Suicide in a community based case management service

Over a 9 year period, 532 people with a long term mental illness received the services of a community based case management program. Of the 532 clients, 13 committed suicide (2%). This group was compared to a control group matched for age, sex and length of stay in the program. No differences were found with regard to most socio-demographic and clinical variables investigated. However, statistically significant differences were found with regard to chronicity and number of post-admittance hospitalizations. Difficulties in establishing a working relationship were noted more often for clients who committed suicide. Some of the implications for case management programs are discussed.Melanie J. Steers, MSW, was a case manager with the Community Rehabilitation Services program of CRCT at the time of preparing this paper.     

Inpatient Hospitalizations and Emergency Service Visits Among Participants in an Individual Placement and Support (IPS) Model Program

Supported employment (SE) is considered an "evidence-based" practice for people with serious mental illness. We examined inpatient hospitalizations and emergency service visits among clients in a SE program based on the Individual Placement and Support (IPS) model in comparison to a propensity score matched group of clients who did not participate in IPS. A significant interaction showed that only IPS/SE clients who were also high in regular mental health services had fewer hospitalizations and emergency service visits than matched controls. The interaction effect was moderate, even when we controlled for client functioning. These findings provide support for the integration of mental health and vocational rehabilitation services, a key feature of evidence-based SE services.     

The Economic Impact of Providing Evidence-Based Pediatric Mental Health Literacy Training to Primary Care Physicians

ObjectiveThis paper presents a review of the current state of child and adolescent mental health literacy and provides current evidence of the economic impact of a pediatric mental health literacy (MHL) training program. MethodsEmploying a case-series-comparison design, physician referrals to urgent and specialized mental health services were linked with patient-specific information comparing referrals from MHL participants and non-participating physicians. The economic impact analysis was based on changes in the admitted referral frequency and lengths of stay for the MHL group, compared to themselves pretraining, and over the same time period compared to non-participating physicians. ResultsAverage scheduled ambulatory admission rates per physician remained constant for trained and untrained pre-post groups. Average scheduled ambulatory admission wait time and length of stay reduced significantly post-training for MHL-trained physicians compared to pre-training and untrained physicians. In addition to reductions in length of stay, the total bed costs saving for emergency/inpatients admission deferrals was $2,932,112 or about $20,000 per MHL-trained physician. ConclusionThe estimated economic impact of the MHL training shows a substantial return on investment and supports wider implementation. The MHL training program should be a key feature of mental health reform strategies, as well as continuing and undergraduate medical education.     

Functioning and health service use among elderly nursing home residents with alcohol use disorders: findings from the National Nursing Home Survey.

OBJECTIVE: The author asked whether older nursing home residents with alcohol use disorders differ from demographically-matched residents without alcohol use disorders on functioning, admission characteristics, and health services use. METHOD: National Nursing Home Survey data were used to compare nursing home residents with alcohol use disorders (N=216) with demographically-matched residents without alcohol use disorders (N=216) on functioning, admission characteristics, and health services use. RESULTS: Residents with alcohol use disorders functioned somewhat better than did residents in the demographically-matched sample group, as indicated by performance of basic activities of daily living. However, they were significantly more likely to have lived alone before admission and to have obtained mental health and social services. There was a significant group x gender interaction on length of stay: men with alcohol use disorders had shorter lengths of stay than did men without alcohol use disorders; women with alcohol use disorders had longer lengths of stay than did women without such disorders. CONCLUSIONS: Having fewer social resources may contribute to elevated admission risk and need for mental health and social services among older nursing home residents who have alcohol use disorders. Duration and severity of alcohol problems may help explain gender differences in length of stay among these residents.     

A family approach to severe mental illness in post-war Kosovo

This study describes the effects of a psychoeducational multiple-family group program for families of people with severe mental illness in post-war Kosovo that was developed by a Kosovar-American professional collaborative. The subjects were 30 families of people with severe mental illnesses living in two cities in Kosovo. All subjects participated in multiple-family groups and received family home visits. The program documented medication compliance, number of psychiatric hospitalizations, family mental health services use, and several other characteristics, for the year prior to the groups and the first year of the groups. The families attended an average of 5.5 (out of 7) groups, and 93% of these families attended four or more meetings. The uncontrolled pre- to post-intervention comparison demonstrated decreases in medication non-compliance and hospitalizations, and increases in family mental health service use. The program provided training for mental health professionals, led to policy change in the Ministry of Health, and resulted in dissemination to other community mental health centers. This study provides preliminary evidence that a collaboratively designed and implemented psychoeducational, multiple-family program is a feasible and beneficial intervention for families of people with severe mental illness in impoverished post-war settings.     

Psychotherapy of Psychosest†

Abstract

This study describes the effects of a psychoeducational multiple—family group program for families of people with severe mental illness in post—war Kosovo that was developed by a Kosovar—American professional collaborative. The subjects were 30 families of people with severe mental illnesses living in two cities in Kosovo. All subjects participated in multiple—family groups and received family home visits. The program documented medication compliance, number of psychiatric hospitalizations, family mental health services use, and several other characteristics, for the year prior to the groups and the first year of the groups. The families attended an average of 5.5 (out of 7) groups, and 93% of these families attended four or more meetings. The uncontrolled pre- to post—intervention comparison demonstrated decreases in medication non—compliance and hospitalizations, and increases in family mental health service use.

The program provided training for mental health professionals, led to policy change in the Ministry of Health, and resulted in dissemination to other community mental health centers. This study provides preliminary evidence that a collaboratively designed and implemented psychoeducational, multiple—family program is a feasible and beneficial intervention for families of people with severe mental illness in impoverished post—war settings.     

The impact of coexisting depression and timing of psychiatric consultation on medical patients' length of stay

Patients with a psychiatric disorder are known to make greater use of medical resources than patients without a psychiatric condition, but the impact of highly prevalent psychiatric illnesses, such as depression, on use of medical resources has not been fully explored. This study assessed the lengths of stay of 92 medical and surgical patients who met DSM-III criteria for depression and the relationship of their length of stay to the timing of psychiatric consultations. The 92 patients were hospitalized significantly longer (a mean of 2.52 days more) than they would have been had their length of stay been determined by their medical diagnosis-related group (DRG). A subgroup of 38 Medicare patients were hospitalized a mean of 5.22 days more than the mean stay allowed by their DRG. Consultations occurring earlier in the hospitalizations were linked to shorter stays.     

Relationship between criminal arrest and community treatment history among patients with bipolar disorder

OBJECTIVE: This study examined the relationship between criminal arrest and gender, substance use disorder, and use of community mental health services among patients with bipolar I disorder. METHODS: Los Angeles County's computerized management information system was used to retrospectively identify all inmates with a DSM-IV diagnosis of bipolar I disorder who were evaluated over a seven-month period in the psychiatric division of Los Angeles County Jail and had a history of psychiatric hospitalization in the community. Patients without a history of arrest who were involuntarily hospitalized in the community and treated for bipolar I disorder over the same seven-month period served as a comparison group. The use of community mental health services that inmates received before their arrest was quantified and compared with the services that patients in the comparison group received before their involuntary hospitalization. RESULTS: Patients who had been arrested (N = 66) were more likely than patients in the comparison group (N = 52) to be male (55 percent compared with 31 percent) and to have a history of substance use disorder (76 percent compared with 19 percent) but were less likely to have a history of treatment while under a mental health conservatorship (8 percent compared with 29 percent). In contrast to patients in the comparison group, patients who had been arrested were hospitalized more frequently (a mean of 3.4 hospitalizations per year compared with a mean of 1.1 hospitalizations per year) and had a briefer average length of stay (a mean of 9.2 days compared with a mean of 16.4 days). CONCLUSIONS: In contrast to patients in the comparison group, patients who had been arrested were more likely to be male, to have comorbid substance use disorder, and to have a treatment history characterized by more frequent, briefer hospitalizations.     

Inpatient psychiatric morbidity of HIV-infected soldiers

To determine differences in inpatient psychiatric morbidity, a total of 573 soldiers seropositive for the human immunodeficiency virus (HIV) were matched with 2,266 seronegative soldiers by age, sex, race, marital status, military rank, length of active service, military occupation, and date of HIV test. An HIV-infected individual was seven times more likely to be hospitalized than an uninfected individual. The rate of total hospitalizations was 16 times higher for the HIV-infected soldiers. The median length of hospital stay was six days for the infected soldiers and four days for the control group. The incidence of psychosis, organic mental disorders, and adjustment disorder in the HIV-infected group was significantly higher.     

Differences between long-stay and short-stay inpatients and estimation of length of stay

Summary To find possible differences between new long-stay inpatients and patients with shorter lengths of stay, a prospective study of 340 inpatients in the 4th week of hospitalization was carried out. The new long-stay patients differed from the others in diagnoses, symptoms, duration of prior hospitalizations, and socio-demographic data. On the basis of the data assessed in the 4th week of hospitalization, we tried not only to predict future new long-stay patients, but also to estimate the length of stay for all 340 patients. A time-function model was employed with length of stay as a continuous variable, and this resulted in correct allocation to the quartiles in 38–48% of the cases. Six variables proved to be important for estimating length of stay: emotional withdrawal, blunted affect, mannerisms, duration of previous hospitalizations, living conditions (prior to admission), and marital status.     

An outpatient psychiatry program for offenders with mental disorders found not guilty by reason of insanity

OBJECTIVE: Rehospitalization and criminal recidivism were examined among a group of offenders with mental disorders adjudicated as not guilty by reason of insanity and mandated to receive treatment in a forensic psychiatric outpatient program as a condition of release. METHODS: A retrospective chart review was conducted for 43 offenders with mental disorders who were acquitted as being not guilty by reason of insanity for the index offense and were active in the outpatient treatment program in 1996. Data were abstracted on sociodemographic, psychiatric, and criminal characteristics predating the index offense; rehospitalizations and new crimes and rearrests after the offense; and clinical and psychosocial functional outcomes after enrollment in the outpatient program. RESULTS: For the 43 patients, the mean length of stay in the program was 68 months, with a range of 4.9 months to 18.4 years. Almost two-thirds of the patients were diagnosed as having schizophrenia, schizoaffective disorder, or a nonaffective psychotic disorder; 58 percent had a comorbid substance use disorder, and 63 percent had an axis II diagnosis. Since program enrollment, 20 patients (47 percent) were rehospitalized at least once, and eight (19 percent) were rearrested or had committed a new crime. At the end of 1996, only nine (24 percent) were in full remission, and 26 (68 percent) showed at least one indicator of difficulty reintegrating into the community. CONCLUSIONS: Even after treatment in a specialized forensic program, this sample of offenders with serious mental disorders remained impaired symptomatically and functionally. Although avoidance of rehospitalization is considered a successful outcome, rehospitalization is preferable to rearrest for this forensic population.     

State Variation in Out-of-Home Medicaid Mental Health Services for Children and Youth: An Examination of Residential Treatment and Inpatient Hospital Services

This research investigated state variation in the use of out-of-home mental health services among children and youth enrolled in Medicaid during 2003. Medicaid claims from three states were used to describe the demographic and diagnostic characteristics of children and youth under age 22 who received mental health services in general hospitals, psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings and to examine their lengths of stay, repeat stays, and expenditures. Depending on the state, 6–13% of children and youth with a mental health diagnosis received out-of-home services during the year; 37–58% of these children and youth had more than one out-of-home stay. Out-of-home mental health services accounted for 21–75% of Medicaid mental health expenditures for children and youth, depending on the state. States varied considerably in lengths of stay and per beneficiary expenditures for out-of-home care. Although some similarities in out-of-home care were found across states, substantial state variation in out-of-home care warrants further research in the context of state service systems and Medicaid policies.     

Effects of the Personalized Recovery Oriented Services (PROS) Program on Hospitalizations

Though the recovery model has been implemented widely in outpatient mental health settings, there are no large sample evaluations of recovery oriented psychiatric rehabilitation programs that address both serious mental illness (SMI) and co-occurring disorders (COD) using a more comprehensive Medicaid reimbursable approach. This study examined preliminary hospitalization outcomes, for adults with SMI and COD enrolled in the NYS Personalized Recovery Oriented Services (PROS) program. McNemar’s chi-square test was used to examine changes in hospitalization rates from pre-PROS admission to post-PROS discharge in a sample of 12,006 adults discharged from PROS. Negative binomial regression models were used to calculate adjusted rates of hospitalizations and hospital days. Demographic, psychosocial, and diagnosis predictor variables were extracted from the OMH web-based Child and Adult Integrated Reporting System. Hospitalization data were extracted from the Mental Health Automated Recordkeeping System, and Medicaid. From pre-admission to post-discharge, psychiatric hospitalization rate decreased significantly, from 24% to 14%. Substance related hospitalizations also decreased significantly, from 5% to 3%. Average number of hospitalizations and number of days hospitalized decreased even after adjusting for sociodemographic factors. PROS serves a high number of COD patients, and the number of psychiatric and substance related hospitalizations decreased after an episode of PROS, as did the number of days hospitalized. Findings support the maintenance of psychiatric rehabilitation models that include recovery oriented components. Further analyses with control samples are proposed.     

Patients’ satisfaction with hospitalization in a mixed psychiatric and somatic care unit

A patient satisfaction survey was undertaken in a mixed psychiatric and somatic care unit. An anonymous self-report questionnaire covering setting and satisfaction with care was completed by 60 patients. Median age was 42 (range 20-64), and the majority female (63%). Main ICD-10 diagnostic categories were depressive disorders (51.7%), substance-related disorders (33%) and personality disorders (25%). Somatic comorbidity was present in 60% of patients. Overall satisfaction with care and setting was high. Higher satisfaction was significantly associated with a history of previous hospitalizations in a psychiatric hospital and with being referred to the program by a psychiatrist. These findings emphasize the perceived advantages of mixed units, such as decreased stigmatization of psychiatric inpatients and opportunity to receive adequate treatment for both physical and mental problems during a single hospital stay.     

A day hospital program for dual diagnosis patients in a VA Medical Center.

A day hospital program for patients with mental illness and substance abuse problems at a Veterans Affairs medical center uses nonconfrontational group therapy as the primary treatment modality. The goals of the six-to-eight-week program are to reduce substance abuse, improve medication compliance, and reduce the number of hospitalizations. Aftercare is available for patients who complete the program. The authors suggest that patients' ability to relate well to others in group therapy is the primary factor influencing successful outcome. During a 30-month period, 66 percent of the patients admitted to the day hospital program completed it. Three cases illustrating the variable outcomes of patients treated in the program are presented.     

An evaluation of a mental health program for homeless men

The authors report the results of a before-and-after evaluation of an on-site mental health day treatment program for homeless men. Thirty-two subjects were interviewed 6 or more months after placement from a crisis shelter to community housing in order to probe housing stability, aftercare treatment compliance, employment, rehospitalization, and criminal justice contacts. In the after phase, living on the street was virtually eliminated, use of shelters decreased sevenfold, aftercare utilization tripled, and contacts with the criminal justice system were halved. Psychiatric hospitalizations and unemployment were higher in the after phase. Findings are discussed in relation to the need to conduct controlled experiments of new psychosocial treatments for the homeless mentally ill.     

Crisis homes for adult psychiatric patients

Introduction

Inspired by the Crisis Home programme in Madison, we have adapted and evaluated the programme at the Community Mental Health (CMH) Centre in Tønder, Denmark.

Material and methods

Procedures and schedules from the Crisis Home programme were applied in this open trial. Questionnaire data concerning satisfaction with the stay and registration data concerning the admissions and bed days two years before and two years after the first stay were obtained.

Results

During four years, 52 different patients had a total of 187 stays in a crisis home. Twenty (38.5%) of the patients were attached to the ACT team. The average duration of the stays was 4.0 days. The number of readmissions and bed days after the first stay showed a significant downward tendency for the subgroup of patients with a more severe mental disorder, but not for the whole group. The patients, the crisis homes families and the referrers were very satisfied with the programme and the treatment.

Conclusion

Crisis home stays represent a quality improvement in the treatment package, especially for patients with a more severe mental disorder. Further documentation will require a controlled study.     

Predicting involuntary patients' length of stay

A comparison was made of lengths of stay for involuntary patients treated in a local facility with those admitted to a state mental hospital. Involuntary patients treated in the local facility had much shorter lengths of stay than those treated at the state hospital even though the case mix was similar at both institutions. These findings suggest that local treatment may be less costly than state hospitalization for involuntary patients.     

Patient and Program Predictors of 12-Month Outcomes for Homeless Veterans Following Discharge from Time-Limited Residential Treatment

The U.S. Department of Veterans Affairs provides transitional residential treatment to homeless veterans through three types of programs: VA-staffed Domiciliary care, and two types of community-based treatment (one funded through locally managed contracts and the other through national grants). This study compared treatment process and outcomes in these three programs and also sought to identify differences in outcome between dually diagnosed veterans, veterans with substance abuse problems or psychiatric problems alone, and those with no psychiatric diagnoses. Altogether, 1,338 veterans admitted to the 3 types of program were recruited to participate in a prospective naturalistic study which evaluated housing, clinical and community adjustment outcomes during the year following discharge. Data on 1,003 veterans for whom psychiatric diagnostic, social climate and length of stay data were available were used to compare participants in the three program types at baseline. Regression models were used to compare outcomes across program and diagnostic types net of baseline differences between study participants, and of differences in social climate and length of stay. The overall follow-up rate across all time points was 72%. Significant differences across programs were observed on only 2 baseline measures as well as on several baseline values of the outcome measures, length of stay and a measure of social climate. Adjusting for veteran baseline differences alone there were no differences in outcomes by program after correction for multiple comparisons. Dually diagnosed veterans had poorer mental health and overall quality of life outcomes. Longer length of stay and more positive social climate were associated with superior outcomes on several measures. The adjusted mean estimate of the proportion of veterans housed at 12 months follow-up was 78%, similar to published outcomes for supported housing. Length of stay, rather than program funding configuration or diagnostic group, was the strongest predictor of outcomes in time-limited residential treatment programs in which 1-year housing was similar to those in direct-placement supported housing programs.     

Efficacy of a Community-Based Trauma Recovery Program after a Fire Disaster

As industries develop, fire disasters and their associated damage are increasing. Investigating the mental health of victims is imperative because this is an essential issue for community recovery after a disaster. This study was conducted to determine the efficacy of a program implemented by a community mental health center based on the investigation of the victims’ depression and post-traumatic stress disorder (PTSD) levels immediately after the disaster and at one-year follow-up. As a result, victims’ depression and PTSD recovered over time, and more changes were confirmed. In particular, the high-risk group for PTSD showed a high program participation rate, and there was significant recovery over time compared with the group without PTSD. Based on these results, community mental health programs are an effective way to increase community mental health after disasters. In the future, community-based recovery programs after disasters should be expanded, and administrative support for them should be developed.