Public Psychiatric Facilities Research Articles

Make an impact: Attend the 2012 CPNP Annual Meeting

We are now literally weeks away from our annual meeting in Tampa. The Recertification and Program Committees have once again put together a stellar agenda of recertification and programmatic topics for attendees, and there are the always compelling poster sessions and roundtables for networking and enhancing clinical acumen. I want to point out three particularly noteworthy aspects of the program that are timely and which I believe bear special mention. These sessions, among a cadre of interesting and cutting edge topics that lie before us, are worthy of CPNP's 15th annual meeting.In response to the enormous “buzz” created by her presentation at the 2011 annual meeting, Dr. Linda Strand has agreed to conduct the pre-meeting workshop on effective strategies for integrating medication therapy management into our practices. Consistent with the recent CPNP position statement on the integration of psychiatric pharmacists into the primary care medical home, the emphasis of this workshop will be on the role of the pharmacist in the new organizational structures of the medical home and accountable care organizations. Further, the program will demonstrate what payers want from pharmacists who wish to provide medication management services. Attendees will have the opportunity to get important questions answered and understand what changes are needed to achieve and maintain a successful practice, as well as to learn from individuals in the private sector who have experience in delivering medication management services.In this era of healthcare reform and mounting economic pressures, where the pace of change is ever-quickening and often seems to occur randomly, our own Dr. Barbara Wells will share her insights into effective leadership strategies to positively direct and effect change. From the perspective of the renowned Dr. Wells, we will hear how all pharmacy practitioners are leaders in that we are all change agents and influencers of the thinking of our patients, students, and colleagues. Dr. Wells' presentation is designed to help us select strategies to maximize our ability to bring about change in our professional setting and to better realize our potential to build programs, improve the care of patients, and increase personal effectiveness.Lastly, we are all acutely aware of the transition, over the last 40 years, of persons with severe and persistent mental illness from being served by public psychiatric inpatient facilities to increasingly becoming incarcerated. The deinstitutionalization of psychiatric facilities has been a major factor that has led to the current crisis of the “criminalization” of the mentally ill. Judge Steven Leifman, a Miami-Dade County Judge who has also served as Special Advisor on Criminal Justice and Mental Health for the Supreme Court of Florida, is responsible for chairing the Court's Mental Health Subcommittee. He and his group authored a ground-breaking report entitled, Transforming Florida's Mental Health System. Judge Leifman will discuss with us some new and effective strategies that are being developed and employed to transform the mental health system. Further, he will discuss how pharmacists and other health care professionals can get involved in a legislative manner to help transform the mental health system.If you are undecided about attending this meeting, I invite you to review the meeting brochure and share it with your colleagues. On behalf of the Board of Directors, the Program Committee, and the Recertification Committee, we look forward to hosting you in Tampa as we prepare to make a difference.Until next time-Jerry McKee Pharm.D., M.S., BCPPPresident- CPNP

Tech-Check-Tech Pilot in a Regional Public Psychiatric Inpatient Facility

Purpose A pilot project assessing the impact of utilizing well-trained, competency-assessed, certified pharmacy technicians (referred to as advanced practice pharmacy technicians or APPTs) to check unit dose medications prepared by other technicians is described. The pilot site, a regional inpatient public mental health facility, petitioned the North Carolina Board of Pharmacy for a waiver pursuant to Board Rule .2510 to conduct this pilot to compare the accuracy of APPTs to pharmacists in similar roles. Further, the pilot assessed clinical pharmacist time savings generated by improved personnel utilization and the subsequent redeployment by use of this time. Summary Four pharmacy technicians were trained and their competency assessed per the approved protocol. The project entailed 3 distinct components: (1) submitting the petition to the Board of Pharmacy and obtaining approval, (2) training pharmacy technicians and assessing their competency, and (3) incrementally implementing new work processes and project assessment. Clinical pharmacist time saved, in excess of 50 hours per month at full pilot implementation, was utilized in deploying increased patient-focused clinical services. The full pilot implementation was in place for 13 months, with a reported variance rate of 0.31 per month (95% CI, 0-0.77). Two variances were detected by nursing and corrected prior to reaching the patient (near misses). In 2 cases, the medication reached the patient; neither case led to patient harm. The mean number of pharmacist variances (near misses and reaching the patient) for the 12-month period immediately preceding the pilot implementation was 1.42 per month (95% CI, 0.95-1.88), while performing similar functions. Conclusion For this public inpatient psychiatric facility, the APPT variance rate was substantially lower than that for pharmacists in routine checking functions. This superior accuracy is consistent with other documented studies, however it is the first in a non-acute care setting, further demonstrating the potential for the utility of expanded technician roles.

DRGs and other patient-, service- and area-level factors influencing length of stay in acute psychiatric wards: the Veneto Region experience

This study aimed to identify services-related and area-based measures together with socio-demographic factors that could improve diagnosis-related groups in explaining length of stay variability in general hospital psychiatric units in Veneto Region (North East of Italy). Data were collected from the regional hospital discharge records database. A hierarchical multiple regression model with only diagnosis-related groups as predictors of actual and ln-transformed length of stay was compared with a second model in which patient-, service- and area-level variables were included. Local health district was used as group-level in the hierarchical multiple regression analysis. The only diagnosis explains 6.4% of actual length of stay total variance (14.8% for ln-transformation). In the second model length of stay resulted related also to gender, age, severity of hospitalization, patient's local health district, number of psychiatrists, psychologists, hospital attendants/nurses, social workers and educators in the general hospital psychiatric units, number of outpatients in each local health district and percentages of divorced and single people, with almost a 2% point increase on actual length of stay in explained variance (5% point increase for ln-transformation). For the first time the hospital discharge card regional survey of all public acute inpatient psychiatric facilities in Veneto Region were used. The innovative aspect of this study was the attempt to investigate the relationship between length of stay and other indexes, characterizing not only the inpatient facilities, but also the resident population structure in each area. The information about factors that influence length of stay can be useful to inform service planning and resource allocation.

Violent Behavior in Acute Psychiatric Inpatient Facilities

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Implementing a Music Therapy Program at a New 72-Hour Acute Psychiatric Admissions Unit: A Case Study of a Patient Who Was Malingering

Because of the relatively poor treatment available, the high financial costs of hospitalization, multiple and complex issues of persons with severe mental illnesses, and advancements in pharmacotherapy, psychiatric patients are often only hospitalized for a few days before they are discharged. Thus, brief psychosocial interventions for persons who are mentally ill have become an important treatment methodology. This article presents a brief review of crisis intervention and its literature as it relates to persons with severe mental illnesses and music therapy. Additionally, it provides clinical guidelines for therapists working in this setting along with a description of an innovative 72-hour program and approach to crisis intervention treatment at a public inpatient psychiatric facility. The article concludes with a clinical case example of music therapy treatment on this pioneering unit with a patient who was diagnosed with malingering.

State Hospital Admissions on Unexpected Upswing

State Hospital Admissions on Unexpected Upswing

Influence of Spirituality and Religiousness On Smoking Among Patients With Schizophrenia or Schizo-Affective Disorder in Switzerland

The rates of cigarette smoking among patients with schizophrenia are two to four times the rates observed in the community. Spirituality and religiousness have been shown to be associated with lower smoking rates in the general population. This study assessed the role of religion in cigarette smoking among patients with schizophrenia or schizo-affective disorder. Some 115 stabilized outpatients from Geneva's public psychiatric facilities were included. Interviews were conducted to investigate spiritual and religious beliefs, religious practices and religious coping. Cigarette smoking was assessed through interviews and medical records. Some 58% of patients were smokers. Two-thirds of the total sample considered spirituality as very important or essential in their every day life. Religiosity was negatively associated with tobacco use: there were more current smokers without religious affiliation than non-smokers (p < 0.05). For non-smokers, the support of their faith community was significantly more important and they reported more frequent group religious practices than smokers ( p < 0.05). This relation persisted after controlling for demographic confounders (gender, age, ethnicity, education, civil status). In patients with schizophrenia, religion and spirituality seem to be related to smoking behaviour. Similar results were previously found in the general population. These results underscore the need for a systematic exploration of religious issues in the care of smokers with schizophrenia.

Staff Perspectives of Precipitants to Aggressive Behavior of Adolescents in Residential Treatment Facilities

summary Face-to-face, semistructured interviews with 18 staff in a public psychiatric adolescent residential treatment facility were conducted to obtain an inductive approach to their understanding of what leads to aggressive behavior among adolescents. Staff's views of the precipitants of aggressive behavior centered on three themes: understanding of the adolescent, views of interactions within the milieu, and perspective of the service system policies and procedures. Important service system factors included the culture and climate of professional development, the professional practice standards, and the available resources and technologies. A key message was the need for consistent training and awareness of philosophical differences in staff's approaches.

The Long Road Home: Rebuilding Public Inpatient Psychiatric Services in Post-Katrina New Orleans

In August 2006, a year after Hurricane Katrina, the first acute inpatient public psychiatric unit for adults was opened in New Orleans to serve patients referred from local emergency departments. This article describes the clinical and administrative experiences of providing inpatient care in post-Katrina New Orleans, including the increased demand for programs to treat patients with co-occurring disorders, the expanded scope of practice for psychiatrists to include primary care, and ongoing staff shortages in a traumatized and displaced workforce. Lessons learned in regard to disaster planning and recovery are also discussed.

Religious Beliefs in Schizophrenia: Their Relevance for Adherence to Treatment

The study examined how religious beliefs and practices impact upon medication and illness representations in chronic schizophrenia. One hundred three stabilized patients were included in Geneva's outpatient public psychiatric facility in Switzerland. Interviews were conducted to investigate spiritual and religious beliefs and religious practices and religious coping. Medication adherence was assessed through questions to patients and to their psychiatrists and by a systematic blood drug monitoring. Thirty-two percent of patients were partially or totally nonadherent to oral medication. Fifty-eight percent of patients were Christians, 2% Jewish, 3% Muslim, 4% Buddhist, 14% belonged to various minority or syncretic religious movements, and 19% had no religious affiliation. Two thirds of the total sample considered spirituality as very important or even essential in everyday life. Fifty-seven percent of patients had a representation of their illness directly influenced by their spiritual beliefs (positively in 31% and negatively in 26%). Religious representations of illness were prominent in nonadherent patients. Thirty-one percent of nonadherent patients and 27% of partially adherent patients underlined an incompatibility or contradiction between their religion and taking medication, versus 8% of adherent patients. Religion and spirituality contribute to shaping representations of disease and attitudes toward medical treatment in patients with schizophrenia. This dimension should be on the agenda of psychiatrists working with patients with schizophrenia.

Season of Birth and Schizophrenia in Northeast Brazil

Although the association of schizophrenia and winter birth has been replicated many times in the Northern hemisphere, studies in the Southern hemisphere have been less consistent in their findings. A study from NE Brazil indicated the period between May and July, 3 months after the peak in rainfall, as a risk period for schizophrenia birth. We report findings from a random selection of charts (N = 1789) from the only public inpatient psychiatric facility in Ceará, Brazil (2 degrees to 5 degrees S). We compared the seasonality of birth in the schizophrenia group (N = 406) to multiple control groups: (1) psychosis not otherwise specified (N = 868), (2) other psychiatric diagnoses (N = 515), and (3) the average monthly birth rate in the general population. Patients with schizophrenia had a significantly greater risk of being born in the risk period compared with any of the control groups. There is a significant association between rainfall in a month and schizophrenia births 3 (p = 0.03) and 4 months (p = 0.01) later. This study corroborates findings of a significant seasonality in schizophrenia births in northeast Brazil.

Spirituality and Religious Practices Among Outpatients With Schizophrenia and Their Clinicians

Religious issues may be neglected by clinicians who are treating psychotic patients, even when religion constitutes an important means of coping. This study examined the spirituality and religious practices of outpatients with schizophrenia compared with their clinicians. Clinicians' knowledge of patients' religious involvement and spirituality was investigated. The study sample included 100 patients of public psychiatric outpatient facilities in Geneva, Switzerland, with a diagnosis of nonaffective psychosis. Audiotaped interviews were conducted with use of a semistructured interview about spirituality and religious coping. The patients' clinicians (N=34) were asked about their own beliefs and religious activities as well as their patients' religious and clinical characteristics. Sixteen patients (16 percent) had positive psychotic symptoms reflecting aspects of their religious beliefs. A majority of the patients reported that religion was an important aspect of their lives, but only 36 percent of them had raised this issue with their clinicians. Fewer clinicians were religiously involved, and, in half the cases, their perceptions of patients' religious involvement were inaccurate. A few patients considered religious practice to be incompatible with treatment, and clinicians were seldom aware of such a conflict. Religion is an important issue for patients with schizophrenia, and it is often not related to the content of their delusions. Clinicians were commonly not aware of their patients' religious involvement, even if they reported feeling comfortable with such an issue.

Turning the tables: Inpatients as decision makers in the treatment mall program at a state hospital.

Professionals have traditionally accomplished rehabilitative program development at public inpatient psychiatric facilities with limited input from program users. This report describes initial results and observations associated with the introduction of a user-controlled decision-making council built into the program development design of an evolving treatment mall at a state facility. Participant productivity and the satisfaction expressed by participants with regards to this approach captured the attention of staff facilitators and clinical managers, providing a sound basis for future impact studies.

Abuse Said to Be Rampant In Turkey's Mental Hospitals

Abuse Said to Be Rampant In Turkey's Mental Hospitals

Gestion clinique et réhabilitation du patient souffrant de schizophrénie et réfractaire au traitement : fondements conceptuels et résultats (première partie)

Despite advances in psychopharmacology for people with schizophrenia, many patients remain too disabled to be discharged from public psychiatric facilities. This paper describes the development of a public-private partnership which led to the creation of a specialized, intensive behavioral rehabilitation program for schizophrenia patients who were considered to be treatment-refractory at public hospitals. The essential elements of this treatment program are described, along with the philosophical bases of its treatment. Outcome data are discussed to emphasize the point that when evidence-based treatment is implemented with this population, outcomes can be positive in most cases, and therefore, the number of "treatment-refractory" patients is actually less than is estimated based on response to medication alone.

Cigarette Smoking in Psychiatric Settings: Occupational Health, Safety, Welfare and Legal Concerns

In the current climate of growing concern for the harmful effects of cigarette smoking and passive smoking, the high prevalence of this activity within psychiatric settings can no longer be ignored. This paper reviews the findings of research in a public stand-alone psychiatric facility in South Australia where significant legal and occupational health, safety and welfare (OHSW) concerns were apparent for both patients and staff as a consequence of the strong culture of smoking in that setting. The aim of this paper is to raise awareness of this significant health and legal issue and to inform policy and practice change. This paper reviews legal issues associated with smoking in psychiatric settings and presents relevant findings from previous studies in which in-depth interviews and observations in community and inpatient psychiatric settings were conducted. Significant legal and OHSW concerns were apparent for both patients and staff in all settings. The potential for future litigation was high. There are a number of legal and OHSW implications of continued smoking by staff and patients within mental health settings. Several administrative, clinical and cultural practices need to change within this system of care in order to improve overall patient wellbeing and to avoid the potential for litigation by patients and staff.

Treatment of a Transgender Client with Schizophrenia in a Public Psychiatric Milieu: A Case Study by a Student Therapist

SUMMARY This case presentation discusses an unusual clinical experience for a psychology student in training. It addresses the role of gender identity in the treatment of a transgender person with major mental illness receiving care in a public psychiatric milieu. The example here describes one of a few open male-to-female individuals on the caseload of the milieu. The client regularly discussed her view that she had not been understood in prior therapy settings, all of which have been public psychiatric facilities. Working with this patient provided a glimpse into an unusual system where the gender identity component was relevant to the overall planning and execution of treatment. Lesbian, gay, bisexual, and transgender (LGBT) individuals may be resistant to disclose details of their sexual identity to therapists in public settings for fear of being rejected, abandoned, or further diagnosed as sexually deviant. While most public psychiatric facilities have diverse caseloads, it appears that LGBT issues, ...

Effect of second-generation antipsychotics on employment and productivity in individuals with schizophrenia: an economic perspective.

Schizophrenia is a serious mental illness that imposes a considerable burden not only on those who are ill, but also on their families, neighbours and the wider society. Costs associated with treating people with schizophrenia are those derived from the use of a wide range of services provided by public psychiatric facilities and/or by voluntary and private agencies. In addition, a large part of the economic impact of schizophrenia is related to the difficulties that patients encounter in finding and keeping paid employment. The introduction of second-generation antipsychotics (SGAs), also defined as atypicals, has increased the therapeutic options available for individuals with schizophrenia. Potential benefits of these agents include a more favourable profile in terms of positive and negative symptoms, less adverse effects and better cognitive functioning than first-generation antipsychotics (FGAs). As a consequence, SGAs might favourably affect the capacity, seriously impaired in schizophrenia, of finding and keeping paid employment. To date, only 13 published studies have investigated the effect of SGA agents on employment and work productivity. Clozapine was studied in eight studies, while both olanzapine and risperidone were studied in three. Clozapine emerged as the SGA with at least some effect on work status. However, all but one clozapine study enrolled only a few individuals and did not adopt an experimental design, making it very difficult to judge the validity and generalisability of findings. Taken together, studies found little benefit, in terms of employment and work productivity, for the use of SGAs compared with FGAs. The evidence available suggests that until data demonstrate a robust effect of newer agents on employment, it remains mandatory for mental health professionals to use the most effective drug treatment together with non-pharmacological interventions, such as vocational rehabilitative programmes nested into models of community psychiatric care, which have proven effect on the capacity of finding and keeping paid employment. This will ensure that the economic impact of schizophrenia is most effectively contained.

Utility of collateral information in assessing substance use among psychiatric outpatients.

This study addressed the utility of collateral informants for validating self-reported substance use by psychiatric outpatients. Participants were 92 men and women with severe and persistent Axis I disorders, attending outpatient programs at a public psychiatric facility. As part of a substance use assessment, each participant identified a collateral who would provide information about the participant's substance use in the last month. The collaterals consisted of family (35%), peers (23%), and others (40%) who were primarily mental health staff. Comparisons of participant and collateral reports showed high percent agreement with significant but modest measures of association. The likelihood that collateral reports will have information value (i.e., corroborate or exceed self-reports) was greater when the topic is illicit drug use and the frequency of contact is once a week or more. In this sample, siblings were more likely to be uninformative than other types of collaterals, whereas treatment staff were comparable to other types of collaterals in the information value of their corroborative reports. Overall, the collateral reports rarely provided more information than was provided by the participants themselves. This pattern is consistent with the pattern observed in non-psychiatric samples and supports the accuracy of self-reported substance use by psychiatric outpatients.

Ethnicity, Marginalisation and Mental Illness in Hawaii

This study examines the characteristics, treatment and care of severely and persistently mentally ill patients at Hawaii's largest public sector psychiatric facility, Hawaii State Hospital. The implications of this information are then discussed, in terms of treatment and care. Consistent with previous studies, the 88 patients included in this study were most often male, less than 40 years of age, with a high school education or less, and hospitalized under a penal code. More remarkable variations were revealed, however, when patients were grouped according to ethnicity and racial origin. For example, patients from marginalised groups had a significantly higher likelihood of violence than patients from more politically, economically and socially powerful groups in Hawaii. The findings of this research challenge health care providers in general, and nurses in particular, to combine social advocacy with clinical expertise to ensure that patients receive effective and complete treatment and care.