Involuntary first admission of patients with schizophrenia as a predictor of future admissions.

OBJECTIVE: The extent to which the legal status of a first psychiatric admission-voluntary or involuntary-predicted the legal status and number of future admissions was examined among patients with schizophrenia. METHODS: Data on all patients in Israel who had a nonforensic first admission between 1978 and 1992 and a diagnosis of schizophrenia (N=9,081) were extracted from the national psychiatric hospitalization case registry. Also obtained from the registry was information about the patients' subsequent hospitalizations through 1995, demographic data, and diagnosis. Analyses adjusted for time since first admission, age at first admission, country of origin, and religion. RESULTS: The first admission of 12.9 percent of the patients was involuntary. The legal status of the first admission was not related to the number of readmissions. However, female patients whose first admission was involuntary were 4.1 times more likely to have an involuntary second admission than female patients whose first admission was voluntary; these odds were 3.4 for males. Further analysis examined the percentage of involuntary admissions among all hospitalizations of the 3,420 patients who had four or more admissions (chronic patients). Among the chronic patients who had an involuntary first admission, 41 percent of subsequent admissions were involuntary. This figure was significantly lower among the chronic patients who had a voluntary first admission-13 percent. The percentage of involuntary admissions was not related to the number of admissions. CONCLUSIONS: The strong association of involuntary legal status at first admission with involuntary status at second admission and with the number of involuntary admissions over time suggests that involuntary first admission might be an important factor in assessing whether patients are likely to be readmitted involuntarily.     

Morbidity and social mobility in an upper class educational group.

Approximately 18,000 19-year-old graduates from the high schools of Norway were followed for 50 years after graduation by means of a national case register of hospitalized psychoses. Six hundred and sixty-eight graduates were found to have been admitted to a psychiatric institution. The admission rate for male graduates was found to be 95.7 % of the expected rate, while for the female sex the percentage was 115.8. In both sexes, the number of manic-depressive cases was higher than the national average, while schizophrenia was rarer. The number of admissions related to alcohol or drug addiction was much higher in the graduates, and these admissions were concentrated mainly among members of the medical professions. A detailed study was made of 450 male and 218 female graduate patients for whom information was available about the occupation of the father as well as that of the graduate himself. The hospital admission rate was significantly higher in the graduates who had an occupation lower than that of their fathers, and vice versa. Within each social group, the rate of admission was highest in the graduates who had remained in the same occupation as their fathers: Professional sons of professional fathers had an admission rate of 109 % of the expected rate, while those who had moved to other occupations had a rate of only 87 % of the expected. It would seem that inter-generational change of occupation is associated with a lowering of psychiatric morbidity. High admission rates were found in groups which can be regarded as relative failures in relation to their level of aspiration (or that of their parents) in going to high school.     

Prediction of first episode of clinical depression in patients newly admitted to a medical long-term care facility: Findings from a prospective study

A cohort of 104 patients newly admitted to a medical long-term care facility was studied over 1 year for evolution of depression. Seven variables that were associated with level of depression were used in discriminant function analyses. Results showed that the variables had about 90% accuracy in predicting depressed versus non-depressed groups with good sensitivity and specificity. The variables measured: coping with admission; life satisfaction at admission; affective and non-affective symptoms at admission; clinical health status after admission; friends in hospital after admission; and changes in affective symptoms after admission before the onset of depression.     

Physical assaults by psychogeriatric patients: Patient characteristics and implications for placement

The case notes of 137 patients admitted to a psychogeriatric assessment ward over 12 months were reviewed. The characteristics of patients who were assaultive prior to, or during admission were compared with those who were not. The reported prevalence of assaultive behaviour from the case notes was compared with that from the formal ‘violent incident’ forms. Twenty-three per cent of the patients had assaulted others prior to their admission, and 23% were assaultive during their admission. Those patients who were assaultive prior to admission were likely to be assaultive during their admission. Assaultive behaviour prior to and during admission was associated with male gender, dementia, and increased age in female patients. Assaults were underreported on the formal ‘violent incident’ forms by nursing staff. Assaultive behaviour prior to admission predicted discharge to a higher dependency setting, but assaultive behaviour during admission did not. The implications of these findings are discussed.     

Effects of compulsory treatment orders on time to hospital readmission

To evaluate the effect of compulsory community treatment orders on subsequent time out of the hospital, the authors studied the admission dates of psychotic patients who had repeated hospitalizations in Quebec, Canada, and divided each admission according to its time in relation to the index admission, during which the judicial order was obtained. The data were stratified by type of admission (early, preindex, index, or postindex), and the hypothesis tested was that the median time to readmission would be greatest for the index admission. The hypothesis was confirmed, supporting previous findings that judicial orders that mandate severely ill psychotic patients to undergo compulsory community treatment are associated with decreased time spent in the hospital and thus increased personal freedom.     

What predicts the course of expressed emotion in relatives of patients with schizophrenia or related psychoses?

The expressed emotion (EE) index may not be as stable as it was once believed to be. The aim of this study was to identify variables associated with spontaneous change from low to high and from high to low levels of EE and EE subscales – critical comments (CC), hostility (H), emotional overinvolvement (EOI). Using a longitudinal, prospective study design, of 59 relatives having at least weekly face-to-face contact with 40 patients with an acute episode or relapse into schizophrenia (DSM-III-R) were interviewed by means of the Camberwell Family Interview (CFI) at admission and at 4 1/2 months after discharge. The results showed that high-high or unstable levels of CC, H or EE were associated with the patient not working or studying prior to admission. Relatives with low-high and high-high EOI patterns had more weekly face-to-face contact with the patient prior to admission than relatives with a low-low EOI pattern. Patients whose relatives had low-high CC and EE patterns were less ill at admission than patients whose relatives had low-low patterns. Higher perceived family burden was associated with, at admission, an unstable pattern of CC, and at follow-up, high-high EOI or EE patterns rather than low-low patterns. Our study suggests that it is possible to identify which relatives will have a stable and which a changing EE level, allowing for more focused intervention. Accepted: 29 June 1998     

Predicting revolving-door patients in a 9-year national sample

We attempted to predict revolving door (RD) patterns of admission (four or more admissions with less than 2.5 years between consecutive admissions) in a random sample of 10% of all first admissions to psychiatric hospitals and psychiatric wards of general hospitals in Israel from 1983 to 1990 with follow-up into 1993. This included 4570 hospitalizations of 2220 patients. Data were extracted from the National Psychiatric Case Registry of the Ministry of Health. Almost 59% of the sample had only one admission, 41% had two or more, 23% had three or more, and 14% had four or more admissions. Patients with four or more admissions were all RD patients. They had an average of 200 days between admissions. The average number of admissions for RD patients was 6.17, and the average number of years between the first admission and the last admission was 3.28 years. Using discriminant analysis were correctly predicted 73.9% of the non-RD group (about chance level since 80% of the cases were non-RD) and 71.2% of the RD group (considerably better than chance, only 12.0% of the sample were RD). The main predictors of RD in descending order were not being married at the time of first hospitalization, unemployment and more severe initial diagnosis. The minor predictors were older age, more education and longer first admission. Substance abuse, patients ability to care for their affairs, voluntary status of first admission and suicide attempts did not predict RD. The predictors of RD were almost the same as predictors of more than one admission. We were not able to identify a variable that clearly differentiated between the two or more, three or more and four or more admissions groups. Variability between hospitals is also presented.     

Pituitary-adrenal regulation over multiple depressive episodes

Pituitary-adrenal activity was evaluated with the dexamethasone suppression test in 11 patients over their multiple hospitalizations for major depression. All six patients who were suppressors during their index admission had one subsequent admission over the period of study during which they were again suppressors. Of five patients who were nonsuppressors during their index admission, three had one subsequent admission and two had three subsequent admissions. Four of these patients were again nonsuppressors during a subsequent admission. For patients who were nonsuppressors during some but not all admissions for depression, pituitary-adrenal activity appeared related to the persistence of the depressive episodes.     

Hypomanic switching caused by the psychological effects brought on by a change in environment due to hospital admission: two cases of bipolar II patients who showed a hypomanic switch

Hypomanic episodes in two cases involving depressed patients (bipolar II) were observed after admission to an open psychiatric ward. The patients had not exhibited any prior (hypo)manic episodes during outpatient treatment. Thus, manic switching was thought to have been caused by the psychological effects brought on by the change in environment due to hospital admission. Hospital admission was believed to have been an unloading from their stressful lives, given that the affective state of both patients prior to admission was characterized by depression resulting from work-related stress. The close relationship between the patients and the predominantly female nursing staff may have triggered a psychological regression in both patients. These factors appear to have led to the hypomanic switching.     

Factors interfering with the 1 mg dexamethasone suppression test in depression

The 1 mg dexamethasone suppression test (DST) was performed in 50 depressive inpatients in order to investigate factors which might interfere with its sensitivity and specificity for endogenous depression: improvement within one week after the test, recent admission to a psychiatric ward, and weight loss. Four out of five endogenous depressive patients whose depression improved within one week after the test had normal suppression, thus supporting the assumption that normalization of the DST may precede the improvement in depression. Nonendogenous depressive patients had an accumulation of pathologic test results on the day after admission that may be due to "admission stress". However, in endogenous depressives this effect was not observed. An influence of weight loss on the percentage of suppressors and nonsuppressors was not demonstrable. It is concluded that in the evaluation of DST results time parameters should be considered to a greater degree.     

The 2-Minute Spontaneous Swallowing Screening Predicts Independence on Enteral Feeding in Patients with Acute Stroke

BackgroundIt is recommended that enteral feeding should be offered to patients with dysphagia estimated to be unable to take adequate diet orally within 7 days of admission after acute stroke, but there is no clear criterion for initiation of enteral feeding. Recent studies have reported that the frequency of spontaneous swallowing is useful in screening for dysphagia in acute stroke. The present study was aimed to investigate whether measurement of frequency of spontaneous swallowing for 2 minutes could predict independence on enteral feeding 1 week after admission in patients with acute stroke.MethodsPatients with acute stroke were subjected. Within 72 hours of stroke onset, the number of swallows for 2 minutes was measured by auscultation. Subsequently, 1-hour frequency of spontaneous swallowing was measured using a laryngeal microphone. Functional Oral Intake Scale (FOIS) was evaluated 1 week after admission.ResultsTwenty-six out of 40 patients were independent on enteral feeding 1 week after admission based on FOIS. The presence of spontaneous swallowing for 2 minutes had .89 sensitivity, .54 specificity to predict independence on enteral feeding 1 week after admission, whereas the 1-hour frequency of spontaneous swallowing had 1.00 sensitivity, .46 specificity. Logistic regression analysis demonstrated that the presence of spontaneous swallowing for 2 minutes was independent predictor for independence on enteral feeding 1 week after admission, independently of age, sex, and NIHSS.ConclusionsThe 2-minute spontaneous swallowing screening predicts independence on enteral feeding 1 week after admission in patients with acute stroke.     

Short-term outcome of inpatient psychiatric care—impact of coercion and treatment characteristics

Aims Little is known about the outcome of brief inpatient treatment interventions in routine psychiatric practice. The aim of this article was to study if subjective and assessed outcome of brief psychiatric inpatient care are related to patient characteristics, coercion at admission and during care, and other treatment characteristics. Method A total of 233 involuntarily and voluntarily admitted patients were interviewed within 5 days from admission and at discharge or after 3 weeks of care. Outcome was measured as reported by patients and by change in GAF (Global Assessment Scale) scores. Results Predictors for a positive subjective outcome were if the patients reported that they had been well treated by the staff and had contact persons at the ward. Predictors for a GAF improvement were a low GAF score at admission and a mood disorder diagnosis. Conclusions Subjectively reported outcome and outcome measured by assessing change in level of functioning differed. Coercion was not related to outcome. The way the patient perceived they had been treated by the staff was strongly related to subjective outcome.     

Immigration,moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991–1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.     

Effect of intravenous immunoglobulin therapy in a case of idiopathic recurrent brachial and lumbosacral plexopathy]

We report a case of a 23-year-old woman with idiopathic brachial and lumbosacral plexopathy who presented a relapsing course of weakness and numbness following acute onset of pain in the right shoulder or pelvic girdle area. On her first admission, the patient recovered gradually with oral prednisolone. But after about 1 year, her symptoms worsened. In the second admission, oral prednisolone had no effect on her symptoms, so intravenous immunoglobulin (IVIG; 0.1 g/kg/day, 5 days) therapy was tried. The patient improved about 2 weeks after IVIG therapy. About 1 year later, her symptoms worsened and was administered again. In the third admission, IVIG therapy of which dose was the same as that in the previous admission had an effect on her symptoms. The dose of IVIG in our case was relatively low, compared with those in cases reported before (0.2-2 g/kg/day). This findings suggest that a relatively low-dose IVIG therapy is effective for idiopathic plexopathy.     

头颅外伤血糖水平与病情和预后的关系

为明确头颅外伤与高血糖间的关系，研究５７例头颅外伤患者入院时及外伤１５ｄ时的血糖水平。结果显示：①头颅外伤后，６５％的患者血糖水平高于正常，仅３５％的患者血糖水平在正常范围。②入院时高血糖与头颅外伤程度密切相关，ＧＣＳ记分高者，血糖水平接近正常；ＧＣＳ记分低者，血糖水平高。③入院时的血糖水平可能是反映预后的一个重要指标。     

Variables related to outcome following child psychiatric hospitalization

Children (N = 110) hospitalized on a child psychiatric unit improved significantly in psychological functioning at discharge and 1- and 6-months follow-up relative to their functioning at admission. Children who were more impaired at admission made more progress during admission but were more impaired at follow-up than children who had milder symptoms at admission. Children without a behavior disorder had a better outcome than children with a behavior disorder. None of the other variables, alone or in combination, was significantly related to admission progress or follow-up outcome, including specific diagnoses, gender, race, age, IQ, family functioning, negative life events, parent education and employment, biological family history, length of hospitalization, parent involvement during admission and follow-up services.     

A prospective 1–5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity,premorbid adjustment,duration of disease and education level at index admission and neuroleptic treatment

Wieselgren, I-M, Lindström LH. A prospective 1–5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity, premorbid adjustment, duration of disease and education level at index admission and neuroleptic treatment. Acta Psychiatr Scand 1996: 93: 9–19. © Munksgaard 1996. In a prospective outcome study, 120 DSM-III-R schizophrenic patients were followed for up to 5 years after index admission, when a comprehensive clinical and demographical examination was undertaken with the aim to find early prognostic factors for outcome. They were 86 males (72%) and 34 females (28%), and 66 (55%) were first-admitted and never before treated at index admission from a geographically defined area. Outcome was evaluated 1, 3 and 5 years after index admission by use of a Strauss-Carpenter outcome scale. At year five, 101 patients could be evaluated. Seven (7%) patients had committed suicide during the 5 years' follow-up period. 30% of the patients was considered to have a good, 14% a poor and 56% an intermediate outcome. It was found that 58% had not been in hospital during the last year, 27% were employed on the open market, 25% met friends regularly and 38%) had no or only mild symptoms at the five years' follow-up evaluation. Females had a significantly better outcome than males. High education level and absence of premorbid deviant behaviour at index admission predicted a good outcome whereas problems in school (with friends and/or teachers) reported by relatives predicted poor outcome. No relationship was found between outcome and age at onset of the disorder and no gender difference in age at onset of the disorder. Patients with a family history of schizophrenia improved more between year one and five as compared with those without a family history, but heredity in itself was not an important factor for outcome. At 5 years after index admission, 40% of patients were on classical neuroleptics and 33% on clozapine whereas 19% were without medication. Of the total sample of 101 patients, 10% were drug-free and had a very good outcome at the 5 years' evaluation. The data indicate that there is a substantial subgroup of schizophrenic patients with a good prognosis and they can be characterized by female sex (even in a group without gender difference in age at onset), absence of premorbid deviant behaviour and a high education level at index admission.     

Correlates and antecedents of hospital admission for attempted suicide: a nationwide survey in Italy

The present study examined data on symptom patterns in the week prior to admission for suicide attempt, in a nationwide representative sample of patients. Socio-demographic, clinical, and treatment data was gathered for 1,547 patients admitted over a 12-day index period during the year 2004 to 130 public and 36 private psychiatric facilities in Italy. Patients were evaluated in terms of whether they had been admitted for having attempted suicide or not. A detailed checklist was used to assess symptom pattern at admission; diagnoses were based on ICD-10 categories. Two-hundred thirty patients (14.8%) in the sample had been admitted for suicide attempt. Patients with depression or with personality disorders were more frequently observed among suicide attempters. First-contact patients were significantly more likely to have been admitted after a suicide attempt, the only exception being individuals with bipolar disorder, manic phase. No diagnosis was statistically related to admission after suicide attempt, once symptoms pattern at admission had been accounted for. Disordered eating behavior, depressive symptoms, substance abuse, and non-prescribed medication abuse were positively related to attempted suicide, as were any traumatic events in the week prior to admission; symptoms of psychosis (hallucinations/delusions) and lack of self-care were negatively associated with suicide attempt admission. Greater attention to symptoms immediately preceding or concomitant with admission after a suicide attempt can be a key factor in establishing the best treatment plan and discharge strategy, the most effective community-service referral, and targeted intervention programmes for patients hospitalized for a suicide attempt.     

Relatives of psychiatric inpatients--do physical violence and suicide attempts of patients influence family burden and participation in care?

A common concern of psychiatric patients' relatives is that patients might be a danger to themselves or others. The aim of this study was to investigate family burden and relatives' participation in care in relation to physical violence towards others and suicide attempts by psychiatric inpatients before admission. Information concerning violence and suicide attempts by the patients prior to admission was collected from the medical records of 155 acutely voluntarily and involuntarily admitted psychiatric inpatients. Relatives were interviewed a month after admission, using a semi-structured questionnaire. Violence towards other persons and suicide attempts were recorded in 16% and 17% of the cases, respectively. There were no differences between relatives of patients who had been violent and other relatives regarding burden and participation in care. Relatives of patients with suicide attempts more often stated they had been prevented from having own company, worried about suicide attempts by the patient, had mental health problems of their own, and had own need for care and support. It was concluded that violence of acutely admitted psychiatric patients, targeted at other people, was not associated with burden of family, but the results corroborate the need for psychiatric services to involve and support relatives of psychiatric patients with suicidal behaviour.     

Do not overlook acute isoniazid poisoning in children with status epilepticus

A previously healthy 2-year-old girl was admitted with generalized convulsive status epilepticus. She was in a stupor and could respond only to painful stimuli. She also had severe metabolic acidosis. Although initial liver function tests were normal, they were found to be moderately high on the fifth day of admission; however, they dropped to their normal ranges on the twelfth day of admission. Initially, the patient was diagnosed as having idiopathic status epilepticus, and classic anticonvulsant agents, including diazepam, phenytoin, and then phenobarbital, were given. However, her seizures did not subside, and diazepam infusion was initiated. After initiation of diazepam infusion, the seizures were completely controlled. On the fourth day of admission, her parents said that she had accidentally received 20 tablets (a total dose of 2000 mg) of isoniazid just before admission to our hospital. Later, we injected 200 mg of pyridoxine intravenously. During follow-up, her general condition improved, and anticonvulsant agents were discontinued because an electroencephalogram was found to be norma. She was discharged from the hospital on the twelfth day of admission. At the fourth month of follow-up, she was seizure free. Because of this case, we would like to re-emphasize that acute isoniazid poisoning should also be considered in a child with unexplained status epilepticus.