The changing role of the state psychiatric hospital

A Choice-Based Conjoint Analysis of the Psychiatrist Decision-Making Process Used in Determining When to Discharge Adults With Major Depressive Disorder Hospitalized for Active Suicidal Ideation With Intent

ABSTRACT

To ascertain the relative importance of attributes considered when deciding to discharge patients hospitalized with major depressive disorder (MDD) and active suicidal ideation with intent, a choice-based conjoint analysis was conducted via online survey among US-based psychiatrists actively managing such patients. Potential attributes and attribute levels were identified. Attribute importance in decision to discharge and the discharge time frame were assessed. One hundred psychiatrists completed the survey. The relative importance of attributes were current MDD severity (relative importance weight [out of 100] 24.8 [95% confidence interval, 23.3-26.3]), clinician assessment of current suicidal ideation (20.8 [18.5-23.0]), previous history of suicide attempts (16.7 [15.9-17.6]), psychosocial support at discharge (13.0 [11.7-14.4]), postdischarge outpatient follow-up (9.8 [8.8-10.8]), current length of hospital stay (9.2 [8.1-10.3]), and suicidal ideation at admission (5.7 [4.8-6.6]). Thus, current clinical symptoms were considered the most important attributes by psychiatrists when discharging patients initially hospitalized with MDD and active suicidal ideation with intent.

Psychiatric hospital reform in low- and middle-income countries: a systematic review of literature

PURPOSE

Psychiatric hospitals or mental asylums grew across the world in the colonial era. Despite concerns over quality of care and human rights violations, these hospitals continue to provide the majority of mental health care in most low- and middle-income countries (LMICs). We sought to review the evidence of reform of mental hospitals and associated patient outcomes.

METHODS

We adopted an integrative review methodology by including experimental and non-experimental research. The review protocol was registered on PROSPERO (CRD42019130399). A range of databases and systematic hand searches were conducted by two independent reviewers. Research conducted between 1980 and May 2019, that focused on any aspect of reform in mental hospitals for adults (age 18 and upwards) with severe mental illness and published in English, were considered.

RESULTS

16 studies were included in the review. 12 studies met inclusion criteria, and four additional reports emerged from the hand search. Studies covered-India, China, South Africa, Grenada, Georgia, Sri Lanka, Argentina and Brazil. Key findings emphasise the role of judicial intervention as a critical trigger of reform. Structural reform composed of optimisation of resources and renovations of colonial structures to cater to diverse patient needs. Process reforms include changes in medical management, admission processes and a move from closed to open wards. Staff engagement and capacity building have also been used as a modality of reform in mental hospital settings.

CONCLUSION

There is some documentation of reform in psychiatric hospitals. However, poor methodological quality and variation in approach and outcomes measured, make it challenging to extrapolate specific findings on process or outcomes of reform. Despite being integral service providers, psychiatric hospitals still do not adopt patient centric, recovery-oriented processes. Hence, there is an urgent need to generate robust evidence on psychiatric reform and its effect on patient outcomes.

Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Implementation of a specialized program to treat violence in a forensic population

A shift within state psychiatric hospitals toward serving a predominantly forensic population has resulted in increased violent incidents within those settings. Thus, addressing criminogenic needs in addition to mental illness is an important paradigm shift. Relying on seclusion or restraint as the primary mechanisms to address violence interferes with the provision of effective care to patients struggling with aggressive behaviors. Implementing new treatment programs aimed at reducing violence in forensic inpatient settings is warranted. This article focuses on the step-by-step process of developing such a specialized treatment program within the California Department of State Hospitals. Leadership within this hospital system collaborated with labor unions and other stakeholders to obtain funding to create a novel treatment environment. This treatment program includes a ward design aimed to improve safety and delivers treatment based on the Risk Needs Responsivity Model. Treatment is guided by violence risk assessment and primarily focused on addressing criminogenic needs. The selection of treatments with a focus on violence reduction is discussed.

The Relationship Between Hospital and Community Psychiatry: Complements, Not Substitutes?

Community-based psychiatric services are essential to mental health. For decades, researchers, advocates, and policy makers have presumed that expanding the supply of these services hinges on reducing the supply of hospital-based care. Cross-national data from the World Health Organization call this presumption into question. Community and hospital psychiatry appear to be complements, not substitutes.

Predictors of 30-day Postdischarge Readmission to a Multistate National Sample of State Psychiatric Hospitals

BACKGROUND

Early discharge from psychiatric inpatient care may pose challenges for the patient's recovery and may incite a rapid return to the hospital. This study identified demographic, clinical, and the continuing of care characteristics associated with rapid readmission into a sample of psychiatric inpatient hospitals.

METHODS

Cross-sectional analysis of 60,254 discharges from state psychiatric hospitals. Logistic regression explored the relationship between predictors of rapid readmission.

RESULTS

Eight percent of discharges were readmitted to the same hospital within 30 days after discharge. Factors significantly related with rapid readmission included white (odds ratio, 1.23; 95% confidence interval, 1.13-1.34), non-Hispanic (1.48, 1.26-1.73), not married (1.53, 1.32-1.76), voluntarily admitted (1.18, 1.05-1.33), with length of stay (LOS) ≤ 7 days (3.52, 3.04-4.08), or LOS 8-31 days (3.20, 2.79-3.66), or LOS 32-92 days (1.91, 1.65-2.22), with a schizophrenia or other psychotic disorders (1.69, 1.46-1.96) or personality disorder (1.76, 1.50-2.06), referred to a setting different from the outpatient (1.27, 1.16-1.40), or with a living arrangement different from private residence (1.54, 1.40-1.68).

CONCLUSIONS

Disparities in rapid readmission rates exist among state psychiatric hospitals. A national overview of the individuals with mental illness at risk of being prematurely discharged may suggests insights into quality initiatives aimed at reducing rapid readmissions into psychiatric inpatient care.

Forensic patients in state psychiatric hospitals: 1999-2016

INTRODUCTION

In recent years mental health officials have reported a rise in the number of forensic patients present within their state psychiatric hospitals and the adverse impacts that these trends had on their hospitals. To date there have been no large-scale national studies conducted to determine if these trends are specific only to a few states or representative of a more global trend. The purpose of this study was to investigate these reported trends and their national prevalence.

METHODS

The forensic directors of each state behavioral health agency (including the District of Columbia) were sent an Excel spreadsheet that had two components: a questionnaire and data tables with information collected between 1996 and 2014 from the State Profiling System maintained by the National Association of State Mental Health Program Directors Research Institute. They were asked to verify and update these data and respond to the questionnaire.

RESULTS

Responses showed a 76% increase nationally in the number of forensic patients in state psychiatric hospitals between 1999 and 2014. The largest increase was for individuals who were court-committed after being found incompetent to stand trial and in need of inpatient restoration services.

DISCUSSION

The data reviewed here indicate that increases in forensic referrals to state psychiatric hospitals, while not uniform across all states, are nonetheless substantial.

CONCLUSION

More research is needed to determine whether this multi-state trend is merely a coincidence of differing local factors occurring in many states, or a product of larger systemic factors affecting mental health agencies and the courts.

Understanding barriers and facilitators to therapeutic relationships in state psychiatric hospitals

OBJECTIVE(S)

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.

METHOD

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

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.

CONCLUSIONS

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.

Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care

OBJECTIVES

To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.

DESIGN

Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database.

SETTING

Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents.

PARTICIPANTS

A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes.

MEASUREMENTS

Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s).

RESULTS

For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74).

CONCLUSION

Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019.

Inception of a Peer-Run Wellness Center at a State Psychiatric Hospital

Peer-run wellness centers provide safe places in the community for individuals with psychiatric disorders to develop personal and community supports, feel needed, and be accepted and grow. Until now, these centers have existed only in the community, not in the state hospital setting. The current article chronicles the development of what the authors believe is the first peer-run wellness center on the grounds of a state psychiatric hospital. After 8 years of operation, the center has served hundreds of visitors. In that time, centers have opened in the state's other state hospitals and contributed to peer presence in the hospitals' units and treatment malls. The benefits of peer-run wellness centers are important in the hospital setting as well as the community. Despite institutional barriers, the center was able to address the needs of hospitalized individuals while informing a more recovery-oriented inpatient culture. [Journal of Psychosocial Nursing and Mental Health Services, 56(12), 31-35.].

Falling through the cracks: the decline of mental health care and firearm violence

BACKGROUND

This paper argues that the decline in the availability of long-term, intensive mental health services, particularly through state mental health hospital systems, has had negative impacts on firearm-related deaths and possibly on the incidence of mass shooting events.

AIMS

Establish the effect of reduced availability of long-term, intensive mental health treatment on firearm-related violence in the United States.

METHOD

Ordinary least squares regressions on cross-sectional data of US states.

RESULTS

Mass shooting perpetrators had significantly higher rates of mental illness than the general population. In addition, using simple regressions, this paper's results demonstrate that increasing the number of state psychiatric hospital beds is associated with lower rates of homicide.

CONCLUSIONS

The shrinking number of intensive, long-term mental health facilities in US states has had many negative consequences, including higher rates of firearm homicide.

Mental Hospitals in India in the 21st century: transformation and relevance

Mental hospitals in India, as elsewhere in the world, have played an important role in the care of persons with mental illness. Since their inception, they have both been decried for gross violations of human rights and dignity as well as lauded as places of refuge and care for persons turned away by the communities. In a country where community interventions for mental health care are still fragmentary, the mental hospital still continues to be a relevant and legitimate locus of care along with other limited resources available for the care of persons with mental illness outside of the family. In India, positive changes in the infrastructure and resourcing of mental hospitals, reductions in involuntary admissions and improvements in facilities have largely occurred through judicial interventions. Recent pilot interventions for rehabilitation of long-stay patients point towards the need to develop rehabilitation and community facilities for persons with severe mental illness.

Treatment of Cognition in the Schizophrenia Spectrum: The Context of Psychiatric Rehabilitation

Evidence-based approaches and modalities for targeting and treating the cognitive impairments of schizophrenia have proliferated over the past 15 years. The impairments targeted are distributed across the cognitive spectrum, from elemental perception, attention, and memory, to complex executive and social-cognitive functioning. Cognitive treatment is most beneficial when embedded in comprehensive programs of psychiatric rehabilitation. To personalize comprehensive treatment and rehabilitation of schizophrenia spectrum disorders, practitioners and participants must select from a rapidly expanding array of particular modalities and apply them in the broad context of the participant's overall recovery. At present, no particular treatment, cognitive or otherwise, can be considered more important or primary than the context in which it is applied. Persistent difficulty in dissemination of new technology for severe and disabling mental illness compounds the significance of the context created by a full treatment array. In this article, a case-study of a mental health service system is described, showing the broad-ranging effects of degrading the rehabilitative context of treatments, obviating the benefits of cognitive treatment and other modalities. To realize the promise of cognitive treatment, the problems that prevent dissemination and maintenance of complete psychiatric rehabilitation programs have to be addressed.

Medical Student Education in State Psychiatric Hospitals: A Survey of US State Hospitals

OBJECTIVE

State hospitals may be underutilized in medical education. US state psychiatric hospitals were surveyed on current and potential psychiatry medical student education.

METHODS

A 10-item questionnaire, with multiple response formats, was sent to identified hospitals in late 2012.

RESULTS

Ninety-seven of 221 hospitals contacted responded. Fifty-three (55%) reported current medical student education programs, including 27 clinical clerkship rotations. Education and training in other disciplines was prevalent in hospitals both with and without medical students. The large majority of responders expressed enthusiasm about medical education. The most frequent reported barrier to new programs was geographic distance from the school. Limited resources were limiting factors for hospitals with and without current programs.

CONCLUSIONS

Only a minority of US state hospitals may be involved in medical student education. While barriers such as geographic distance may be difficult to overcome, responses suggest opportunities for expanding medical education in the state psychiatric hospitals.

Preventing Persons Affected by Serious Mental Illnesses from Obtaining Firearms: The Evolution of Law, Policy, and Practice in Massachusetts

A history of commitment to a mental health facility disqualifies applicants for gun licenses. Identifying such a history has become increasingly complex as the locus of confinement has become more diversified and privatized. In Massachusetts, prior to 2014, the databases used to identify individuals who would be disqualified on such grounds had not contemporaneously matched the evolution of the state's mental health systems. A survey of Massachusetts police chiefs, who, as in many jurisdictions, are charged with certifying qualification, indicates that some have broadened the scope of their background checks to include the experience of their officers with respect to certain applicants. The survey identifying these patterns, conducted in 2014, preceded by one month significant legislative reforms that mandate the modification of the reporting into a centralized database commitments to all types of mental health and substance use facilities, thus allowing identification of all commitments occurring in the state. The anticipated utilization of a different database mechanism, which has parallels in several other states, potentially streamlines the background check process, but raises numerous concerns that need to be addressed in developing and using such databases.

Adult general psychiatric patients served in Nebraska's state hospitals: patient characteristics and needs

This study identified the characteristics and needs of adults discharged from state psychiatric hospitals. A retrospective analysis of data on patients discharged from adult psychiatric units of three state psychiatric hospitals in Nebraska 2005-2008 was conducted. Diagnoses were classified into six groups, and Axis III data from the state psychiatric hospitals provided information about medical comorbidity. Only 12% of admitted patients had private insurance or could pay for their own treatment. Almost all discharged patients (95%) had a diagnosis of serious mental illness, and substance abuse (68%) and personality disorder (68%) were common, as were significant general health problems. Fourteen percent of patients used emergency services five or more times during the study period. Greater efforts must be made to diagnose, treat, and monitor major somatic illnesses and to better understand the factors that contribute to readmission and emergency service use in this population.

Demographics, clinical characteristics, and treatment of aggressive patients admitted to the acute behavioral unit of a community general hospital: a prospective observational study

OBJECTIVE

Aggressive patients are not uncommon in acute inpatient behavioral health units of general hospitals. Prior research identifies various predictors associated with aggressive inpatient behavior. This prospective observational study examines the demographic and clinical characteristics of aggressive inpatients and the routine medications these patients were receiving at discharge.

METHOD

Thirty-six adults diagnosed with a DSM-IV mental disorder who met 2 of 6 established inclusion criteria for high violence risk and a Clinical Global Impressions-Severity of Illness (CGI-S) scale score ≥ 4 were observed for a maximum of 28 days on the 23-bed case mix acute behavioral health unit of St Luke's University Hospital, Bethlehem, Pennsylvania, from January 2012 to May 2013. Primary outcome measures were the Modified Overt Aggression Scale (MOAS) and CGI-S; secondary measures were symptom outcome measures and demographic and clinical characteristics data. Analysis was conducted using repeated measures methodology.

RESULTS

Younger males with a history of previous violence, psychiatric admissions, and symptoms of severe agitation were more at risk for aggressive behavior. Positive psychotic symptoms, a diagnosis of bipolar disorder, substance use, and comorbid personality disorders also increased risk. Significant improvements from baseline to last visit were observed for the CGI-S and MOAS (P < .001 for both), with a significant correlation between the MOAS and CGI-S at last visit (P < .001). Only the symptom of agitation was significantly correlated to MOAS scores at both baseline and last visit (P < .001).

CONCLUSION

Patients significantly improved over time in both severity of illness and level of aggression.

Deinstitutionalization? Where have all the people gone?

Although there is broad consensus that the state psychiatric hospital population drastically declined over the past five decades, the destination and well-being of people with serious mental illness (SMI) have been in greater doubt. In this article, we examine the aftermath of the deinstitutionalization movement. We begin with a brief historical overview of the move away from state hospitals, followed by an examination of where people with SMI currently reside and receive treatment. Next, we review recent trends reflecting access to treatment and level of community integration among this population. Evidence suggests the current decentralized mental health care system has generally benefited middle-class individuals with less severe disorders; those with serious and persistent mental illness, with the greatest need, often fare the worst. We conclude with several questions warranting further attention, including how deinstitutionalization can be defined and how barriers to community integration may be addressed.

Nursing home admissions and long-stay conversions among persons with and without serious mental illness

The appropriateness of nursing homes for individuals with serious mental illness remains a controversial issue in long-term care policy more than a decade since the landmark U.S. Supreme Court Olmstead decision in 1999 , which affirmed the rights of persons with disabilities to live in their communities. Using national nursing home Minimum Data Set assessments from 2005, the authors compared the demographic, clinical, and functional characteristics of persons with and without serious mental illness newly admitted to nursing homes. They found that newly admitted people with serious mental illness were younger and more likely to become long-stay residents than those admitted with other conditions, despite a higher proportion of residents with serious mental illness, including the elderly, classified as low-care status. The most substantial and clinically significant difference for rates of low-care status 90 days after initial admission are for persons younger than 65 with serious mental illness versus those younger than 65 without serious mental illness (33% vs. 8.5%, or 3.9 times greater). There is a notable difference in low-care status between persons aged 65 and older with serious mental illness and those aged 65 and older without serious mental illness (14% vs. 6.6%, or 2.1 times greater). These results suggest that a substantial number of adults with serious mental illness residing in nursing homes may have the functional capacity to live in less restrictive environments.

Long-stay psychiatric patients: a prospective study revealing persistent antipsychotic-induced movement disorder

OBJECTIVE

The purpose of this study was to assess the frequency of persistent drug-induced movement disorders namely, tardive dyskinesia (TD), parkinsonism, akathisia and tardive dystonia in a representative sample of long-stay patients with chronic severe mental illness.

METHOD

Naturalistic study of 209, mainly white, antipsychotic-treated patients, mostly diagnosed with psychotic disorder. Of this group, the same rater examined 194 patients at least two times over a 4-year period, with a mean follow-up time of 1.1 years, with validated scales for TD, parkinsonism, akathisia, and tardive dystonia.

RESULTS

The frequencies of persistent movement disorders in the sample were 28.4% for TD, 56.2% for parkinsonism, 4.6% for akathisia and 5.7% for tardive dystonia. Two-thirds of the participants displayed at least one type of persistent movement disorder.

CONCLUSIONS

Persistent movement disorder continues to be the norm for long-stay patients with chronic mental illness and long-term antipsychotic treatment. Measures are required to remedy this situation.