Reasons for hospitalization from a psychiatric emergency service

Consistency in the application of civil commitment standards in psychiatric emergency rooms

In the controversy over civil commitment procedures, reliability as well as validity of clinicians' assessments have been challenged. In this study, the generalizability of TRIAD, an observational assessment device, was tested. Patient load strongly influenced the degree to which TRIAD predicted case disposition and clinician global ratings of dangerousness and grave disability. Given comparable patient-clinician ratios, TRIAD predicted 81% to 86% of case dispositions. Agreement between clinician global assessments and TRIAD ratings was high to moderate. Clinicians apparently agree on sets of indicators which can be consistently weighted, but the application of the standard described by TRIAD may be jeopardized by increasing patient loads.

Non-compliance and related phenomena

Objective:Review of literature on non-compliance with medication in psychiatric patients.

Method:Computer and manual search of English language literature on non-compliance with drugs, psychiatric disorder, and phenomena which may be related, such as readmission and discharge against medical advice.

Results:The literature is discussed and a tentative checklist of risk factors for non-compliance is offered, as is advice on ways in which the problem may be minimised. It is noted that there is an emphasis on major mental disorders in the published literature.

Conclusion:There is no stereotypical defaulter. A high index of suspicion is essential. As far as possible, the patient should be educated to share in the responsibility for treatment, and concerned relatives and others can often play a pivotal role. More research is required on compliance problems in the minor psychiatric disorders. Close liaison with the general practitioner is vital.

The base rates and factors associated with reported access to firearms in psychiatric inpatients

OBJECTIVE

The aim of this study was to define whether specific patient demographic groups, diagnoses or other factors are associated with psychiatric inpatients reporting firearms access.

METHODS

A retrospective medical records review study was conducted using information on access to firearms from electronic medical records for all patients 16 years and older admitted between July 2007 and May 2008 at the Mayo Clinic Psychiatric Hospital in Rochester, MN. Data were obtained only on patients providing authorization for record review. Data were analyzed using univariate and multivariate logistic regression analyses accounting for gender, diagnostic groups, comorbid substance use, history of suicide attempts and family history of suicide/suicide attempts.

RESULTS

Seventy-four percent (1169/1580) of patients provided research authorization. The ratio of men to women was identical in both research and nonresearch authorization groups. There were 14.6% of inpatients who reported firearms access. In univariate analysis, men were more likely (P<.0001) to report access than women, and a history of previous suicide attempt(s) was associated with decreased access (P=.02). Multiple logistic regression analyses controlling for other factors found females and patients with history of previous suicide attempt(s) less likely to report access, while patients with a family history of suicide or suicide attempts reported increased firearms access. Diagnostic groups were not associated with access on univariate or multiple logistic regression analyses.

CONCLUSIONS

Men and inpatients with a family history of suicide/suicide attempts were more likely to report firearms access. Clinicians should develop standardized systems of identification of firearms access and provide guidance on removal.

Relationships between patient, family, and significant other disposition preferences in psychiatric emergency services and the clinical symptom ratings and disposition decisions of psychiatrists

A previous paper examined the relationship between 10 clinical ratings made by psychiatrists and 465 psychiatric emergency service (PES) dispositions. A logistic regression model explained 52% of the variance in the psychiatrist's decisions to admit to inpatient services or release. The 5 clinical ratings in the model, rated on 8-point scales, were severity of danger to self, psychosis, inability to care for self, impulse control, and depression. The current paper examines the relationships between patient and family/significant other dispositional preferences expressed in the PES, and the psychiatrist's disposition decision and the 10 clinical ratings. It found that the dispositional preferences of the patient, family, and other individuals (community clinician, police, or ambulance driver) were very consistent with the actual decision made by the PES psychiatrist. Further, it found that these preferences explained an additional 35% of the variability in the psychiatrist's decision to admit or release. Finally, the ten clinical ratings made by the PES psychiatrist explained only a small amount of the variance in the dispositional preferences, and some of the significant coefficients were in the opposite direction expected. Patient, family and other significant individuals' expressed preferences and expectations in the PES are important and should be routinely recorded in the charts. The small relationships between clinical ratings and preferences suggests that the reasons the family/significant other and the patient seeks hospital admission or release may differ with psychiatrists' reasons for disposition.

[Decision making process for compulsory admission: study of a group of psychiatrists of Sardinia, Italy]

OBJECTIVE

The aim of the study was to investigate the attitudes in the decision making process for admitting patients compulsorily under the Italian Law 180/78.

SETTING

A group of psychiatrists (n = 81) working in the area of Cagliari (Sardinia, Italy).

MAIN OUTCOME MEASURES

Three case-vignettes describing different hypothetical clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. Each vignette was followed by a list of 11 factors reported in the literature as important in the decision to admit compulsorily (current mental state, severity of the disease, dangerousness to self or others, psychiatric history, likely response of the mental state to the medical treatment, age and gender of the patient, owning a home, occupational status, social support available). Psychiatrists were asked: a) whether they would admit the patient compulsorily; and b) to rate 11 factors from the most to the least important in their decision.

RESULTS

We obtained responses from 57 psychiatrists (26 males and 31 females). The most important factors for deciding to detain a patient compulsorily were: current mental state, diagnosis, severity of the illness and possible contribution of medical treatment. Perceived dangerousness to self and others was considered the most important factor by 23% of the sample.

CONCLUSIONS

Our results confirm that, in three different hypothetical situations, there is agreement in the factors perceived as the most important in the decision to admit compulsorily, although their application is highly subjective. The factors correspond to those recommended by the Italian Law 180. The need for protection of the patient or others has an important role in the decision and may take precedence over the current mental state of the patients [corrected].

Hospitalizing the suicidal adolescent: decision-making criteria of psychiatric residents

OBJECTIVE

The primary purpose of this research is to investigate the criteria used by general psychiatric residents in determining the appropriateness of hospitalization.

METHOD

A questionnaire containing 64 vignettes describing adolescent suicide attempts was completed by a sample of 33 residents from a general psychiatry training program. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette.

RESULTS

Hospitalization preference was significantly predicted by all risk factors except for gender, with the presence of depression emerging as the most important predictor of hospitalization. Residents recommended hospitalization more frequently than did experienced child and adolescent clinicians. In comparison with experienced clinicians, residents placed more importance on depression, and less importance on conduct disorder/substance abuse, in making decisions to hospitalize.

CONCLUSIONS

Although psychiatric residents use known risk factors for adolescent suicide in assessing need for hospitalization, there was clear support for further training initiatives for psychiatric residents concerning the assessment of suicidal adolescents.

Emergency psychiatry training and the decision to hospitalize : a longitudinal study of psychiatric residents

To assess the impact of a 6-month emergency psychiatry training program on emergency psychiatric decision making, we studied 577 emergency psychiatric patient evaluations conducted by 15 first-year psychiatry residents. By their fifth month of training, the residents' rates of emergency patient hospitalization declined from 33% to 19%. For residents in the early training phase, various clinical features, including psychosis, thought disorder, schizophrenic diagnosis, dangerousness, and overall symptoms, were associated with higher rates of patient hospitalization. By the end of training, only dangerousness and overall symptoms remained significantly related to the hospitalization decision. Specific training in emergency psychiatry may affect psychiatric decision-making practices as early as the first year of residency training.

Factors related to psychiatric hospitalisation for first contact patients

In a consecutive series of 178 first contact patients hospitalisation was significantly related to greater distance travelled, low income, acute onset, short duration, past history of illness and history of substance abuse compared to those receiving outpatient disposition. Hospitalised manics and paranoid schizophrenics had higher BPRS scores while hospitalised non-paranoid schizophrenics had lower scores. There was a significant positive correlation between hospitalisation and BPRS items: grandiosity, excitement, elated mood, motor-hyperactivity and distractibility and negative correlation with somatic concern, anxiety, depressive mood and social incompetence. Stepwise multiple regression analysis found the combination of loss of functioning, social incompetence and grandiosity to best predict disposition decision.

Emergency room dispositions of professionally referred psychiatric patients

Emergency room records of professionally referred and nonprofessionally referred patients are reviewed. Professionally referred patients were significantly more likely to be admitted than non professionally referred patients. Female, white, and employed patients were all overrepresented among the professionally referred. Suicidality, homicidality, and depression were also more common in this group. After accounting for the clinical and demographic differences, referral source did not significantly modify the disposition from the emergency room. Among schizophrenic patients, however, professional referral independently improved the likelihood of admission. These results are discussed in terms of social factors which may influence emergency room decision making.

Psychiatry in the emergency department: factors associated with treatment and disposition

Patients with psychiatric problems present difficult treatment and dispositional decisions to physicians in general hospital emergency departments (ED). We studied the relationships between the psychosocial characteristics of patients given psychiatric diagnoses and clinical decisions made by nonpsychiatrists and psychiatrists in our ED. Decisions concerning psychiatric consultation in the ED, dispositional decisions (admission, discharge), and referral for psychiatric outpatient care for patients discharged were reviewed for 246 patients. The relationships between decisions and 13 indicators of patients' psychosocial characteristics were evaluated by use of stepwise logistic regression techniques. Psychiatric-related variables (severity of symptoms, history of psychiatric hospitalization or outpatient treatment, and psychotropic medications at entry to the ED) were associated with decisions made by both psychiatrists and nonpsychiatrists. However, nonpsychiatric variables including patient's age, "rudeness," diffuseness of medical complaints, time of day, and month of presentation also were related to decisions. Practitioners should be sensitive to social factors that affect their decisions about psychiatric patients.

Differentiating psychiatric readmissions from nonreadmissions

This study tracked a cohort of 550 discharged state hospital patients through an entire publicly-funded mental health aftercare system. Data from hospital and community agency records indicate that neither social-demographic nor clinical characteristics successfully differentiated psychiatric readmissions from nonreadmissions. Use of aftercare services--in terms of the variety available and their relevance to discharged patients' assessed needs--had the greatest influence on predicting the likelihood of readmission.

Organizational and client influences on psychiatric admissions

This paper analyzes the decisions which take place at the entrance gate of the mental hospital-the organizational and client factors which influence the decision to admit. More specifically, it explores variations in the determinants between first admissions and readmissions. In the process, a theoretical model will be developed, based on a study of admissions to state hospitals, which may help explain several of the underlying and continuing obstacles confronting efforts to reduce readmissions.

Into the breach: emergency psychiatry in the general hospital

In its position at the interface between the community and the general hospital, the emergency ward (EW) serves to reconcile the complex needs of the local population with the traditional organizational structure of the hospital. In recent years, the EW has been faced with the dilemma of managing increasing numbers of psychotic patients with chronic illness and psychosocial problems. In response to this impressive growth in the utilization of psychiatric emergency services, a variety of general hospitals have developed model programs of service delivery and methods for the evaluation of their effectiveness. This paper is an overview of utilization patterns, organization of services, and assessment of the evaluation and referral model. This issues facing general hospitals in the development of emergency care are clarified. The need for further research, program development, and clinical implementation is discussed.

Suicide attempts 1970--75: updating a United States study and comparisons with international trends

This paper brings up to date a 1970 study of suicide attempters coming to a major emergency room in an United States urban community and reviews international trends in suicide attempts. Results of the study and the review of the international literature indicate that the high rates of suicide attempts that were observed in 1970 are continuing into 1975. The incidence of suicide attempts continues to be a public health problem primarily amoung young women. Pill ingestion, usually barbiturates and psychotropic drugs, continues to be the most common method used.