Involuntary Readmission Research Articles

The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment.

A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

Mental capacity and capacity to consent: multicentric study in a involuntary psychiatric hospitalized patients sample

The purpose of this longitudinal observational study is to evaluate the course and impact of clinical, social, and behavioral variables on the involuntary readmission of psychiatric patients, during a 6-months follow-up after discharge from a prior involuntary hospitalization. N=131 involuntarily committed psychiatric patients were enrolled in three university hospitals (Bari n=57; Perugia n=42; Rome n=32). At the first assessment cognitive functioning (MMSE), psychiatric symptoms severity (BPRS-E), capacity to consent to treatment (MacCAT-T) as well as principal socio-demographic and clinical variables were collected. At 6-months follow-up, we collected data concerning involuntary psychiatric readmissions, pharmacotherapy adherence, new deliberate self-harm or harm to others as well as having been legally prosecuted. N=120 patients were reevaluated at follow-up (M=188 days, SD=12.6); among these n=15 (12.5%) have had a new involuntary psychiatric admission due to an acute mental disorder. Re-hospitalized patients showed higher rates of harm to others (p<0.05) and legal prosecution (p<0.05); there was moreover a trend toward higher pharmacological dropout rates in involuntarily rehospitalized patients. We found no differences between the two groups in baseline psychiatric symptoms severity and cognitive functioning, whereas involuntary re-hospitalization was associated with more frequent involuntary hospitalization during last year (p<0.05) and higher MacCAT-T reasoning (p<0.05). Involuntary psychiatric readmission rates proved to be poorly associated with clinical features assessed during previous hospitalization. Our data suggest that social and legal factors, including those connected to patients' dangerousness, could play a role also in a civil commitment system based solely on the need for treatment.

Profiles of youth in therapeutic group care: Associations with involuntary psychiatric examinations and readmissions.

The study aims were to identify distinct subgroups among youth placed in therapeutic group care (TGC) and to examine the effect of specific constellations of risk factors on readmission to residential mental health care and involuntary psychiatric examination among youth in TGC. Several administrative databases were merged to examine outcomes for youth placed in TGC during fiscal year FY04-05 through FY07-08 (N = 1,009). Latent class analysis (LCA) was conducted. Two classes were identified: youth with multiple needs (Class 1) and lower risk youth (Class 2). Class 1 represented 45% of youth in TGC. Compared with Class 2, these youth had a greater probability of having physical health problems, parents with substance abuse problems, and more extensive histories of maltreatment. Compared with Class 2, youth with multiple needs were almost twice more likely to exhibit self-injurious behavior leading to involuntary mental health examinations, but they were less likely to be readmitted to a residential mental health care of higher level of restrictiveness, such as state inpatient psychiatric programs (SIPPs). Youth placed in Florida TGC represent a heterogeneous population and services tailored to these youth's needs are important. Youth with multiple risk factors would benefit from interventions that would address multiple areas of risk. Lower risk youth (Class 2) would benefit from interventions that would focus on promoting mental health, especially among those who have experienced threatened harm, and providing services and supports necessary for stabilizing these youth in the community. (PsycINFO Database Record

Denial of Access to Individuals Seeking Inpatient Care: Disposition Determinants and 12 Month Outcomes.

Objective:This study considers the denial of access to inpatient care to those seeking hospitalization following psychiatric emergency service (PES) evaluation. It evaluates how civil commitment criteria, functional status, institutional constraints, social bias, and procedural justice indicators are likely to impact denial of care decisions, and considers 12 month outcomes.Methods:PES evaluations of 583 patients in 9 California county general hospitals were examined via logit modeling to determine those factors contributing to the decision to deny access to inpatient care. Differences in the importance of influences on the decision making process and outcomes at 12 months are examined in two contrasts: first, admitted and released patients seeking care, then, the latter group versus all other patients. Outcome measures include numbers of deaths, violent crimes, and involuntary readmissions to the PES.Results:Of the patients evaluated, 8.4 % were denied access to inpatient care despite their avowed wish to be hospitalized. When compared to admitted patients seeking hospitalization or to all other patients, analyses show that clinicians relied on civil commitment admission criteria and the availability of a less restrictive alternative to the hospital in making decisions on patient retention. When compared with all other patients, the probability of unwanted release was greater for individuals evaluated in difficult circumstances, for those without insurance, and for those with higher functional status. Fewer deaths were observed in the group denied admission, though no other significant outcome differences were observed.Conclusion:Dangerousness and mental disorder in the absence of a less restrictive alternative to hospitalization, along with an overall assessment of the patient’s functional status, are effectively employed as triage criteria in determining who is denied access to inpatient care following PES evaluation. While some higher functioning individuals are subjected to a variant standard of access to inpatient care because of a lack of insurance, and endure the misfortune of being evaluated under difficult clinical circumstances, outcomes seem contingent on clinicians’ ability to distinguish between groups on the aforementioned triage criteria.

Changing patient perspectives after compulsory admission and the risk of re-admission during 5 years of follow-up: The Amsterdam Study of Acute Psychiatry IX.

Given increasing numbers of compulsory admissions, it is important to assess patient risk profiles and identify factors that are appropriate for intervention. A sample of 116 patients who were compulsorily admitted was studied. Socio-demographic and clinical characteristics were recorded. Patients were interviewed twice using the Verona Service Satisfaction Scale and the Birchwood Insight Scale. Changes in insight and satisfaction during 2 years were linked to the incidence of involuntary re-admissions in the next three follow-up years. A higher mean score for patient satisfaction was found (mean=3.77, standard deviation (SD)=0.56; p⩽.001) in the second interview than in the baseline interview (mean=3.26, SD=0.65). There was also an improvement in insight (in the second interview: mean=7.22, SD=2.86 and in the baseline interview: mean=6.34, SD=3.18; p=.027). There was an inverse correlation between increasing satisfaction (in years 1-2) and the incidence of involuntary admission in years 3-5 (odds ratio (OR)=0.445, 95% confidence interval (CI)=0.252-0.793; p=.006). This association proved to be dependent on a history of involuntary admission. Increasing patient satisfaction in the first 2 years was associated with a lower risk of compulsory re-admission in the subsequent follow-up period, but this association proved to be dependent on a history of involuntary admissions in these first two follow-up years. Increase in insight during the same period did not show any effect whatsoever.

Patterns of Care Consumption after Compulsory Admission: A Five-Year Follow-Up to the Amsterdam Study of Acute Psychiatry VIII

:Significant numbers of involuntary admissions and the fact that compulsory hospitalization is a drastic intervention in a patient’s life justify the introduction of preventive measures. This study looks at the five-year outcome of involuntary admissions after psychiatric emergency consultations in Amsterdam. A cohort of 460 involuntarily admitted patients was investigated prospectively. The annual numbers of involuntary readmissions and the utilization of mental health services were studied, with sociodemographic and clinical characteristics and psychiatric history as predictors. The odds ratios for involuntary readmission during the fourth and fifth follow-up years were 0.71 (95%CI = 0.50–1.01; P = 0.059) and 0.64 (95%CI = 0.45–0.92; P = 0.015), respectively. Readmission was associated with low discontinuity of treatment (Chi2 P ≤ 0.001) and high total consumption of services (Chi2 P ≤ 0.001) during follow-up. It emerged that involuntary readmission could be predicted on the basis of high care consumption five years before inclusion (OR 2.61 CI 1.44–4.73; P 0.002), a history of involuntary admission (OR 1.56 CI = 1.03–2.35; P = 0.034), being older than 44 years at baseline (OR 0.57 CI = 0.39–0.84; P = 0.007), and living alone (OR 1.68 CI = 1.22–02.33; P = 0.002). The risk of involuntary readmission declines after three years. In Amsterdam, low levels of treatment discontinuity and high levels of service use do not seem to reduce this risk for patients with severe and persistent psychiatric disorders. Our findings should be an incentive to explore and reappraise the methods employed in our current system of community mental health care.

Predicting voluntary and involuntary readmissions to forensic hospitals by insanity acquittees in Maryland.

The current study investigated factors associated with voluntary and involuntary readmissions to forensic hospitals 356 insanity acquittees on conditional release in the state of Maryland from 2007, 2008, and 2009 and monitored their community progress for a 3-year follow-up period. The results indicated that voluntarily readmitted insanity acquittees had fewer reported arrests on conditional release and fewer reported instances of non-compliance with treatment compared with insanity acquittees who were returned involuntarily to hospital. As expected, arrests and treatment non-compliance predicted involuntary readmission. A third group of insanity acquittees who were not readmitted on conditional release presented with numerous differences compared with voluntarily and involuntarily readmitted acquittees. These included a longer duration in the community prior to any psychiatric readmission and fewer community psychiatric admissions than both the voluntary and involuntary groups. Data from this study provide useful information on where community monitoring resources for insanity acquittees may best be allocated.

Efficacy of continuous follow-up for preventing the involuntary readmission of psychiatric patients in Japan: A retrospective cohort study

Providing aftercare to psychiatric inpatients is important for preventing frequent readmissions; however, the lack of social resources is a problem in Japan. The prefectural Tama-Fuchu Public Health Centre has attempted to establish a new continuous follow-up system for all discharged psychiatric patients in order to reduce the frequency of readmissions. This study aims to evaluate the efficacy of this system. The subjects of the present study were 200 psychiatric inpatients from the Tokyo catchment area. The continuous follow-up system was applied to 130 subjects for one year in addition to conventional standard care (the intervention group). Seventy subjects received conventional care alone (the comparison group). The incident rate ratios (IRR) of total and involuntary readmission to hospital were compared by survival analysis. During the observation period, there were 41 readmissions and 29 involuntary readmissions in 49,731 person-days. The patients subjected to continuous follow-up showed a trend towards a lower overall risk of readmission (IRR = 0.56, 95% CI: 0.29-1.10, p = .057) and a significantly reduced risk of involuntary admission (IRR = 0.48, 95% CI: 0.22-0.96, p = .047). This study provides empirical evidence that providing continuous follow-up examinations as aftercare for discharged psychiatric patients significantly reduces the incidence of involuntary readmission.

Analysis of Episodes of Involuntary Re-admission in Ireland (2007-2010).

Initial examination of data held by the Mental Health Commission indicated a number of patients having repeated involuntary readmissions (defined as patients having three or more involuntary episodes in a calendar year). The Commission sought more empirical analysis of the data relating to these patients, to determine if there were any trends or commonality regarding their demographic characteristics, length of episode, and diagnoses. From 1 November 2006 the Mental Health Commission has been notified of all involuntary admissions in Ireland under the Mental Health Act (2001). From this national database information on patients who have had three or more involuntary admissions per year was analysed. In the period studied there has been an overall reduction in the number of voluntary and involuntary admissions to Irish psychiatric hospitals and units. However, the use of involuntary admission remains constant at around 10% of all admissions. Seven percent (n=569) of involuntary admission orders in this four year period relate to two percent (n=121) of all involuntary patients. Patients who have experienced repeated involuntary admissions are predominantly male (59%), often have a diagnosis of schizophrenia, or schizotypal and delusional disorders (57%), or mania (20%), are in the age band 22-64 (80%) and more often live in rural counties. Potential appears to exist to significantly reduce the number of involuntary admissions by focusing on the care given to patients who are repeatedly re-admitted. More analysis is needed of voluntary and involuntary re-admissions if inpatient facilities are to be effectively configured.

Perceptions of involuntary admission and risk of subsequent readmission at one-year follow-up: The influence of insight and recovery style

Background. Involuntary admission is one of the most ethically challenging practices in medicine, yet we are only beginning to learn more about the patient's perspective.Aims. To investigate (i) peoples' perception of the necessity of their involuntary admission at one year after discharge (ii) readmission rates to hospital and the influence of insight and recovery style.Methods. We interviewed individuals admitted involuntarily at one year following discharge using the Mac Arthur Admission Experience Interview, Birchwood Insight Scale, the Drug Attitude Inventory, Global Assessment of Functioning and the Recovery Style Questionnaire.Results. Sixty-eight people (84%) were re-interviewed at one year and fewer (60%) reported that their involuntary admission had been necessary when compared to inception (72%). Of the 33% that changed their views, most reflected negatively on their involuntary admission. We found that insight was moderately associated with the acknowledgement that the involuntary admission was necessary. Within a year, 43% were readmitted to hospital and half of these admissions were involuntary. Individuals with a sealing over recovery style were at four times the risk of involuntary readmission.Conclusions. Peoples' perception of the necessity of their involuntary admissions is not stable over time and risk of involuntary readmission is associated with recovery style.

Treatment adherence therapy in people with psychotic disorders: randomised controlled trial

Interventions to improve adherence to treatment in people with psychotic disorders have produced inconclusive results. We developed a new treatment, treatment adherence therapy (TAT), whose intervention modules are tailored to the reasons for an individual's non-adherence. To examine the effectiveness of TAT with regard to service engagement and medication adherence in out-patients with psychotic disorders who engage poorly. Randomised controlled study of TAT v. treatment as usual (TAU) in 109 out-patients. Most outcome measurements were performed by masked assessors. We used intention-to-treat multivariate analyses (Dutch Trial Registry: NTR1159). Treatment adherence therapy v. TAU significantly benefited service engagement (Cohen's d = 0.48) and medication adherence (Cohen's d = 0.43). Results remained significant at 6-month follow-up for medication adherence. Near-significant effects were also found regarding involuntary readmissions (1.9% v. 11.8%, P = 0.053). Symptoms and quality of life did not improve. Treatment adherence therapy helps improve engagement and adherence, and may prevent involuntary admission.

Coercion and Treatment Satisfaction Among Involuntary Patients

Coercion and Treatment Satisfaction Among Involuntary Patients

Coercion and Treatment Satisfaction Among Involuntary Patients

This study aimed to assess involuntary inpatients' satisfaction with treatment and explore how coercion and other factors are associated with satisfaction. An observational prospective study was conducted in 67 acute wards in 22 hospitals in England. A total of 778 involuntary inpatients were recruited, and their satisfaction with treatment was assessed a week after admission and at the one-month, three-month, and one-year follow-ups. Perceived and documented coercion at admission and during hospital treatment, sociodemographic and clinical characteristics, and clinical improvement were tested as potential predictors of satisfaction. Mean scores on the Client's Assessment of Treatment Scale measuring satisfaction with treatment ranged from 5.5 to 6.0 (on a scale with possible scores ranging from 0 to 10) at different time points and improved significantly from admission to the follow-ups. Patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the medical records were not linked to satisfaction. Patients with more symptom improvement expressed higher levels of treatment satisfaction. Satisfaction with treatment among involuntary patients was associated with perceptions of coercion during admission and treatment, rather than with the documented extent of coercive measures. Interventions to reduce patients' perceived coercion might increase overall treatment satisfaction.

PW01-206 - People's perception of their involuntary admission at one year follow-up and readmission rates to hospital

BackgroundThere is limited knowledge of how individuals reflect on their involuntary admission.ObjectivesTo investigate, at one year after an involuntary admission,(i)peoples perception of the necessity of their involuntary admission(ii)the enduring impact on the relationship with their family, consultant psychiatrist and employment prospects(iii)readmission rates to hospital and risk factors for readmission.MethodsPeople that were admitted involuntarily over a 15 month period were re-interviewed at one year following discharge.ResultsSixty eight people were re-interviewed at one year and this resulted in a follow-up rate of 84%. Prior to discharge, 72% of people reported that their involuntary admission had been necessary however this reduced to 60% after one year. Over one third of people changed their views and the majority of these patients reflected negatively towards their involuntary admission.One quarter of people continued to experience a negative impact on the relationship with a family member and their consultant psychiatrist one year after an involuntary admission, while 13% reported a positive impact. A similar proportion perceived that it had negative consequences in their employment.Within one year, 43% of all patients involuntarily admitted in the study period were readmitted to hospital and half of these admissions were involuntary. Involuntary readmission was associated with a sealing over recovery style.ConclusionsPeoples’ perception of the necessity of their involuntary admissions changes significantly over time. Involuntary admissions can have a lasting negative impact on the relationship with family members and treating consultant psychiatrist.

S22-01 - Preventive monitoring of psychiatric patients at risk for compulsory readmission: preliminary results of a multi-center RCT

ObjectivesThis study aims at reducing the risk for compulsory readmission in psychiatric patients by a comprehensive intervention comprising psychoeducation on warning signs, crisis cards and a continuous telephone monitoring of the patients‘ mental health status and health care utilization over a two-year period. Beyond reducing involuntary admissions, further objectives of the intervention are to reduce number and duration of inpatient stays and to result in a more cost-effective service provision.MethodsPsychiatric inpatients suffering from schizophrenia or an affective disorder were randomly allocated to the intervention group or the control group (treatment as usual). Risk for compulsory readmission was defined by a current involuntary treatment episode or involuntary treatment within the previous 24 months. Both groups are assessed at baseline, at 12-month and 24-month follow-up. Interviewer ratings cover psychopathology (Positive and Negative Syndrome Scale, Young Mania Rating Scale, Hamilton Depression Sale, Global Assessment of Functioning), psychopathy (Hare Psychopathy Checklist Screening Version) and risk for violence (HCR 20). Treatment satisfaction, empowerment and quality of life is measured by self-report questionnaires. Health care utilization and prescription of psychotropic medication is recorded continuously in the intervention group and over a 3-month period in the control group.ResultsPreliminary results of this ongoing study will be presented, illustrating sample characteristics and first results of the one year follow-up. Focusing on data of type, number and duration of inpatient stays, the potential of the intervention to reduce the risk for involuntary readmission to psychiatry will be discussed.

Does mental health service integration affect compulsory admissions?

Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services. In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up. Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district. Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions.

Patients' views and readmissions 1 year after involuntary hospitalisation

Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals. To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes. Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year. At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission. Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.

Involuntary vs. voluntary hospital admission

This article systematically reviews the literature on the outcome of acute hospitalization for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily. Inclusion and exclusion criteria qualified 41 out of 3,227 references found in Medline and PSYNDEXplus literature searches for this review. The authors independently rated these articles on six pre-defined indicators of research quality, carried out statistical comparisons ex-post facto where not reported, and computed for each adequate result the effect size index d for the comparison of means, and the Phi- or contingency coefficient for cross-tabulated data. Methodological quality of the studies, coming mostly from North American and European countries, showed significant variation and was higher concerning service-related than clinical or subjective outcomes. Main deficits appeared in sample size estimation, lack of clear follow-up time-points, and the absence of standardized instruments used to assess clinical outcomes. Length of stay, readmission risk, and risk of involuntary readmission were at least equal or greater for involuntary patients. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. Further, involuntary patients demonstrated lower levels of social functioning, and equal levels of general psychopathology and treatment compliance; they were more dissatisfied with treatment and more frequently felt that hospitalization was not justified. Future methodologically-sound studies exploring this topic should focus on patient populations not represented here. Further research should also clarify if the legal admission status is sufficiently valid for differentiating the outcome of acute hospitalization.

Postdisharge Follow-Up: Research and Practice Disconnect

Back to table of contents Next article Taking IssueFull AccessPostdisharge Follow-Up: Research and Practice DisconnectCarol E. Adair M.Sc., Ph.D.,Carol E. Adair M.Sc., Ph.D.Search for more papers by this author,Published Online:1 Dec 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In this month's issue Stein and colleagues show that only 30% and 49% of Medicaid-enrolled adults hospitalized for psychiatric care in one mid-Atlantic state received aftercare within seven and 30 days of discharge, respectively. African Americans, those with co-occurring disorders, and those discharged against medical advice had increased risk of lack of timely aftercare. The authors concluded, "Efforts to improve follow-up utilization should target higher-risk individuals while developing and evaluating interventions to address specific barriers among these groups."These findings come as no surprise. Many studies have documented risk factors for poor aftercare, and broad searches of academic and "grey literature" still yield typical ranges from 41% to 96% for 30-day follow-up (even lower for seven-day follow-up)—values that vary unacceptably. Even so, in the context of performance report cards, some providers are reporting very high follow-up rates (up to 100% for the 30-day indicator).There is a marked disconnect between research and practice here. Clearly some organizations have found ways to improve follow-up rates. However, only a few quality improvement projects are reported. They rarely describe how the aftercare levels were achieved, and rigor is suboptimal, limiting validity, generalizability, and opportunities for best practice dissemination. In addition, much research on the topic remains descriptive (analyses of administrative data); such studies are also very limited for illuminating the mechanisms that produce better follow-up. Although these analyses will continue to be helpful for monitoring, substantial improvement of practice will depend on rigorous studies of innovative interventions.The attachment of timely aftercare to the performance imperative seems to have motivated improvement in some organizations but not all. We may also need to shift away from a focus on those "at risk" toward greater recognition that a psychiatric hospitalization is a very serious event, sufficient in itself to justify everyone's being seen within a short time after discharge, regardless of individual characteristics. It may be that we need to "up the ante" by attaching timely aftercare to the patient safety imperative. This is not unreasonable given the evidence that postdischarge suicides tend to cluster in the first week. For example, it may be necessary to define timely aftercare as a universal standard of care for all psychiatric admissions and to define failure to provide aftercare as a health care error (of omission). In research, we probably need to spend less time describing levels of and risk factors for poor aftercare and more time designing and testing innovative interventions aimed at ensuring universal follow-up for all persons admitted for a psychiatric illness and documenting their outcomes.Department of Psychiatry and Community Health Sciences, University of Calgary, Alberta, Canada FiguresReferencesCited byDetailsCited ByEfficacy of continuous follow-up for preventing the involuntary readmission of psychiatric patients in Japan: A retrospective cohort study16 January 2012 | International Journal of Social Psychiatry, Vol. 59, No. 3Predictors of Psychiatric Aftercare among Formerly Hospitalized Adolescents23 June 2016 | The Canadian Journal of Psychiatry, Vol. 57, No. 11Returning Home in Systems of Care24 November 2008 | Journal of Emotional and Behavioral Disorders, Vol. 17, No. 3 Volume 58Issue 12 December, 2007Pages 1521-1521PSYCHIATRIC SERVICES December 2007 Volume 58 Number 12 Metrics PDF download History Published online 1 December 2007 Published in print 1 December 2007

Conditional Hospital Release: Conveying the Wrong Message?

Back to table of contents Next article Taking IssueFull AccessConditional Hospital Release: Conveying the Wrong Message?Robert Bernstein Ph.D.,Robert Bernstein Ph.D.Search for more papers by this author,Published Online:1 Nov 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The three articles in this issue by Segal and Burgess offer strong arguments that conditional release from psychiatric hospitalization holds important benefits for people with serious mental illness. Drawing on a large ten-year database, these Australian studies demonstrate widespread reliance on conditional release, associated with outcomes such as reduced inpatient days and lower mortality rates. Yet this research leaves many important details blurred. The data do not establish causal links, and the outcomes included are at best blunt indicators of clinical effectiveness. Also unclear is how court-endorsed postdischarge monitoring—a rather indirect intervention as things go in public mental health—can prod better outcomes for consumers who are ostensibly among the hardest to serve.What is clear from the data is the mental health system's blithe engagement of the courts in postdischarge planning, a notably perplexing scenario for the many individuals who entered the hospital voluntarily only to find court-mandated oversight after "successful" inpatient care. Also revealing is the pervasive sense of powerlessness among consumers in challenging such arrangements. In reality, many consumers know that hospital discharge is always conditional; involuntary readmission looms whenever civil commitment criteria are met.Still, conditional release is more than mere ritual. Although the authors frame this intervention as a vehicle for earlier hospital release, thus furthering the system's "least restrictive" ambitions, myriad factors that erode basic rights are also at play: court action misdirected at the victims of neglect rather than at neglectful public systems, a coercive tradition that undermines personal responsibility and recovery, and cynicism about the true potentials of both good clinical interventions and individuals with mental disabilities.Research suggests that good community services may be the actual key to success after discharge. However, conditional release can be viewed as an official affirmation of skepticism about an individual's prospects in the community service system. By relying on this legal tactic, mental health professionals turn to the courts for what should be regarded as a sentinel clinical problem: a substantial number of people with the serious mental illnesses common in the public mental health system are at extreme risk of relapse. In obtaining court orders to push engagement with the existing service array, the system tacitly endorses as adequate the 15-minute outpatient "therapy" sessions often available to these individuals and suggests that limited professional know-how offers no recourse but the legal system. Beyond being inconsistent with the science, this sense of hopelessness, unthinkingly expressed in routine court documents, sends a disparaging message to mental health consumers and to society.executive director; Judge David L. Bazelon Center for Mental Health Law FiguresReferencesCited byDetailsCited ByBehavioral Sciences & the Law, Vol. 34, No. 2-3LetterBenjamin McCommon, M.D.1 December 2006 | Psychiatric Services, Vol. 57, No. 12LetterDavid J. Rissmiller, D.O.Joshua Rissmiller1 December 2006 | Psychiatric Services, Vol. 57, No. 12LetterSteven P. Segal, Ph.D.Philip M. Burgess, Ph.D.1 December 2006 | Psychiatric Services, Vol. 57, No. 12LetterElaine Boyd, R.N., M.A.1 December 2006 | Psychiatric Services, Vol. 57, No. 12LetterMark R. Munetz, M.D.Jennifer L. S. Teller, Ph.D.Ann Morrison, M.D.1 December 2006 | Psychiatric Services, Vol. 57, No. 12LetterHerbert S. Peyser, M.D.Richard A. Shadoan, M.D.1 December 2006 | Psychiatric Services, Vol. 57, No. 12 Volume 57Issue 11 November, 2006Pages 1553-1553PSYCHIATRIC SERVICES November 2006 Volume 57 Number 11 Metrics PDF download History Published online 1 November 2006 Published in print 1 November 2006