Use Of Inpatient Psychiatric Services Research Articles

Adolescent and Adult Transitions From Major Depressive Disorder to Bipolar Disorder

Bipolar disorder (BD) often first appears in adolescence after onset of major depressive disorder (MDD), but diagnosis and treatment are commonly delayed. This delay is a concern because untreated BD is associated with adverse long-term outcomes, a more recurrent disease course and difficult-to-treat illness, and suicide attempts and deaths. To examine the association of age at MDD onset with early transition to BD and the subsequent use of psychiatric inpatient services as a severity indicator. This retrospective cohort study analyzed comprehensive data sourced from the Stockholm MDD Cohort data from 1997 to 2018, which encompass both outpatient and inpatient care. Individuals with an initial MDD episode from January 1, 2010, to December 31, 2013, who transitioned to BD by December 31, 2018, were identified. Data were analyzed between September 5 and December 28, 2023. Post MDD assessments included a depression severity index, comorbidities, psychotherapy, psychotropic drugs, and electroconvulsive therapy. The main outcome was the transition from MDD to BD, dichotomized as occurring early (within 3 years of MDD onset) or late (3 years after MDD onset). Secondary outcomes encompassed the use of psychiatric inpatient services post transition and patterns of medication usage. A robust propensity score matching framework was used to estimate outcomes. The final balanced cohort included 228 individuals, with an equal distribution between adults (n = 114; mean [SD] age, 24.5 [6.3] years; 96 female [84.2%]; 20 experiencing an early transition to BD [17.5%]) and youths (n = 114; mean [SD] age, 15.3 [1.6] years; 93 female [81.6%]; 8 experiencing an early transition to BD [7.0%]). Youths were substantially less likely to transition early (odds ratio, 0.42; 95% CI, 0.20-0.88; P = .02), despite having more outpatient visits (mean [SD] visits per month, 1.21 [1.07] vs 0.97 [0.98] for adults; P = .01). Both groups experienced substantially reduced inpatient care following a BD diagnosis, concurring with a marked decline in antidepressant use without increased lithium use. These findings suggest that adolescents may experience delayed BD progression and that diagnosis substantially reduced inpatient care in all age groups, which coincided with a reduction in the use of antidepressants. These findings may inform pharmacologic strategies in patients with first-episode MDD at risk for BD.

Community-Based Service Use After Clozapine Treatment: A Mirror-Image Analysis of Public Claims Data.

Although clozapine demonstrates unique efficacy for treatment-resistant schizophrenia, its impact on community-based services remains largely underexplored. The authors examined changes in use of community-based services after clozapine treatment among a sample of 163 patients with schizophrenia by using public claims data in Allegheny County, Pennsylvania. Mirror-image analyses of service utilization were used to compare the 180-day period before treatment initiation with the 180-day period that began after 6 months of adherent treatment, accounting for age, race, and gender. Across demographic variables, clozapine treatment was associated with increased use of community-based services and decreased use of psychiatric inpatient services (p<0.05, Bonferroni corrected), suggesting that clozapine treatment shifts service needs from emergency care to community-based care and recovery.

The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness

To examine the impact of co-morbid personality disorder (PD), on inpatient and community-based service use and risk of involuntary hospitalization, amongst patients with severe mental illness (SMI). We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) with and without co-morbid PD, and PD cases, aged ≥18 years, in a large secondary mental healthcare case register. Using multivariable logistic regression, we examined the association between co-morbid PD and high level of inpatient and community-based service use (defined as the top decile of service use), and involuntary hospitalization, respectively, adjusting for socio-demographics, clinical symptoms and social functioning. Severe mental illness patients with co-morbid PD (SMI-PD) (n = 961) had more severe symptoms and social functioning problems compared to SMI patients without PD (n = 10,963) and patients who had PD but no concurrent SMI (n = 2,309). A greater proportion of SMI-PD patients were high inpatient service users (22.4 vs. 10.1 %). This association was attenuated but remained significant, after adjustment (fully adjusted odds ratio, OR 2.31, 95 % CI 1.88-2.84). The association between SMI-PD and high community-based service use was confounded by symptoms and social functioning. Compared to patients with SMI, SMI-PD patients were significantly more likely to experience involuntary hospitalization (fully adjusted OR 1.56, 95 % CI 1.31-1.85). In SMI patients, co-morbidity with PD is robustly associated with both high use of inpatient psychiatric services and an increased likelihood of involuntary hospitalization. Patients with SMI and co-morbid PD are likely to require tailored interventions that target both the underlying personality pathology as well as the Axis I disorder.

Patterns of service utilisation in psychosis: Findings of the 2010 Australian National Survey of Psychosis

This paper reports patterns of health service utilisation in the second Australian national survey of psychosis corresponding with changes in available services of this period. Semi-structured interviews were carried out of an age-stratified random sample of adults who screened positive for psychosis. Multivariate logistic regressions were used to identify predictors of service use for a sample of 1825 individuals. Use of psychiatric inpatient services was associated with higher symptom levels, suicidal ideation, poor social functioning and younger age. High users of emergency mental health services similarly reported higher symptom levels, poor functioning and younger age, and also reported being married or in a de facto relationship. Recipients of general practitioner services had greater anxiety symptoms and suicidal thoughts, fewer negative symptoms, single marital status and English as their first language. Rehabilitation service use was associated with greater anxiety symptoms, unemployment, younger age of illness onset, living alone and having no dependent children living at home. Last, outpatient/community services were more frequently used by younger people with good premorbid adjustment, hallucinations and a less severe course of illness. Service utilisation patterns vary with the clinical and socio-demographic features of those who use them - inpatient and emergency service users being similar in such features and differing from users of other services. Comparison with the first national survey of psychosis revealed a significant decline in acute inpatient service use and a substantial increase in the use of outpatient/community and rehabilitation services over the past 10 years.

Use of psychiatric inpatient services by heavy users: Findings from a national survey in Italy

Purpose To analyze factors associated with a patient's probability of being a Heavy User (HU) of inpatient psychiatric services and to compare the HU inpatient population with Non-Heavy Users (NHUs). Patients and methods The survey was conducted among inpatients enrolled in the PROGRES-Acute-project, an Italian nationwide survey of public and private inpatient facilities. Patients with three or more admissions over the last 12 months were considered HUs, and patients who had undergone one or two admissions during the same period made up the NHU group. Results Four hundred and thirty-five (40.5%) were HUs, and 640 (59.5%) NHUs. HUs were younger, more frequently unmarried, unemployed, receiving a disability-pension, and either homeless or living in a residential facility. HUs were more likely to have experienced conflicts with their partners or family members during the week prior to admission. A logistic regression analysis revealed that age, age at first admission, number of life-time admissions, and having been the victim of violence were the most important predictive factors for the HU phenomenon. Conclusion Our study suggests that specific attention should be given to patients’ family context, due to its crucial role in daily informal care and in the triggering of events leading to rehospitalization.

The Role of Social Network and Support in Mental Health Service Use: Findings From the Baltimore ECA Study

The Role of Social Network and Support in Mental Health Service Use: Findings From the Baltimore ECA Study

Trends in psychiatric hospitalisation of people with schizophrenia: A register-based investigation over the last three decades

The number of psychiatric beds has declined considerably in many countries over the past decades. Long-term studies on the impact of these health care changes for the severely mentally ill, however, are still scarce. This epidemiological study investigates the use of inpatient psychiatric services by people with schizophrenia, compared to that by people with other mental disorders. We used psychiatric register data of the Swiss canton Zurich to establish the annual treatment prevalence in the period 1977–2004. For patients with psychoses, the length of inpatient episodes decreased by half. The annual number of inpatient admissions doubled. The proportion of schizophrenia patients, which accounted for 36%–41% of all inpatient treatments up to 1993, dropped to 20% in 2004, while that of other psychoses remained about the same (8%–10%) throughout the study period. This contrasts with a 2–3 fold increase in other patient groups. The annual treatment prevalence for people with schizophrenia declined from 7.3 to 2.2 per 10 000 population since the 1990s and affected patients of all ages and of both sexes equally. The treatment prevalence for other psychoses remained virtually unchanged (1.3 per 10 000). For all other mental disorders, there was an up to twofold increase. The study suggests that the downsizing of psychiatric hospitals has resulted in a far-reaching redistribution of overall inpatient treatment resources. The considerable decrease in inpatient treatment for people with schizophrenia emphasizes the need to further investigate the current state of coverage for and the appropriateness of health care available to this patient group.

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterJulie Kreyenbuhl Pharm.D., Ph.D.Marcia Valenstein M.D., M.S.John F. McCarthy Ph.D., M.P.H.Julie Kreyenbuhl Pharm.D., Ph.D.Search for more papers by this authorMarcia Valenstein M.D., M.S.Search for more papers by this authorJohn F. McCarthy Ph.D., M.P.H.Search for more papers by this authorPublished Online:1 Jul 2007https://doi.org/10.1176/ps.2007.58.7.1011aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: We appreciate Dr. Babbar's letter, which brings much needed attention to a serious safety concern—hospitalization for adverse drug reactions, which could result from treatment with multiple antipsychotic medications. We share his concern about this and other potential adverse consequences of a treatment strategy that lacks solid evidence for its efficacy and safety. Dr. Babbar correctly notes that patients prescribed antipsychotic polypharmacy in our study were more likely to receive several other psychiatric medications, which could further increase their risks of adverse effects and subsequent hospitalizations. In addition, patients receiving polypharmacy were prescribed antipsychotic dosages that were the same as or higher than for those receiving monotherapy and had greater use of anti-Parkinson agents, which suggests that they were at risk of or were already experiencing side effects related to excess antipsychotic exposure. These findings lend further support to Dr. Babbar's hypothesis that rather than reflecting the severity of patients' psychotic symptoms (a potential indication for the use of polypharmacy), the higher rate of past-year psychiatric hospitalization was a result of the adverse effects of multiple medications. The overall goal of our study was to describe patient characteristics and treatment patterns associated with long-term antipsychotic polypharmacy. Although the safety and effectiveness of antipsychotic polypharmacy are important and unresolved issues, evaluating the outcomes of this treatment strategy was beyond the scope of our cross-sectional investigation. Further, we were not able to determine the reasons for the hospitalizations in question, although we do know that they reflected admissions to psychiatric or addiction treatment units. It is also important to note that the psychiatric hospitalizations occurred in the year before the period during which we documented patients' antipsychotic and other psychotropic treatments. We have no information regarding the medications prescribed before these admissions. This led us to infer that the previous hospitalizations were indicators of the severity of psychiatric illness of patients receiving antipsychotic polypharmacy, a conclusion reached by others who have reported a similar association between polypharmacy and previous hospitalization ( 1 , 2 , 3 ). Patients with refractory and disabling psychiatric symptoms (that may be reflected in increased use of inpatient psychiatric services) may be more likely to receive complicated psychotropic regimens that in turn induce adverse effects severe enough to result in hospitalization. We agree with Dr. Babbar that more research is needed to determine the extent to which this may be happening in routine clinical practice.

Heavy use of inpatient psychiatric services: an analysis from a systemic view point

Objective:There is an inequity in resource utilization among psychiatric in-patients. About 20-30% of them absorb 60-80% of the total resources allocated to this form of treatment. To develop interventions to contain this utilization pattern requires an agreement on a definition of who is a “heavy user”?Methods:Using data from a random sample (n = 15000) from the annual Swiss Hospital Survey we compared different definitions of heavy service use as to their usefulness to map and quantify the effect of interventions targeted to reduce inequity of resource consumption.Results:To deal with heavy service use necessitates to take a look from different levels of service provision. To create a satisfactory definition that can be generalised across different service systems seems out of reach at an individual level. However, various inequity indices commonly used in economic sciences (e.g. Gini-index) are well suited to specify heavy service use from a systems level.Conclusions:Quantifying the heavy service use from a systemic level allows for an estimation of the impact of services targeted to contain heavy service use.

The impact of severe mental illness, co-morbid personality disorders and demographic factors on psychiatric bed use

The use of inpatient psychiatric services has been correlated with certain demographic and clinical variables. However, there is limited information about the impact of personality disorder. To describe the impact of severe mental illness, personality disorders and demographic variables on psychiatric bed use amongst people in contact with a Community Mental Health Team (CMHT). Two-year retrospective and 2-year prospective bed use by the caseload of one Community Mental Health Team. Psychotic disorders (odds ratio 2.7), personality disorders (OR 2.2), marital status (OR 2.1) and unemployment (OR 1.9) were significantly related to psychiatric admissions from community care. Gender, accommodation, drug and alcohol problems, and ethnicity were not. Psychosis, personality disorder and unemployment appear to have independent effects on psychiatric bed use. Patients with a combination of psychotic disorders and diffuse personality disorders were very high users of inpatient services. This suggests that this group have particular needs that community mental health teams find difficult to manage.

Factors contributing to frequent use of psychiatric inpatient services by schizophrenia patients

Although present findings about frequent users of psychiatric inpatient services vary from study to study, some potentially important predictors of frequent use were extracted. The purpose of this study was to examine the potentially contributory factors of frequent use of psychiatric inpatient services by schizophrenia patients and to test the influence single factors have in an overall model. A total of 307 schizophrenia patients were interviewed five times with intervals of 6 months. Data were collected about service receipt and health care costs, strength of primary diagnosis and comorbidities, as well as about patients' needs for care and satisfaction with care. Patients with three or more psychiatric admissions within a 30-month period were defined as frequent users. According to this criterion, 12% of the study population were frequent users. Compared with ordinary users, these patients accounted for significantly higher costs in hospital- and community-based care. Important predictors for frequent use of psychiatric inpatient services were the number of previous hospitalizations and current scores of psychopathology. In addition, a longitudinal analysis showed the importance of social factors for the use of psychiatric inpatient care. Therefore, a number of the frequent users' multiple admissions could also be caused by social problems. The mental health system should, thus, provide well-directed community-based resources, which give frequent users support to solve their social problems.

The program of assertive community treatment: Implementation and dissemination of an evidence-based model of community-based care for persons with severe and persistent mental illness

The Program of Assertive Community Treatment (PACT), a multidisciplinary team approach, delivers integrated community-based treatment, rehabilitation, and support services to help persons with severe and persistent mental illness to avoid psychiatric hospitalization and to live independently in natural community settings. Twenty-five randomized clinical trials of PACT and its close adaptations, conducted over the past 30 years in several countries, demonstrate its effectiveness for this population in reducing use of inpatient psychiatric services and sustaining tenure in normalized housing. Programs based on the PACT model now operate in many countries and most states. Several states have disseminated these programs statewide using a mix of standards, financial incentives, monitoring of program performance, and expert training and consultation. However, despite the strong evidence base for PACT, most states have neither committed the resources nor implemented fidelity assurance methods necessary to widely disseminate PACT and/or its close variants. For the PACT model, we offer our hypotheses about behavioral change processes underlying its approach, describe its major operational structure and process elements, briefly review the research evidence of its effectiveness, and summarize statewide dissemination efforts and factors facilitating effective dissemination. Lastly, as a case study of implementation and dissemination, we report our difficulties in implementing PACT in a rural South Carolina community mental health center (1995–2000), discuss how supervision and consultation by national PACT experts prevented a collapse of our project and turned it into a success, and outline our present plans, supported with a federal grant, to disseminate an integrated PACT and supported employment service in South Carolina's community mental health center system.

Factors associated with high use of public mental health services by persons with borderline personality disorder.

The research presented here was a pilot study to identify clinical factors associated with high use (as opposed to lower use) of inpatient psychiatric services by persons with borderline personality disorder. The initial sample was a random sample of English- and Spanish-speaking persons aged 18 to 60 years who had received at least one outpatient mental health service in the previous 90-day period and were enrolled in one of the participating mental health centers in King County, Washington. A random sample of persons who met selection criteria was randomly drawn; persons with high levels of use were oversampled to ensure adequate representation. Twenty-nine participants met full criteria for borderline personality disorder on the Personality Disorders Examination structured interview and completed all measures. Fifteen (52 percent) of these had a high level of use of inpatient services, and 14 did not. High use of inpatient psychiatric services was predicted by a history of parasuicide in the previous two years but not by the number or severity of parasuicides; by the presence and number of anxiety disorders but not by depression or psychotic or substance use disorders; and by poorer cognitive functioning. Life stressors, global functioning, and health service variables did not differentiate patients with high levels of service use from other patients with borderline personality disorder. Further research should explore these predictors of service use to determine whether they are replicated in larger samples, and treatments that target these variables should be evaluated.

Patterns of Service Use Among Persons With Schizophrenia and Other Psychotic Disorders

This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use. As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year. People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies. The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.

Association between interruptions in medicaid coverage and use of inpatient psychiatric services.

Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.

A psychiatric primary care clinic for chronically ill veterans.

A psychiatric primary care clinic for chronically ill veterans.

The effects of public managed care on patterns of intensive use of inpatient psychiatric services.

The effects of public managed care on patterns of intensive use of inpatient psychiatric services.

Household crowding and compliance with outpatient treatment in patients with non-affective functional psychoses in São Paulo, Brazil.

Compliance with outpatient treatment can reduce the use of psychiatric inpatient services by people with severe mental disorders. In developing countries, socio-economic factors may be associated with compliance with outpatient treatment. A 2-year prospective cohort study was conducted of 99 patients with non-affective functional psychoses who were discharged from hospital. Standardized assessments were used for psychopathology, social functioning and use of psychiatric services. Forty-two patients (42.4%) missed all outpatient appointments for at least 2 consecutive months. Household crowding was the only variable associated with poor compliance, patients living in very crowded homes being more than twice as likely to show poor compliance as those living in less crowded homes. In large urban centres in developing countries, strategies to improve compliance with outpatient treatment targeted towards those living in overcrowded households may reduce use of psychiatric beds.

How does case management for long-term mentally ill individuals affect their use of health care services? An 18-month follow-up of 10 Swedish case management services

As part of an evaluation of 10 Swedish case management services, outcome in terms of changes in use of health care services was explored. The sample consisted of 176 long-term mentally ill individuals. Changes in use of psychiatric inpatient and outpatient services, primary health care services, and somatic inpatient and outpatient services during an 18-month follow-up were investigated. The results showed a marked and significant decrease in use of psychiatric inpatient services, which were on average reduced by 43% in terms of bed days used. There was no significant change in use of compulsory psychiatric care. The reduction in psychiatric inpatient care was largest for individuals with a diagnosis of schizophrenia. Case manager interventions directed towards the client's finances and coordination of care and support was related to less use of psychiatric inpatient services. To have more contacts with the case manager was related to fewer visits in psychiatric outpatient care. The use of primary health care and other somatic health care was unaffected. It is concluded that admission to a case management service resulted in a substantial reduction in use of psychiatric inpatient care, which to some extent was related to specific activities of the case manager.

The effects of public managed care on patterns of intensive use of inpatient psychiatric services.

The study examined the characteristics of frequent users of inpatient treatment under public-sector managed care in Massachusetts between 1992 and 1995 and explored whether their pattern of inpatient utilization affected their overall use of hospital days. Individuals with five or more admissions in any of four fiscal years (1992 to 1995) were identified using the Massachusetts Department of Mental Health client tracking system. The demographic and clinical characteristics of these patients and the types of hospitals they used were compared with those of all patients in case management programs who had a hospital admission but who did not meet study criteria for multiple admissions. Compared with other patients, patients with multiple admissions were more likely to be young Caucasian females with personality disorder and a history of substance abuse but not a current substance use disorder. They tended to be lower functioning as measured by the Georgia Role Functioning Scale (GRFS) and to have higher levels of distress, as measured by the global personal distress portion of the GRFS. They made up 6 to 8 percent of all clients with a psychiatric admission who were enrolled in a case management program, but they accounted for 21 to 27 percent of all admissions in the four fiscal years. Patients with multiple admissions had significantly longer lengths of stay when admitted to a hospital where they had not been previously admitted in the past 12 months. States setting up public-sector managed care or revising existing public-sector managed care contracts should ensure that subpopulations of persons at high risk for multiple admissions receive special attention. They should also create networks of inpatient providers to enable frequent users of acute care facilities to return to the same facility that previously discharged them.