population, applied concept of comorbidity, and study protocol.

Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature

BACKGROUND

Readmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.

METHODS

Studies on the association between pre-discharge variables and readmission after discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. Relevant publications published between January 1990 and June 2014 were included. For each variable, the number of papers that considered it as a predictor of readmission and that found a significant association was recorded, together with the association direction and whether it was found respectively in bivariate and in multivariate analyses.

RESULTS

Of the 734 articles identified in the search, 58 papers were included in this review, mainly from the USA and concerning patients with severe mental disorders. Analysed variables were classified according to the following categories: patients' demographic, social and economic characteristics; patients' clinical characteristics; patients' clinical history; patients' attitude and perception; environmental, social and hospital characteristics; and admission and discharge characteristics. The most consistently significant predictor of readmission was previous hospitalisations. Many socio-demographic variables resulted as influencing readmission, but the results were not always homogeneous. Among other patients' clinical characteristics, diagnosis and measures of functional status were the most often used variables. Among admission characteristics, length of stay was the main factor studied; however, the results were not very consistent. Other relevant aspects resulted associated with readmission, including the presence of social support, but they have been considered only in few papers. Results of quality assessment are also reported in the review. The majority of papers were not representative of the general psychiatric population discharged from an inpatient service. Almost all studies used multivariate analytical methods, i.e., confounders were controlled for, but only around 60% adjusted for previous hospitalisation, the variable most consistently considered associated to readmission in the literature.

CONCLUSIONS

The results contribute to increase knowledge on pre-discharge factors that could be considered by researchers as well as by clinicians to predict and prevent readmissions of psychiatric patients. Associations are not always straightforward and interactions between factors have to be considered.

Patient-Rated Outcome Assessment With the German Version of the Outcome Questionnaire 45 in People With Severe Mental Illness

Abstract. The purpose of this study was to assess the feasibility and psychometric properties of the German version of the Outcome Questionnaire (Ergebnisfragebogen; EB-45) in people with severe mental illness (N = 294). Reliability and sensitivity to change were assessed. Convergent validity was examined through correlations with the measures Health of the Nation Outcome Scales (HoNOS-D) and Global Assessment of Functioning (GAF), and predictive validity through correlation with length of inpatient stay. The EB-45 showed good reliability and sensitivity to change, as well as good internal consistency for the total score and the subscale “symptom distress.” The EB-45 was found to be acceptable and feasible for use within inpatient psychiatric settings. Also predictive validity was good. However, psychometric properties of the subscales “interpersonal relations” and “social role” were equivocal. Thus, interpreting subscale scores only is not advisable. Also low convergent validity is a concern. Taken together, the EB-45 can be recommended for outcome assessment in a wide range of mental health service settings including inpatient psychiatric services. However, treatment planning and evaluation of effectiveness of services for people with severe mental illness should not be based on EB-45 data alone.

Exploring the predictors of early readmission to psychiatric hospital

BACKGROUND

Aims of this study are to explore the associations of readmission to psychiatric hospital over time, to develop a statistical model for early readmission to psychiatric hospital and to assess the feasibility of predicting early readmission.

METHOD

The sample comprised 7891 general psychiatric discharges in South London, taken from a large anonymised repository of electronic patient records. We initially explored time to readmission using Cox regression - this included investigation of time-dependent effects. Subsequently, we used logistic regression to create a predictive model for 90-day readmission. We investigated the effect on readmission of a set of variables that included demographic variables, diagnosis and legal status during the index admission, previous service use, housing variables and individual item scores on the Health of the Nation Outcome Scales (HoNOS) at admission and at discharge.

RESULTS

Fifteen per cent of those discharged were readmitted within 90 days. Cox regression demonstrated that the estimated baseline hazard of readmission declined steeply after discharge and that the effects of several predictors, especially diagnosis, changed over time - most notably, personality disorder was associated with increased readmission relative to schizophrenia at the time of discharge, but did not significantly differ by 1-year postdischarge. In the logistic regression, increased readmission was associated with personality disorder diagnosis; shorter length of the index admission (excepting zero length admissions); number of discharges in the preceding 2 years; and having a high score at discharge on the HoNOS overactive and aggressive behaviour item, cognitive problems item or hallucinations and delusions items. Detention under Section 3 or a forensic section of the Mental Health Act during the index admission was associated with reduced readmission. The coefficient of discrimination for the logistic regression, which is equivalent to r 2, was 0.04 and the estimated area under the receiver operating curve was 0.65.

CONCLUSIONS

The association found between early readmission and personality disorder diagnosis merits further investigation, as does the possible trade-off between reduction in length of stay and increased readmission. Other novel findings such as the associations found with HoNOS item scores also merit replication. As with previous studies, we found that the rate of readmission declines steeply after hospital discharge, so that the period immediately subsequent to discharge is a period of comparatively high risk. However, prediction of early readmission within this high-risk group remains challenging - it seems most likely that many unmeasured influences operate subsequent to the time of discharge.

The long-term effect on mental health symptoms and patient activation of using patient feedback scales in mental health out-patient treatment. A randomised controlled trial

OBJECTIVE

To investigate the long-term effect on mental health symptoms and patient activation, from using the Partners for Change Outcome Management System (PCOMS) feedback scales in out-patient mental health consultations, compared to not using feedback scales.

METHODS

An open parallel-group randomised controlled trial was conducted in a mental health hospital in Norway. Eight therapists treated the intervention group, using two feedback scales, and seventeen therapists treated the treatment as usual group.

RESULTS

Seventy-five patients participated. Six and twelve months after starting treatment there were no significant effects on the primary outcomes mental health symptoms or patient activation. Compared to baseline assessment the PCOMS group had significantly improved their patient activation scores after twelve months.

CONCLUSION

We found no long-term effects from using the PCOMS scales on mental health symptoms or patient activation.

PRACTICE IMPLICATIONS

This study shows that the use of a feedback system does not increase mental health outcomes or patient activation.

The French adaptation of the Health of the Nation Outcome Scale for Children and Adolescents Self-Rated Form (F-HoNOSCA-SR): validation and clinical routine use

The current study aimed to explore the validity of an adaptation into French of the self-rated form of the Health of the Nation Outcome Scales for Children and Adolescents (F-HoNOSCA-SR) and to test its usefulness in a clinical routine use. One hundred and twenty nine patients, admitted into two inpatient units, were asked to participate in the study. One hundred and seven patients filled out the F-HoNOSCA-SR (for a subsample (N=17): at two occasions, one week apart) and the strengths and difficulties questionnaire (SDQ). In addition, the clinician rated the clinician-rated form of the HoNOSCA (HoNOSCA-CR, N=82). The reliability (assessed with split-half coefficient, item response theory (IRT) models and intraclass correlations (ICC) between the two occasions) revealed that the F-HoNSOCA-SR provides reliable measures. The concurrent validity assessed by correlating the F-HoNOSCA-SR and the SDQ revealed a good convergent validity of the instrument. The relationship analyses between the F-HoNOSCA-SR and the HoNOSCA-CR revealed weak but significant correlations. The comparison between the F-HoNOSCA-SR and the HoNOSCA-CR with paired sample t-tests revealed a higher score for the self-rated version. The F-HoNSOCA-SR was reported to provide reliable measures. In addition, it allows us to measure complementary information when used together with the HoNOSCA-CR.

Factors associated with readmission of patients at a university hospital psychiatric ward in iran

Objectives. Readmission has a major role in the reduction of the quality of life and the increase in the years of lost life. The main objectives of this study were to answer to the following research questions. (a) What was the readmission rate? (b) What were the social, demographic, and clinical characteristics of patients admitted to the Psychiatric Emergency Service at Nour University Hospital, affiliated to Isfahan University of Medical Sciences, Isfahan, Iran? (c) What were the effective factors on readmission? Method. This cross-sectional study was conducted on a total number of 3935 patients who were admitted to Isfahan University Hospital Psychiatric Ward in Isfahan, Iran, from 2004 to 2010. Gender, age, marital status, education, self-report history of previous admission, type of psychiatric disorder, substance misuse, suicide, and the length of the current psychiatric disorder were collected from the registered medical files of patients. The data were analysed using the negative binomial regression model. Results. We found that factors such as psychiatric anxiety disorder, bipolar I, bipolar II, psychotic disorder, depression, and self report history of previous admission were statistically significant in the number of readmissions using the negative binomial model. Conclusion. Readmission to the psychiatric ward is mainly predictable by the type of diagnosis and psychosocial supports.

The short-term effect on alliance and satisfaction of using patient feedback scales in mental health out-patient treatment. A randomised controlled trial

Background

The main aim was to investigate the effect of using two brief feedback scales in mental health out-patient treatment six weeks after starting treatment, compared to treatment as usual. Hypotheses were that use of feedback scales would improve treatment alliance and patient satisfaction.

Methods

An open parallel-group randomised controlled trial was conducted in an out-patient unit in a mental health hospital in Central Norway. Eight therapists trained in using the feedback scales in the Partners for Change Outcome Management System (PCOMS) treated the intervention group. Seventeen therapists treated the controls, providing treatment without using feedback scales. The main outcome measures were treatment alliance and patient satisfaction.

Results

Seventy-five patients participated. There were no differences between the groups in the intention to treat (ITT) analyses on alliance (mean difference = 0.08, 95% CI −0.44, 0.59, p = 0.760) or satisfaction (mean difference = 0.24, 95% CI −1.85, 2.32, p = 0.819), and no statistically significant differences between the groups in the per protocol (PP, n = 58) analyses on alliance (mean difference = 0.32, 95% CI −0.84, 3.16, p = 0.137) or satisfaction (mean difference = 1.16, 95% CI −0.84, 3.16, p = 0.248) six weeks after the treatment started. The effect size in favour of the PCOMS group increased from 0.07 for alliance and 0.06 for satisfaction in the intention to treat analysis to 0.40 on alliance and 0.31 for satisfaction in the per protocol analysis. Among the other outcomes, the PCOMS group had better motivation for treatment (estimated mean difference ITT: 0.29, 95% CI 0.00 to 0.57, p = 0.05, PP: 0.28, 95% CI 0.04, 0.52, p = 0.024).

Conclusion

Six weeks after starting treatment, there were no effects on alliance and satisfaction from using two brief feedback scales. Since the per protocol analyses showed higher effect sizes, future investigations in a larger study with longer follow-up are warranted.

The incremental value of self-reported mental health measures in predicting functional outcomes of veterans

Research on patient-centered care supports use of patient/consumer self-report measures in monitoring health outcomes. This study examined the incremental value of self-report mental health measures relative to a clinician-rated measure in predicting functional outcomes among mental health service recipients. Participants (n = 446) completed the Behavior and Symptom Identification Scale, the Brief Symptom Inventory, and the Veterans/Rand Short Form-36 at enrollment in the study (T1) and 3 months later (T2). Global Assessment of Functioning (GAF) ratings, mental health service utilization, and psychiatric diagnoses were obtained from administrative data files. Controlling for demographic and clinical variables, results indicated that improvement based on the self-report measures significantly predicted one or more functional outcomes (i.e., decreased likelihood of post-enrollment psychiatric hospitalization and increased likelihood of paid employment), above and beyond the predictive value of the GAF. Inclusion of self-report measures may be a useful addition to performance measurement efforts.

Predicting time to readmission in patients with recent histories of recurrent psychiatric hospitalization: a matched-control survival analysis

The most robust predictor of future psychiatric hospitalization is the number of previous admissions. About half of psychiatric inpatients with histories of repeated hospitalizations are readmitted within 12 months. This study sought to determine which patient characteristics predicted time-to-readmission within 12 months after controlling for the number of previous hospitalizations in 75 adults with recent histories of recurrent admissions and 75 matched controls. Results revealed multiple clinical and demographic between-group differences at index hospitalization. However, the only predictors of shorter time-to-readmission in multivariate Cox proportional hazards were unemployment (hazards ratio = 9.26) and residential living status (hazards ratio = 2.05) after controlling for prior hospitalizations (hazard ratio = 1.24). Unemployment and residential living status were not proxies of psychosis or moderated by illness severity or comorbid substance use. Results suggest that early psychiatric readmission may be more influenced by residential and employment status than by severe mental illness.