State Psychiatric Facility Research Articles

Assessing predictive factors for extended hospitalization at acute psychiatric admission.

This study examined whether information obtained early in the hospitalization process can be used to assess a patient's need for extended care. A sample of 2,430 inpatients who were admitted to a state psychiatric facility during a one-year index period (January through December 1997) were randomly assigned to a primary sample or a replication sample. Data were collected on demographic characteristics and history of previous hospitalization. The Brief Psychiatric Rating Scale-Anchored Version (BPRS-A) was administered to patients within 48 hours of admission, and four new subscales derived from ratings of newly admitted patients were calculated. Univariate and multivariate analyses were conducted to identify factors associated with whether a patient was discharged to the community or transported to another hospital for extended care. A discriminant analysis of the data correctly identified 70 percent of the patients who were referred for continued hospitalization and 80 percent of the patients who were discharged to the community. The main correlates of the need for extended inpatient services were, in descending order, scores on the BPRS-A resistance subscale, the number of previous referrals for extended hospitalizations, and scores on the BPRS-A positive symptoms and psychological discomfort scales. BPRS-A subscale scores should be considered to be at least as good as more traditional measures in predicting length of hospitalization.

Impact of risperidone on seclusion and restraint at a state psychiatric hospital.

To evaluate the impact of risperidone on seclusion and restraint in patients at a state psychiatric facility, shortly after risperidone's release. Patients who were in the hospital for at least 3 months prior to receiving risperidone and subsequently received risperidone for at least 3 months formed the cohort. A mirror-image design was used with duration to a maximum of 1 year before and 1 year after initiation of risperidone. The hospital population that did not receive either risperidone or clozapine during the same time period was used for comparison of trends of seclusion and restraint. Seventy-four patients (most with schizophrenia) met the inclusion criteria of the risperidone group. There were statistically significant decreases in the number of seclusion hours (2.2 [SD 5.5] to 0.26 [SD 0.06]) and of events (0.23 [SD 0.59] to 0.05 [SD 0.14]) per person per month during risperidone treatment, compared with the prerisperidone treatment period (P = 0.01). The comparison group also evidenced decreases on these measures during the same time period, but the risperidone-treated cohort achieved a proportionally greater reduction. There were similar trends toward reduction in the restraint measures during risperidone treatment compared with prerisperidone, but these did not achieve statistical significance. The comparison group also showed slightly decreased use of restraints over the study period. Risperidone appears to have had a positive impact on seclusion in this state-hospital psychiatric population. These data support the positive impact of risperidone on violence found in other studies. Violence and aggression are major factors that affect morale among psychiatric patients and staff. So, any benefit in this regard as a result of antipsychotic drug treatment is salutary for patients, families, and health care providers.

Admissions, length of stay, and medication use among women in an acute care state psychiatric facility.

Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility. A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database. The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50. Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.

A Dose-Outcome Analysis of Risperidone

Although the establishment of appropriate dosage ranges for antipsychotics has important ramifications for both short-term treatment and long-term therapeutic outcomes, difficulties in dosing persist. Evidence exists that initial dosing recommendations for the titration of risperidone to 6 mg/day in 3 days are excessive. This study examines dosage trends of risperidone and further examines the relationship between dose and outcome by determination of discharge rates among individuals receiving varying doses of the drug. Records of individuals receiving risperidone in Maryland state psychiatric facilities from March 1994 through February 1997 (N = 1056) were examined. Discharge rates and time to discharge were measured by Kaplan-Meier survival curve analysis. As risperidone use has risen each year since its introduction, mean doses in both inpatients and discharged patients have steadily declined. Additionally, risperidone doses for discharged patients were significantly lower than those for patients remaining in the hospital. Furthermore, patients receiving 2 and 4 mg/day were significantly more likely to be discharged than those receiving 6 mg/day (log-rank chi2 = 13.54, df = 2, p = .0011). This difference was seen in patients with similar diagnoses, ages, and racial status. Patients treated with doses less than the 6-mg/day initial dosing recommendations have better outcomes in terms of discharge. This finding should encourage clinicians to utilize adequate trials of risperidone aimed at stabilizing patients on doses in the 2- to 4-mg/day range before proceeding to higher doses.

Closing of a state hospital: an overview and framework for a case study.

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

Dangerousness and disability as predictors of psychiatric patients' legal status

In a sample of patients admitted to two state psychiatric facilities, discriminant analyses were used to predict (1) legal status at admission (voluntary versus emergency detention), and (2) the subsequent decision to commit patients initially admitted under an order of emergency detention (court commitment versus release). Measures of preadmission dangerousness, followed by variables reflecting degree of disability or impairment, accounted for most of the variance in legal status at admission. Personal resources and demographic characteristics added little to the discrimination. Measures of disability accounted for most of the variance in the later decision to commit, whereas indices of dangerousness, personal resources, and demographics added little to discrimination of discharged and court-committed patients. These findings reflect the gap between legal standards and the practice of civil commitment, and support the argument that degree of disability plays a more important role than dangerousness in decisions to extend the hospitalization of involuntary patients. Copyright © 1999 John Wiley & Sons, Ltd.

Dangerousness and disability as predictors of psychiatric patients' legal status.

In a sample of patients admitted to two state psychiatric facilities, discriminant analyses were used to predict (1) legal status at admission (voluntary versus emergency detention), and (2) the subsequent decision to commit patients initially admitted under an order of emergency detention (court commitment versus release). Measures of preadmission dangerousness, followed by variables reflecting degree of disability or impairment, accounted for most of the variance in legal status at admission. Personal resources and demographic characteristics added little to the discrimination. Measures of disability accounted for most of the variance in the later decision to commit, whereas indices of dangerousness, personal resources, and demographics added little to discrimination of discharged and court-committed patients. These findings reflect the gap between legal standards and the practice of civil commitment, and support the argument that degree of disability plays a more important role than dangerousness in decisions to extend the hospitalization of involuntary patients.

Rehospitalization rates of patients recently discharged on a regimen of risperidone or clozapine.

The purpose of this study was to examine rehospitalization rates of people receiving risperidone or clozapine who had been discharged from state psychiatric hospitals in Maryland. Rehospitalization status was monitored for all patients discharged from state psychiatric facilities on a regimen of either risperidone or clozapine between March 14, 1994, and Dec. 31, 1995. Patients were followed up with respect to readmission until Dec. 31, 1996. Time to readmission was measured by the product-limit (Kaplan-Meier) formula. Risk factors associated with rehospitalization were examined. One hundred sixty patients were discharged on risperidone, 75 having the diagnosis of schizophrenia. The patients with schizophrenia were more likely to be readmitted than the 85 patients with other mental disorders. Recidivism rates for schizophrenic patients discharged on risperidone versus those discharged on clozapine were not significantly different over the 24-month study period. However, no patient who received clozapine and remained discharged for more than 10 months (N = 49) was readmitted, while the readmission rate for risperidone-treated patients appeared to be steady up to 24 months. At 24 months 87% of the clozapine-treated patients and 66% of the risperidone-treated patients remained in the community. No clinical or demographic variables were found to predict rehospitalization. This study demonstrates that the rehospitalization rates of patients taking the second-generation antipsychotics risperidone and clozapine are lower than those in previously published reports of conventional antipsychotic treatment.

The Role of the Public Sector in Ensuring Access to Psychiatric Hospital Care for Elderly and Disabled Medicare Beneficiaries

Purpose: Compare Medicare beneficiaries admitted to public, private not-for-profit, and for-profit psychiatric hospitals. Methods: Administrative data on all beneficiaries admitted to psychiatric hospitals in 1990 were used to estimate multinomial logit models of treatment in for-profit or private not-for-profit (vs. public) hospitals, controlling for patient characteristics. Results: Women and beneficiaries with worse geographic access to public hospitals, better access to private hospitals, or comorbidities were more likely to be treated in private hospitals. Blacks, rural residents, and beneficiaries who were disabled, had previous psychiatric hospitalizations, or a primary diagnosis of schizophrenia were less likely to be treated in private hospitals. Residents of lower-income areas were less likely to be treated in private not-for-profits. Conclusions: In addition to being essential providers for the uninsured, public hospitals also play an important role in ensuring access to care for Medicare beneficiaries. Public psychiatric hospitals treat a disproportionate share of the sickest, lowest-income, and minority patients. Geographic proximity and bed supply also play an important role in provider choices. Plans to privatize state psychiatric facilities should take these considerations into account.

Concurrent and predictive validity of the Allen Cognitive Levels Assessment

The present study examined the concurrent and predictive validity of the Allen Cognitive Levels (ACL) Assessment in a sample of 110 medicated patients with schizophrenia who received the ACL at discharge from a state psychiatric facility. Subsamples within this group of patients had received an Activities of Daily Living assessment ( n=64) and a comprehensive neuropsychological test battery ( n=48) at discharge, or a battery of community follow-up measures ( n=30) 1–3.5 years following discharge as part of other investigations. Positive correlations were found between the ACL and concurrent measures of adaptive and cognitive function. With respect to cognitive variables, stepwise multiple regression analysis revealed that the majority of the variance in ACL scores was predicted by neuropsychological test scores assessing higher level cognitive processes, such as visual organization, manipulation of information in working memory, and ability to inhibit a response to a prepotent stimulus. Finally, results revealed positive relationships between the ACL obtained at discharge and community functioning at follow-up. The results of this study provide some evidence for the concurrent and predictive validity of the ACL for patients with schizophrenia and suggest that further study of this assessment tool would be important to pursue in future investigations.

The impact of substance use screening on a public psychiatric inpatient population.

This study sought to determine the impact of a formal screening program for substance use disorders among psychiatric inpatients. Both identification of these disorders and referrals to aftercare were measured. A total of 193 patients admitted to a state psychiatric facility during a two-month period before screening was initiated were compared with 183 patients admitted during the same two months a year later when screening was in place. Patients were screened using the Chemical Use, Abuse, and Dependence Scale. Data were collected from hospital and statewide computerized files. Consistent with findings of previous studies, the formal screening procedure increased the identification of substance use disorders, even among those who were not screened during the screening period. However, despite heightened awareness of staff, referrals to outpatient treatment in the community after discharge did not increase. In fact, patients who did not have a comorbid substance use disorder were more frequently referred to aftercare than were dually diagnosed patients. Access to services for dually diagnosed patients may be limited by both staff and patient barriers. Underdiagnosis may be partly overcome by formal screening procedures, but staff bias may influence use of screening tools as well as aftercare referrals. In turn, individuals with a comorbid disorder who are not referred to aftercare may be more resistant to treatment and follow-up care. These issues must be clinically addressed by educating and sensitizing staff, as well as by administrative means.

Strategies for Hospital-Wide Dissemination of Psychiatric Rehabilitation Interventions

Abstract An ultimate goal in the development of effective rehabilitation interventions within clinical-research contexts is the dissemination of these techniques to the “typical” treatment setting. Often however, hospital administrators at such settings either see this goal as unattainable, or do not implement a carefully integrated process of staff training and administrative support. In this paper, we describe the steps in an ongoing effort to implement psychiatric rehabilitation practices hospital-wide in a state psychiatric facility. This process has involved a number of critical components including time-limited use of outside experts, focused administrative support and quality assurance, continuing education opportunities, and the establishment of both a unit specializing in rehabilitation interventions that serves as an ongoing training environment for hospital staff, and a core group of practitioners from this program who provide regular external consultation to other hospital programs. These and ...

Growing Up in the Bowels of Violence

Abstract The author chronicles his struggle with violent behavior which stemmed from an abusive family life, both as a child in his parent's home and as a young man. Coupled with delusions brought on by mental illness, the author's violent tendencies led him to murder his own mother. This act led him into the criminal justice system and eventually to psychiatric therapy at a Midwestern state psychiatric facility. The author describes his growing ability to rein in his violent tendencies, and his gratitude to the mental health system for their support and guidance.

The Effects of Clozapine on Symptom Clusters in Treatment-Refractory Patients

Preliminary results of a double-blind clozapine study in a population of chronic psychotic patients at a state psychiatric facility are reported. Thirty "treatment-refractory" schizophrenic patients given a diagnosis according to DSM-III-R criteria (mean age of 44 +/- 9.1 years and a duration of illness of 24.9 +/- 8.8 years) who received 300 mg or 600 mg of clozapine and randomized in a double-blind fashion were analyzed. Subjects were evaluated using the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression (CGI) Scale on a weekly basis for 16 weeks. Based on the changes in their CGI scores at week 16 of clozapine treatment, subjects were retrospectively categorized as "improvers" (N = 12) and "nonimprovers" (N = 18). The two groups were compared for changes in total BPRS and BPRS factor scores. In terms of total BPRS scores, we expected a difference between the two groups because they were categorized based on changes in their CGI scores. However, the total BPRS scores in improvers showed a significant decrease by week 6 of clozapine treatment. On analyzing the four BPRS factors, the improvers showed improvement in the thinking disturbance factor by week 1 that remained steady from week 7. On the hostility-suspiciousness factor, the improvers showed an improvement across time when compared with nonimprovers. The withdrawal-retardation factor showed improvement in both groups across time, whereas the anxiety-depression factor was least influenced by clozapine. These observations suggested that all BPRS symptom factors did not uniformly contribute to improvement in overall psychopathology, which was observed as a decrease in total BPRS scores.

The Due Process Right to a Safe and Humane Environment for Patients in State Custody: The Voluntary/Involuntary Distinction

In December 1995, the Eighth Circuit decided Kennedy v. Schafer, holding that a teenage patient who committed suicide while under treatment at a state psychiatric facility had a constitutionally protected liberty interest in a safe and humane environment under the Due Process Clause of the Fourteenth Amendment if her status changed from voluntary to involuntary during the course of her admission. The fifteen year old patient, Kathleen Kennedy, had been identified as a suicide risk, and had been placed on “Protective Suicide Precautions,” which required a designated staff member to keep her in constant eyesight and to interact with her at fifteen to twenty minute intervals. Despite these stringent requirements for supervision and contact, Kathleen was found dead in her room more than two hours after her last contact with a staff member. Her parents brought suit under 42 U.S.C. § 1983 against state and hospital officials, alleging that chronic understaffing and falsification of the records used to determine staffing levels amounted to a pattern of deliberate indifference to patient safety which violated their daughter’s protected liberty interest in a safe and humane environment.

Neuroleptics in acute mania: a pharmacoepidemiologic study.

To provide an epidemiologic descriptive analysis of the acute drug treatment of inpatients with bipolar mania in state psychiatric facilities in 1990. We surveyed the first 3 weeks of drug treatment of all inpatients with bipolar mania who were admitted to 22 New York State adult psychiatric facilities during a 6-month period (n = 528). Almost all patients with mania were treated with neuroleptics. The mean +/- SD neuroleptic dosage was 684 +/- 543 mg/d chlorpromazine equivalents. Sixty-one percent of the patients received lithium and 12% received carbamazepine or valproate. Neuroleptic dosage was related to age, with older patients receiving lower dosages. Patients receiving combination treatment of a neuroleptic with either lithium, an anticonvulsant, or a benzodiazepine received a mean neuroleptic dosage similar to that of patients treated with a neuroleptic alone. Although their use has been widely discouraged for mood disorders, neuroleptics have been the standard treatment for acute mania.

Patient perspectives on restraint and seclusion experiences: A survey of former patients of New York State psychiatric facilities.

Patient perspectives on restraint and seclusion experiences: A survey of former patients of New York State psychiatric facilities.

Patient perceptions of self-induced water intoxication

This study comprehensively examines self-induced water intoxication (SIWI) from a patient perspective including demographics, reasons for seeking fluids, patterns/behaviors of fluid seeking, and symptoms frequently experienced while in a state of SIWI. The subjects were 45 of an original convenience sample of 62 individuals with a serious mental illness (SMI), hospitalized in a long-term state psychiatric facility, who engaged in self-induced water intoxication. All participants were interviewed in a structured format to complete a 40-item Likert-type questionnaire developed for the study, titled the Self-induced Water Intoxication Questionnaire (SIWIQ). In the study, the majority of participants were smokers, and reported no past problem with alcohol. SIWI occurred more in males than females, and was more predominant in those participants who had longer hospital stays. Anger and vomiting were found to be the two most predominant symptoms experienced when excess fluid consumption occurred. Behaviors of drinking from the shower, the toilet, and one's own urine are consistent with findings of previous studies and illustrate the difficulty in keeping individuals with SIWI from fluids. Data show that participants with SIWI experience considerable anxiety and cognitive difficulties and express these as reasons for engaging in excess fluid consumption. Boredom, obtaining a high, and sad mood were also predominant reasons identified for excess fluid drinking. Significant relationships were found and discussed. The findings provide support for the position that SIWI represents an attempt at treatment by the dysfunctional individual and is pursued for anxiolytic effects and alleviation of boredom. The data support the idea of approaching the problem from a dysfunctional coping framework, realizing that SIWI is a very complex problem, needing examination and intervention at multiple levels, beyond exclusive focus on fluid control.

Factors Related to Psychiatric Consultation for Schizophrenic Patients Receiving Medical Care

About half of the medical admissions of patients with schizophrenia and schizoaffective disorder we studied required psychiatric consultation. In this patient population, psychiatric sonsultation was positively associated with younger age, longer length of stay, and admission through the emergency room or walk-in clinic and negatively associated with transfer from a state psychiatric facility. Whether patients with schizophrenia on schizoaffective disorder actually experienced worsening or improvement of their symptoms during medical hospitalization deserves further study.

Clozapine Therapy and Clinical Outcomes in Kentucky Psychiatric Hospitals

We reviewed the protocol for determining patient eligibility to receive clozapine in Kentucky state psychiatric facilities. Results of a retrospective review of the clinical outcomes of the initial 42 patients who received clozapine under this protocol are reported. Patients receiving clozapine were severely ill patients with a mean duration of illness and mean length of current hospitalization of 11 years and 2 years, respectively. Symptomatic response was dramatic with a reduction in total Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) ratings of 48.4% and 36.3%, respectively. The time patients spent in restraints decreased significantly following clozapine initiation. Clozapine was well tolerated, with sedation being the most common adverse effect reported. One patient experienced a seizure and another developed leukopenia. Following 12 weeks of clozapine treatment, the patient discharge rate was 42.9%.