A psychiatrist-rated battery of measures for assessing the clinical status of psychiatric inpatients

Addiction and suicidal behavior in acute psychiatric inpatients

OBJECTIVE

This study aims to evaluate the relationship of alcohol/drug use and effect severities to the degree of suicidality in acutely admitted psychiatric patients. Both degree of substance dependency and degree of substance-induced syndrome were analyzed. In addition, length of stay, involuntary status, and against medical advice discharge status were determined as they related to these variables.

METHODS

Structured clinical admissions and discharge ratings were gathered from 10,667 consecutive, single-case individual records, from an urban acute care county psychiatric hospital.

RESULTS

Data indicate that of the most severely suicidal group, 56% had substance abuse or dependence, 40% were rated as having half or more of their admission syndrome substance induced, and most had nonpsychotic diagnoses. There was an inverse relationship between degree of substance problem and length of stay. Although these patients more commonly left against medical advice, and were readmitted more frequently, they were less likely to be involuntarily committed.

CONCLUSIONS

A large, potentially lethal, and highly expensive subgroup of patients has been characterized, which might be called the "New Revolving Door acute psychiatric inpatient." This group, which uses the most expensive level of care in the mental health system but is substantially addiction related, poses special challenges for inpatient psychiatric units, addiction treatment providers, and health care planners.

Test of a single-item posttraumatic stress disorder screener in a military primary care setting

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent in primary care, frequently goes undetected and can be highly debilitating when untreated.

OBJECTIVE

We assessed the operating characteristics of a single-item PTSD screener (SIPS) for primary care and compared it to a commonly used four-item primary care PTSD screener (PC-PTSD). The SIPS asks: "Were you recently bothered by a past experience that caused you to believe you would be injured or killed ... not bothered, bothered a little, or bothered a lot?"

METHODS

A total of 3,234 patients from three Washington, DC, area military primary care clinics completed the SIPS. Independent, blinded assessments using a structured diagnostic PTSD interview were completed in 213 of these patients.

RESULTS

The SIPS yielded a reasonable range of likelihood ratios, suggesting capacity to discriminate between low- and high-probability PTSD patients. However, the SIPS sensitivity was only 76% for those reporting "bothered a little" and the four-item PC-PTSD yielded significantly better test characteristics on Receiver-Operator Curve analysis.

CONCLUSION

A single, user-friendly primary care PTSD screening question with three response options, while sensible and worth further investigation, failed to offer sound test characteristics for PTSD screening. Ways of improving SIPS performance are discussed.

Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Evaluation of the Computerized Assessment System for Psychotherapy Evaluation and Research (CASPER) as a measure of treatment effectiveness with psychiatric inpatients

Assessment procedures to evaluate inpatient treatment effectiveness can provide information to inform clinical practice. The Computerized Assessment System for Psychotherapy Evaluation and Research (CASPER) represents a standardized approach to assess patients' target problems that combines elements of individualized and nomothetic approaches. Although previous evaluations of CASPER with other patient populations have been encouraging, its use as a measure of change with an inpatient population has not been examined. In this study, 75 psychiatric inpatients completed CASPER and the Behavior and Symptom Identification Scale-32 (BASIS-32) at hospital admission and discharge. Results supported the concurrent validity of CASPER as a measure of pre- and posttreatment functioning and suggested that CASPER may provide a sensitive measure of change during inpatient treatment. Findings also supported the notion that patients' ratings of the extent to which their treatment focused on the problems they identified as a high priority were related to their overall treatment satisfaction.

Substance abuse and recovery in a Psychiatric Intensive Care Unit

OBJECTIVES

The purpose of this study is to compare the development in symptoms, behaviors, function and treatment between patients with or without a substance use (SU) diagnose in a Psychiatric Intensive Care Unit (PICU).

METHODS

A total of 118 admitted patients were assessed at admittance, day 3 and discharge from the PICU. Symptoms of psychopathology, therapeutic steps taken, violent episodes and length of patient stay were recorded.

RESULTS

More males than females received an SU diagnosis. Substance use patients had less psychiatric symptoms at admittance and showed a faster symptom reduction, more favorable and faster improvement of function and a shorter length of stay. Except for symptom reduction and shorter length of stay, these differences were largely due to differences in sex and diagnoses in the two groups.

CONCLUSION

In a naturalistic group of patients in a PICU, SU is associated with favorable outcomes compared to patients not using substances.

Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients

BACKGROUND

Suicide is a major risk for those with bipolar disorder, a risk amplified by comorbid substance abuse in some, but not all, previous studies. To further explore the relationships of substance abuse, suicide, and bipolarity as they present in clinical practice, we analyzed standardized clinical data from a large acute psychiatric inpatient service.

METHODS

Standardized clinical evaluations of 7819 patients with diagnoses of bipolar depression (n=990), bipolar mania (n=948), unipolar depressive episode (n=3626), or schizophrenia-schizoaffective disorders (n=2255) were analyzed to evaluate the relationship between current substance-use problems, substance-induced symptoms, and a current suicide crisis, as well as lifetime suicide attempts, with logistic regressions adjusting for age, gender, and ethnicity.

RESULTS

Across the combined groups, current substance-use problems were significantly associated with a lifetime suicide attempt (odds ratios [ORs] 1.6-2.5) and to a lesser degree to the admission suicide crisis (ORs 1-2.2). Among bipolar (depressed/manic) patients, but not other diagnostic groups, those with both current substance-use problems and substance-induced symptoms had even higher rates of a recent suicide crisis (ORs 1.5-3.1) and of a lifetime attempt (ORs 2.5-3.4).

CONCLUSIONS

In bipolar patients, substance use disorder doubled and substance use disorder plus substance-induced symptoms tripled the suicidal risk. Implications for future research are discussed.

Geriatric Patients Improve as Much as Younger Patients from Hospitalization on General Psychiatric Units

OBJECTIVES

To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission.

DESIGN

Cohort study.

SETTING

Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999.

PARTICIPANTS

A total of 5,929 inpatients.

MEASUREMENTS

Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses.

RESULTS

Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients.

CONCLUSION

Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Comparison of clinical efficacy and side effects for bitemporal and bifrontal electrode placement in electroconvulsive therapy

OBJECTIVES

Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has become a popular alternative to bitemporal (BT) placement. This study compares the clinical efficacy, side effects, and rehospitalization rates of BT and BF electrode placement in a community hospital setting.

METHODS

Charts from 76 patients receiving ECT treatments at Harborview Medical Center from 1994 to 2000 were reviewed to extract data on the characteristics of the course of ECT, clinical response, total headaches, narcotic and nonsteroidal anti-inflammatory drug doses, as well as documentation of confusion, disorientation, memory loss, and treatment emergent need for assistance with activities of daily living.

RESULTS

The BT patients experienced more clinical improvement during their stay (a 7-point greater change in Psychiatric Symptom Assessment Scale score, P < 0.05) and were significantly less likely to be rehospitalized within a 1-year time frame (odds ratio = 4.9, P = <0.05), even after controlling for relevant covariates. Although the two patient groups had equal rates of headache and analgesic administration, the BT placement caused significantly more cognitive impairment.

CONCLUSIONS

This study suggests that BT electrode placement offers better efficacy but modestly greater cognitive impairment than BF electrode placement.

Further validation of the Psycho-Social Well-Being Scale (PSWS) with community clients

To monitor and evaluate the use of evidence-based approaches with mentally ill persons who abuse alcohol and other drugs, administrators, practitioners and evaluators will need to incorporate brief, reliable, and valid instruments into daily practice. The current two-part study provides further validation of the Psycho-Social Wellbeing Scale (PSWS), a multidisciplinary "debriefing tool" designed to capture and summarize data on clients' wellbeing from multiple sources in team-based community care. In the current investigation the PSWS was correlated with a number of valid instruments including the Brief Psychiatric Rating Scale, the Role Functioning Scale, the Social Functioning-12, the Alcohol Use Disorders Identification Test, the Alcohol Use and Drug Use Scales along with other important indices. Results show strong evidence of internal consistency, concurrent and discriminant validity with these criterion variables. Regression modeling demonstrates that the two main subscales (psychological and social wellbeing) add significantly to a model predicting substance abuse problems.

Transfer of care between physician teams does not affect length of stay or symptomatic improvement in hospitalized psychiatric patients

To determine if the length of stay, discharge against medical advice (AMA) or psychiatric symptom severity differs when patients are treated by a single team of physicians versus transfer to a second team all cases (N=1304) admitted to the high intensity psychiatric unit then transferred to a lower intensity unit of a single hospital over 39 months were reviewed. A modified version of the Psychiatric Symptom Assessment Scale (PSAS) was completed on admission and discharge. Statistical analyses including linear and logistic regressions were performed. We found that the length of stay (mean +/-SD) was 18.7+/-10.9 days for transferred patients (N=871) and 18.3+/- 10.6 days for those cared for by only one team (P=.507). Discharge PSAS scores (11.8+/-9.4 for transferred patients and 14.2+/-10.4 for those who kept their physicians), were not different between groups after adjustment for severity on admission. Discharges against medical advice were not different between the groups (P=.207). Although the previous internal medicine literature and single psychiatric study describe a longer length of stay for those patients transferred between physicians, this study shows no differences in terms of length of stay, severity on discharge or AMA discharge rate.

Interrater reliability of the Brief Psychiatric Rating Scale used at a community-based inpatient crisis stabilization unit

In 1993, the State of Georgia passed a law reforming the mental health system to include more consumers of services and their families on local boards, to provide services in the community, and to measure and report the outcomes of these services. As mental health services expanded in the community, it became necessary to extend the use of reliable and valid instruments appropriate to a brief treatment setting. This field study investigates the usefulness of the Brief Psychiatric Rating Scale (BPRS) using paired ratings to measure the level of psychiatric symptoms of clients treated in an urban community inpatient crisis stabilization unit. Interrater agreement for all paired assessments exceeded .85 comparing favorably with previous studies reported in the literature. The BPRS was found to be a useful and efficient instrument in this community setting.

A brief medical necessity scale for mental disorders: reliability, validity, and clinical utility

Managed care organizations (MCOs) use the concept of "medical necessity" to decide whether a prescribed treatment is warranted for a given medical condition. Because mental disorders lack the objective disease criteria common to medical illness, behavioral health administrators need a validated means to identify and quantify the severity of "medically important" aspects of mental disorders. The authors developed and tested a brief medical necessity scale for mental disorders in 205 patients presenting for initial evaluation. The scale had a factor structure with four subscales; good internal consistency, interrater reliability, and concurrent and predictive validity; and modest ability to identify patients requiring hospitalization and, in hospitalized patients, those requiring involuntary hospitalization. The authors propose use of the scale to better clarify decisions about level of care assignments and to better assess patient characteristics predictive of good outcome.

Interpreting profiling data in behavioral health care for a continuous quality improvement cycle

OUTCOME MEASUREMENT SYSTEM: PsychSentinel, a symptom reduction measure, uses 20 diagnostically defined symptom checklists derived from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Symptoms are enumerated and are assigned weights on the basis of clinical significance, providing an overall assessment of symptom intensity. The availability of multisite benchmark norms makes possible the computation of observed-to-expected ratios.

EXAMPLES OF THE CONTINUOUS QUALITY IMPROVEMENT CYCLE

Six examples, drawn from the experience of a number of behavioral health care programs since 1994, illustrate how outcome data can be used to guide and test changes that will effect improvements over current practices. Example 1: Problem identification is one of the most obvious and immediate applications of outcome data relative to a quality improvement process. Data were presented at a meeting of the hospital medical staff; the data showed that one clinician had significantly poorer outcomes in treating bipolar patients. A review of the medical records for bipolar patients treated by this clinician indicated that this clinician was changing medications too rapidly, a problem that was quickly and easily corrected-with improved outcomes. Example 6: Data revealed that patients who were treated in accordance with the critical pathway showed a greater degree of improvement, even though these patients entered treatment with a 10% greater level of symptom intensity.

SUMMARY AND CONCLUSIONS

Each example provides a sample of variability in outcomes and therefore an opportunity to study the reasons for the variability and institute changes.

Measuring treatment outcome for adults and adolescents: reliability and validity of BASIS-32

This article examines the reliability and validity for adults and adolescents of Behavioral and Symptom Identification Scale (BASIS-32), a 32-item patient-report instrument designed to facilitate psychiatric outcome assessment of adult inpatient populations. This study extends the original analysis of the psychometric properties of BASIS-32 to a different site, using a self-report rather than interview format and samples of both adult and adolescent patients. Responses to the BASIS-32 are reported for two groups of patients consecutively admitted between 1991 and 1994: adults over 18 years old (n = 462) and adolescents between 12 and 18 (n = 244). Results of this investigation confirm the utility of BASIS-32 as an easily administered and scored self-report outcome assessment tool for adult psychiatric patients. Its utility for adolescent patients was not as clearly demonstrated.

The relationship of patient-administered outcome assessments to quality of life and physician ratings: validity of the BASIS-32

The reliability and validity of a patient-administered version of the Behavior and Symptom Identification Scale (BASIS-32) was compared to the original interviewer-administered version. The construct validity of BASIS-32 subscales was assessed by examining their relationship with functional and satisfaction quality of life and physician ratings of functional and clinical status. A total of 361 acute psychiatric inpatients were given a self-administered BASIS-32, nurse-administered Lehman's Quality of Life Interview (QOLI), and Psychiatrist Assessment Form at admission and discharge. The original factor structure, internal consistency reliability, discriminant validity, and sensitivity to change were replicated. The patient-administered BASIS-32 is equally as reliable and valid as the interview. Construct validity analyses revealed that functional and satisfaction QOLI indices were moderately related to the BASIS-32 in the hypothesized directions. All satisfaction scales were associated with significantly less severity. Physician ratings were only mildly related to the subscales. The BASIS-32 used in outcome assessments with inpatients provides important and unique perspectives on functional and clinical status that are not tapped by clinician-rated assessments.

Longitudinal assessment of quality of life in acute psychiatric inpatients: reliability and validity

This study examined the reliability, validity, and responsiveness of Lehman's Quality of Life Interview (QOLI) as an outcome measure on 981 acutely ill psychiatric inpatients assessed longitudinally at admission and discharge. Patients were stratified into five diagnostic (DX) (depressed bipolar, depressed unipolar, schizophrenia, mania, and other diagnoses) and two substance use disorder (SA) strata (with and without concurrent substance abuse/dependence) based on DSM-III-R criteria. There was good replication of the factor structure, excellent internal consistency, overall and within DX and SA groups. Intercorrelations showed that the functional and satisfaction indices measure unique aspects of the quality of life. The construct consistency of the QOLI was dependent upon psychiatric diagnosis and life domain. Intercorrelations of functional and satisfaction indices for patients with depression were greater than for manic patients. We demonstrated strong consistency of construct validity for family and social relation domains, but not safety or leisure activities. Construct validity was shown to hold longitudinally. Analyses of DX and SA group differences on satisfaction and functional indices of the 8 life domains supported discriminative validity: Depressed patients reported the most dissatisfaction, followed by schizophrenic patients, and manic patients reported the greatest satisfaction in most life domains. Patients with concurrent substance abuse generally reported less satisfaction and lower quality of life than patients without a dual diagnosis. Examination of longitudinal changes in satisfaction indicated the QOLI is responsive to changes in global life, leisure activities, living situation, and social relations from hospital admission to discharge (an average of 2 weeks). This study supports the use of the QOLI as an outcome measure to assess quality of life in acutely ill hospitalized psychiatric patients.

Quality management in mental health. II. Managing risk of dangerousness

In 1995 R. L. Coleman and D. E. K. Hunter described a quality management approach that produced measurable improvements in quality of care in a state-operated psychiatric hospital. Continued evolution of this approach has subsequently enabled the development and implementation of effective processes for managing risk of dangerousness among patients throughout the hospital. Supported by management principles that promote hospital-wide quality improvement, clinicians and managers produced an environment that was conducive to promoting quality. The hospital-wide quality improvement context involved integrating multiple activities designed to promote quality of care, including significant collaborations with other health care organizations. The hospital's mission as an acute care psychiatric facility has required that it focus on assessing and managing risk of dangerousness in a systematic manner. This was done through developing and utilizing a predictive risk assessment instrument and indicators for managerial oversight. This was accomplished in these steps. First, clinical leaders rated potential criteria according to estimates of their ability to predict dangerousness behavior and reviewed their estimates in relation to clinical findings. Second (and concurrently), clinicians and managers implemented procedures to monitor clinical risk and performance. Finally, outcome data were reviewed. They suggested that this approach was effective in reducing risk of dangerous behavior among patients on all psychiatric wards.

Measuring outcomes in psychiatry: an inpatient model

BACKGROUND

This article describes a system for measuring outcomes recently implemented in the department of psychiatry of Baptist Memorial Hospital, a 78-bed inpatient and day treatment unit that represents one service line of a large, urban teaching hospital in Memphis. In June 1993 Baptist Hospital began a 15-month pilot test of PsychSentinel, a measurement tool developed by researchers in the Department of Community Medicine at the University of Connecticut. The hospital identified the following four primary goals for this pilot project: provide data for internal hospital program evaluation, provide data for external marketing in a managed care environment, satisfy requirements of the Joint Commission on Accreditation of Health Care Organizations, and generate studies that add to the literature in psychiatry and psychology.

DESCRIPTION OF MEASURE

PsychSentinel is based on the standardized diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). The outcome measure assesses the change in the number of symptoms of psychopathology that occurs between admission and discharge from the hospital. Included in the nonproprietary system are risk adjustment factors, as well as access to a national reference database for comparative analysis purposes. Data collection can be done by trained ancillary staff members, with as much or as little direct physician involvement as desired. The system has proven to be both time effective and cost effective, and it provides important outcome information both at the program level and at the clinician level.

RESULTS

After the pilot test, the staff at Baptist Memorial Hospital determined that the system met all initial objectives identified and recently adopted the system as an ongoing measure of quality patient care in the department of psychiatry.