State Psychiatric Facility Research Articles

C-L Psychiatrists Bring Expertise to End-of-Life Care

C-L Psychiatrists Bring Expertise to End-of-Life Care

High-Dose Therapy in Treatment-Refractory Psychosis: A Retrospective Study.

Objective: To examine the impact of antipsychotic dose adjustments (mainly reduction) on the efficacy and tolerability of antipsychotic medications (APMs) to facilitate hospital discharge in long-term hospitalized forensic patients with treatment-refractory psychosis. Methods: This was a retrospective review of the medical charts of 22 patients with psychosis who were discharged from January 2020 to August 2020 from a long-term state psychiatric facility after restoration of their competency to stand trial. Due to the lack of specific guidelines, the high-dose therapy was defined as a dose ≥ 50% above the average package insert dose. The primary outcome was discharge time after the antipsychotic dosing adjustments. Results: Sixty-eight percent of subjects, who were hospitalized for a mean ± SD total of 11.6 ± 5.3 months, were discharged after 2.3 ± 0.78 months of 44.4% antipsychotic dose reduction. Two patients, who were hospitalized for 14.5 ± 6.7 months, were discharged after 4 months of optimizing their subtherapeutic doses. Five patients, who were already receiving effective dosages, were discharged after a total hospital duration of 6.8 ± 2.17 months. Conclusions: The results from this study extend the finding of beneficial effects of antipsychotic dose reduction from prior reports to the forensic population.

Perceptions and barriers of adverse drug reaction reporting within inpatient state psychiatric facilities.

IntroductionAdverse drug reactions (ADRs) are a leading cause of morbidity and mortality for hospitalized patients. Health care organizations track ADRs to reduce patient mortality, reduce hospital readmissions, decrease costs, and improve patient care. Differing definitions of ADRs cause confusion among providers, leading to hesitation with ADR reporting. The objective of this study was to understand health care professionals' perspectives of ADR reporting within inpatient state psychiatric facilities.MethodsA survey was sent to 143 health care professionals throughout 25 inpatient state psychiatric facilities within 1 state. The survey assessed the definition of an ADR, confidence in reporting, barriers to reporting, the role of reporting, who should report and review ADRs, and strategies for process improvement.ResultsThe survey had a 75.5% response rate with 108 respondents. Most respondents could identify the definition of an ADR, were moderately confident in reporting ADRs, and understood the importance of ADR reporting. Barriers to ADR reporting included the reaction not being serious, a lack of information about the ADR, or not enough clarity on how to report an ADR. Fear of retaliation was an additional barrier to ADR reporting. Training and direction on ADR reporting, education on real versus perceived consequences, a designated point person to aid in reporting, and better access to reporting technology were suggested improvements for ADR reporting.DiscussionFrom this survey, it is evident that respondents believe improved education and training, improved communication regarding reporting consequences, and consensus on the definition of an ADR would encourage reporting.

Antipsychotic factors related to time to competency for forensic inpatients in a state psychiatric facility.

IntroductionA defendant who is deemed incompetent to stand trial may go through competency restoration consisting of mental health treatment and legal education. Antipsychotics are often used in treatment; however, there is little data examining their role.MethodsThis retrospective study included subjects opined competent to stand trial from July 2016 to February 2020 and prescribed an antipsychotic. The primary outcome was difference in time to competency between antipsychotics. Secondary outcomes included difference in time to competency between groups of antipsychotics, difference in length of stay after opined competent based on medication availability in jail, individual antipsychotics, and formulations.ResultsThere were 117 subjects included for analysis. There were no differences in time to competency between individual antipsychotics, first- and second-generation antipsychotics, or formulations. Length of stay after opined competent was significantly longer for subjects who were prescribed a long-acting injectable antipsychotic (103 days vs 56 days), who were not able to receive their antipsychotic in jail (104 days vs 54 days), or who were prescribed any formulation of paliperidone compared with olanzapine (88 days vs 35 days).DiscussionSince there were no differences in time to competency, patient-specific factors should be used to choose an agent for competency restoration. Length of stay differences are likely related to the antipsychotic access differences between jails and state psychiatric facilities. Therefore, policies related to antipsychotic access should better align between state psychiatric facilities and jails to improve the capacity of the system and provide better care.

CPNP 2022 Annual Meeting Poster Abstracts

CPNP 2022 Annual Meeting Poster Abstracts

Factors influencing adjudicative competence and length of time to restoration.

Few studies on adjudicative competence explore the relationship between diagnosis, treatment, and restorability. Most focus on demographics and major psychiatric diagnosis with very few exploring the diagnoses common to the forensic population (i.e., personality disorders and substance abuse). Our study of 365 defendants who were incompetent to stand trial at a state psychiatric facility indicates that non-restored defendants have a greater likelihood of cognitive disorders, misdemeanor charges, and histories of prior hospitalization, and less likelihood of personality disorders. In addition, the odds of having a substance use disorder and being medication non-adherent was greater among restored defendants. The mean length of time to restoration (LOR) of 56days was significantly different from the mean length of time to adjudication (LOA) for those not restored (88days). This study supports prior literature on restorability while distinguishing those treated for psychosis from those treated for substance use and personality disorder. In its novel focus on medication adherence, the study expands the remediable factors available to clinical and forensic professionals and supports interventions that improve treatment and shorten the time to restoration.

The Brody School of Medicine at East Carolina University.

The Brody School of Medicine at East Carolina University.

NASMHPD issues guidance to maintain hospital patients' health in crisis

Individuals held in state psychiatric facilities tend to become the forgotten clients of the mental health system. The same approaches that can protect those served in the community mental health sector during a public health crisis likely do not translate well to locked wards in state hospitals. The National Association of State Mental Health Program Directors (NASMHPD) has therefore issued recommendations for assisting individuals in state facilities during the novel coronavirus crisis.

Presidential Address: Emotion Dysregulation in Children and Adolescents

Presidential Address: Emotion Dysregulation in Children and Adolescents

Understanding barriers and facilitators to therapeutic relationships in state psychiatric hospitals.

This qualitative study aimed to elucidate barriers and facilitators faced by individuals with serious mental illness in establishing positive therapeutic relationships within the public sector. Twenty-two individuals, receiving inpatient treatment and near discharge from three state psychiatric facilities, participated. The sample was diverse with respect to gender (60 % male) and race/ethnicity, with a mean age of 40 years (standard deviation = 12.91). Thematic analysis and a contextualist lens were used to analyze the data. Results indicated that inadequate meeting time, lack of clinically relevant communication, and discrepancies in client/provider perspectives, impeded positive therapeutic relationships. Facilitators to therapeutic relationships included feelings heard and understood by providers, comprehensive, timely discharge plans, and thinking broadly about aftercare. Cultivating positive therapeutic relationships is especially difficult in resource-challenged settings. Enhanced client-provider communication and individually tailored aftercare planning can enhance inpatient therapeutic relationships, convey a greater sense of understanding of clients, and facilitate client-provider collaboration.

Illinois bill includes $80 million for MH facilities

Illinois' new capital bill sets aside $80 million to assist mental health facilities across the state, according to a recent announcement by Gov. J.B. Pritzker, The Center Square reported July 24. Mark J. Heyrman, facilitator with the Mental Health Summit and Mental Health America of Illinois, said there has been a lack of community mental health services. With diminishing financial support, state psychiatric hospitals and community facilities were forced to close their doors. “We used to have 33,000 state psychiatric hospital beds,” he said. “Now, we have fewer than 1,200.” According to Heyrman, the lack of mental health funding has put a burden on those who seek assistance. “There are areas of the city [and] there are areas of the state where it's a long drive to get to a community health provider,” he said. People who suffer from mental illness, said Heyrman, are often not motivated to seek treatment because they are too depressed or have symptoms that interfere with their ability to do so. “For most people, we don't need to do anything coercive, but we do need to make it a little easier for people to get treatment when they want it and need it or when their family members are willing to assist them in getting treatment,” he said.

Factors Associated with Rapid Readmission Among Nevada State Psychiatric Hospital Patients.

Rapid readmission (RR) of psychiatric patients within 30days of discharge places a costly burden on state psychiatric facilities and may indicate suboptimal service provisions. Information regarding variables associated with RR of psychiatric patients is limited, particularly in Nevada. This study attempts to identify factors associated with RR at a Nevada state psychiatric hospital. Participants included 7177 patients admitted between May 2012 and April 2014. Using logistic regression, all admissions were reviewed and rapid readmits compared to counterparts who were not readmitted within 30 days. Nevada suffers from budget cuts in mental health care spending because of recent economic crisis and severe lack of bed space. This study demonstrates that it may be possible to reduce rates of costly RR by focusing on those with a history of RR and modifiable factors including social and financial support, as well as reliable and stable housing.

Evaluation of Outcomes for a Skilled Nursing Facility for Persons Who are Difficult to Place.

Individuals with serious mental illness, prisoners, and ex-offenders needing skilled nursing facility (SNF)-level care are difficult to place in traditional SNFs. SNFs accepting these historically marginalized individuals may offer them a more appropriate level of care. We compared health services use (emergency room (ER) visits, acute hospitalizations), total number of antipsychotic medications prescribed, and quality-of-life indicators (depressive symptoms, cognition, resident behaviors), before and after admission, among 86 individuals admitted to a Connecticut SNF for persons difficult to place. Residents were racially diverse, primarily male (89%), and 58.4 (±12.5) years of age; 56 percent were transferred from state psychiatric facilities. Twelve-month hospitalization rates decreased from 36.5 to 10.6 percent, 27 percent of those taking an antipsychotic medication at admission experienced a reduction in total number of antipsychotics prescribed by six months, and 13 residents transitioned into the community. Quality-of-life indicators did not change between admission and first quarterly assessment. A SNF for persons difficult to place may help prevent hospitalizations, optimize antipsychotic medication use, and serve as an intermediate step into the community. These findings may inform development of an evidence-based model for establishing SNFs in other states for persons who are difficult to place.

Consequences of the 48-h rule: A lens into the psychiatric patient flow through an emergency department

ObjectivePsychiatric patient boarding in emergency department (ED) is a severe and growing problem. In July 2013, Minnesota implemented a law requiring jailed persons committed to state psychiatric facilities be transferred within 48-h of commitment. This study aims to quantify the effect of this law on a large ED's psychiatric patient flow. MethodsA pre- and post- comparison of 2011–2015 ED length of stay (LOS) for adult psychiatric patients was performed using electronic medical record data. Comparisons of the median LOS were assessed using a segmented regression model with time series error, and risk differences (RD) were used to determine changes in the proportion of patients with LOS ≥3 and ≥5days. Changes in patient disposition proportions were assessed using risk ratios. ResultsThe median ED LOS for patients admitted for psychiatric care increased by 5.22h from 2011 to 2015 (95% CI: (4.33, 7.15)), while the frequency of patient encounters remained constant. Although no significant difference in the rate of ED LOS increase was found pre- and post- implementation, the proportion of adults with LOS ≥3days and ≥15days increased (RD 0.017 (95% CI: (0.013, 0.021)); 0.002 (95% CI: (0.001,0.004)), respectively). ConclusionsThe proportion of ED adult psychiatric patients experiencing prolonged LOS increased following the implementation of a statewide law requiring patients committed through the criminal justice system be transferred to a state psychiatric hospital within 48h. Identifying characteristics of subsets of psychiatric patients disproportionally affected could suggest focused healthcare system improvements to improve ED psychiatric care.

An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients

This study aimed to examine the relationship between behavioral variables and aggression among severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility. Using archival data over a 24-month period, a total of 23 severely and chronically mentally ill inpatients comprised the sample in this study. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects). Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities. Our findings provide valuable information regarding aggressive tendencies that can inform treatment planning. Specifically, our results suggested there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill inpatients. Rather, other individualized patient factors may be at play in the expression of aggressive impulses, emphasizing the importance of adequate staff-to-patient ratios so that care planning and implementation can be appropriately individualized.

Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility.

To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital. The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge. Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores. Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.

Insane acquittees and insane convicts: the rationalization of policy in nineteenth-century Connecticut.

A current situation in Connecticut of whether a violent insane acquittee should be held in a state prison or psychiatric facility raises difficult issues in jurisprudence and medical ethics. Overlooked is that the present case of Francis Anderson reiterates much of the debate over rationalization of policy during the formative nineteenth century. Contrary to theories of social control and state absolutism, governance in Connecticut was largely episodic, indecisive and dilatory over much of the century. The extraordinary urban and industrial transformation at the end of the Gilded Age finally forced a coherent response in keeping with longstanding legal and medical perspectives.

Factors Associated With Staff Engagement in Patients’ Tobacco Treatment in a State Psychiatric Facility

Persons with mental illnesses (MI) who use tobacco are likely to experience poorer physical health and worsened psychiatric symptomology as compared to their non-tobacco-using counterparts. Therefore, engaging them in treatment is an important aspect of evidence-based care. To use the theory of planned behavior to examine factors associated with intentions to provide and the provision of evidence-based tobacco treatment. This study is based on a cross-sectional analysis of survey data from 195 staff at a state psychiatric hospital. When controlling for demographic variables, attitudes, subjective norms, and perceived behavioral control toward providing tobacco treatment were associated with intentions to provide tobacco treatment, but only subjective norms and perceived behavioral control were associated with reported provision of evidence-based tobacco treatment. Understanding factors that influence provider delivery of tobacco treatment can better determine strategies to reduce the disproportionate tobacco use and related illnesses in behavioral health settings.

New Facility to Be Capstone of Indiana’s Unified MH System

New Facility to Be Capstone of Indiana’s Unified MH System

Cost-avoidance and qualitative analysis of clinical pharmacy interventions by psychiatric pharmacy residents at state psychiatric facilities.

The cost avoidance and quality of clinical interventions made by postgraduate year 2 (PGY2) psychiatric pharmacy residents are analyzed. A retrospective database review of clinical interventions made by PGY2 psychiatric pharmacy residents in two state psychiatric facilities from July 1, 2007 through June 30, 2014, was conducted using a clinical intervention documentation software system. Cost avoidance was calculated by multiplying the mean cost of an adverse drug reaction (ADR) by the probability of an ADR occurring had the intervention not occurred. Sensitivity analyses were performed to identify a conservative estimate of cost avoidance and an upper limit estimate of cost avoidance. The significance of an intervention was determined based on the potential of the intervention type to impact patient care. A total of 2,329 clinical interventions were documented by 10 residents during the seven-year study period, with a mean of 233 interventions made per resident. Interventions were largely accepted (70.1%), were of moderate significance (61.9%), were associated with management of psychiatric conditions (48.7%), and primarily involved medication adjustments (13.7%), particularly for antipsychotics (24.6%). The estimated overall cost avoidance associated with PGY2 psychiatric pharmacy resident interventions was $406,944 over the study period, with a mean cost avoidance of $40,694 per resident. A detailed qualitative analysis revealed that PGY2 psychiatric pharmacy residents' interventions were largely accepted, focused on medication adjustments for psychiatric conditions, and were of moderate significance at two state psychiatric facilities. Antipsychotics were associated with the greatest cost avoidance and total number of interventions.