Indications for inpatient child and adolescent treatment

When the demand for inpatient treatment in acute psychiatric crisis of adolescents rises, it is not always recommended to admit a patient to the hospital. The limited number of hospital beds forces medical professionals to use their resources cautiously. This leads to the need to activate the intrapersonal and intrafamilial resources. The motivation for change emerging out of a crisis is to be used for clarification of the indication of inpatient treatment and of the order of treatment, a patient (and/or his legal representative) gives to the hospital representatives. A clarification of the aims of a hospitalisation prior to the admission to the ward rises the efficacy of the invested time.     

Measuring the level of compulsory hospitalisation in mental health care: The performance of different measures across areas and over time

ObjectiveA variety of measures are used for reporting levels of compulsory psychiatric hospitalisation. This complicates comparisons between studies and makes it hard to establish the extent of geographic variation. We aimed to investigate how measures based on events, individuals and duration portray geographical variation differently and perform over time, how they correlate and how well they predict future ranked levels of compulsory hospitalisation.MethodsSmall‐area analysis, correlation analysis and linear regressions of data from a Norwegian health registry containing whole population data from 2014 to 2018.ResultsThe average compulsory hospitalisation rate per 100,000 inhabitant was 5.6 times higher in the highest area, compared to the lowest, while the difference for the compulsory inpatient rate was 3.2. Population rates based on inpatients correlate strongly with rates of compulsory hospitalisations (r = 0.88) and duration (r = 0.78). 68%–81% of ranked compulsory hospitalisation rates could be explained by each area''s rank the previous year.ConclusionThere are stable differences in service delivery between catchment areas in Norway. In future research, multiple measures of the level of compulsory hospitalisation should ideally be included when investigating geographical variation. It is important that researchers describe accurately the measure upon which their results are based.     

Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability‐a population perspective

Background There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was to compare hospitalisation rates for ambulatory care sensitive conditions between persons with and without an ID in a publicly insured population. Methods Persons with an ID were identified among the general population of a Canadian province between 1999 and 2003. Using a list of conditions applicable to persons with an ID, rates of hospitalisations for ambulatory care sensitive conditions for persons with and without an ID were calculated and compared. Regression models were used to adjust for age, sex and place of residence. Hospitalisation rates for specific conditions were also compared, controlling for differences in disease prevalence where possible. Results Persons with an ID were consistently hospitalised for ambulatory care sensitive conditions at a higher rate than persons without an ID. Between 1999 and 2003 the adjusted rate ratio (RR) was 6.1 [95% confidence interval (CI) = 5.6, 6.7]. Rate ratios were highest when comparing persons with, to persons without, an ID between the ages of 30–39 (RR = 13.1; 95% CI = 10.6, 16.2) and among urban area dwellers (RR = 7.0; 95% CI = 6.2, 7.9). Hospitalisation rates for epilepsy and schizophrenic disorders were, respectively, 54 and 15 times higher for persons with compared with persons without an ID. Rate ratios for diabetes and asthma remained significant after controlling for the population prevalence of these diseases. Conclusions The large discrepancy in rates of hospitalisation between persons with and without an ID is an indicator of inadequate primary care for this vulnerable population. Decreasing the number of ambulatory care sensitive condition hospitalisations through specialised outpatient programmes for persons with an ID would potentially lead to better health, improved quality of life and cost savings. Future research should include potentially important factors such as disease severity, socio‐economic variables and measures of health service organisation in the analysis. International comparisons of ambulatory care sensitive condition hospitalisation rates could point to the benefits and limitations of the health service policy directions adopted by different countries.     

Innovative care models for treating psychosis

It is generally accepted that modern mental health care gives community treatment priority over partial or full inpatient treatment. The requirements for community treatment of severely ill and chronic psychiatric patients are complex and, together with financing by the different social insurance providers, may lead to a rather problematic fragmentation of health service supply. Schizophrenia is considered the most expensive mental illness in Germany. It is estimated that indirect costs (expressed in financial terms) are five times higher than the direct costs of treatment and care. Innovative concepts of psychosocial intervention show that case management and assertive community treatment reduce the hospitalisation rate and duration of inpatient treatment, enhance social integration, and find the approval of most patients. However, there is no empirical evidence supporting this "psychiatry with no beds". Consideration should be given to psychosocial interventions as an alternative to inpatient hospital treatment such as day hospital care, crisis houses, or acute home treatment.     

Educational level and hospital use in mental disorders A population-based study

This population-based study presents socioeconomic differences in psychiatric inpatient care by diagnosis. Inpatient care among the Finnish population aged 25–64. years was studied using data from the Finnish National Hospital Discharge Register. All major mental disorders in the ICD-9 were included in the study. The socioeconomic status of individual patients was defined by years of education in the population census. Discharge rates, first–time admission rates and hospitalization risk were usually 2- to 4-fold higher in the low educational group compared with the highly educated population. The socioeconomic gradient was steepest for schizophrenia. No gradient was observed for major affective disorders. However, bipolar disorder was most common in the highest educational category. For most conditions, the socioeconomic gradient among women was lower than among men. In Finland hospitalization was more common among low than high socioeconomic groups for most mental disorders and most indicators of inpatient care. Most of these differences are fairly consistent with previous data on socioeconomic gradients in the prevalence of mental disorders.     

Prevalence of depression among general hospital surgical inpatients

Previous studies report a wide range of prevalence rates of depressive illness among general hospital inpatients, all higher than in a non-patient population. Several factors may have influenced on these results. Mixed study population, depression-prone subgroups and continuous shift in what is a surgical inpatient population due to day surgery treatment are examples. In the present study, 108 patients were assessed with the Structured Clinical Interview for DSM-III-R Non-Patient (SCID-NP) version for current major depression (CMD) and for dysthymia. Furthermore, a patient self-rating scale for depressive symptoms and anxiety, the Hospital Anxiety and Depression Scale (HADS), was applied. CMD was diagnosed among 14/108 patients (13%). Depressive symptoms (HADS-D> or =8) were seen in 14 patients. Symptoms of anxiety (HADS-A> or =8) were seen in 12/14 CMD patients (86%). Ten of the 14 patients diagnosed as CMD (71%) did not receive any pharmacological antidepressant treatment. After excluding known depression-prone subgroups of patients representing a bias, this study showed that in a community hospital group of adult surgical patients between 18 and 65 years of age, the prevalence of depression is still somewhat higher than in the general population, but not as high as in the previous studies on general hospital patients to which we referred. Thus, this high prevalence of depression in part could be due to increased depression rates in certain population subgroups. However, this hypothesis alone is not sufficient to explain the present results fully.     

Crisis intervention and affective disorders: A comparative cost-effectiveness study

In recent years, psychiatric institutions have been increasingly urged to justify their clinical policies in order to ensure both effective treatment and efficient management. Assessment instruments for effectiveness and costs are essential to respond to these needs. The aim of this study was to determine the cost-effectiveness of treatments for major depressive disorders. We conducted a comparative pilot investigation of treatment costs in patients with a major depressive episode assigned to specialised out-patient crisis intervention, to specialised in-patient treatment and to standard mental hospital care. The study included 122 subjects. The inclusion criteron was a diagnosis of DSM-III-R major depressive episode. Costs were assessed by determining the average cost for each treatment and the modalities of payment systems. Treatment duration and costs were high, but specialised crisis intervention may considerably reduce the duration of hospitalisation and its associated costs. The average costs of treating major depression were about 4 times greater in the specialised hospital unit than in the standard hospital unit and the crisis intervention centre. The burden of payment was comparatively higher for the state and reduced for insurance companies when the treatment of major depressive disorders involved less in-patient care.     

Associations between community characteristics and psychiatric admissions in an urban area

Purpose

Neighbourhood characteristics are known to be associated with higher rates of hospital admission for psychiatric disorders.

Methods

An ecological study with aggregated data was carried out. All cases for schizophrenia and depression in the 42 city districts of Augsburg were identified over a 4-year-period (2006–2009) and neighbourhood variables were obtained. Negative binomial regression adjusted the effects for year of admission and accommodation in inpatient centres.

Results

There was significant association of high unemployment rate, low proportion of working population and high population density with higher rates of admission for schizophrenia. An increase of 1 % in unemployment rate [incidence rate ration (IRR) 1.0451, 95 % CI 1.0175–1.0734] was associated with 5 % raise of admission rates for schizophrenia and an increase of 1 % in working population (IRR 0.9793, 95 % CI 0.9605–0.9985) with a decrease of admission rates by 2 %. High proportion of single households and high percentage of persons eligible for social security increased admission rate for depression. Thus 1 % increase in the proportion of single households (IRR 1.0095, 95 % CI 1.0030–1.0162) and of the proportion of persons eligible for social security (IRR 1.0148, 95 % CI 1.0002–1.0297) both independently were associated with an increased rate of admission for depression of 1 %.

Conclusion

Our analysis demonstrated that measures of social isolation in neighbourhoods and social contacts at work influenced admission for schizophrenia and depression: in neighbourhoods with less social contacts and with a higher proportion of persons not working the admission rates increased. The problem of confounding in ecological studies need to be considered.     

Assessing methods of predicting the need for psychiatric beds

Actual psychiatric bed utilization in 16 metropolitan areas was compared with projected bed needs in those areas derived from seven common methods of assessing the need for inpatient psychiatric services. Six methods significantly underpredicted actual use, and one significantly overpredicted actual use. Methods that relied on multiple sources, including expert opinion, historical use, epidemiologic data, and social indicators, predicted need more accurately than those that relied exclusively on expert opinion or historical use. The author also found that utilization rates of acute beds in general and specialty hospitals kept pace with licensed bed rates at or below 45 to 50 beds per 100,000 population but remained steady if the number of licensed beds went higher. The author recommends reliance on local indicators to plan inpatient services.     

Risk of incarceration between cohorts of veterans with and without mental illness discharged from inpatient units

OBJECTIVE: This study examined the risk of incarceration among cohorts of veterans treated in the Department of Veterans Affairs (VA) Connecticut Healthcare System. Incarceration rates of persons with and without mental illness were compared and adjusted for various clinical and service utilization variables. Data were compared before and after the closure of over 80% of the Connecticut VA psychiatric inpatient beds in 1996. METHODS: Data from five annual cohorts of patients (1993-1997) treated in an inpatient unit in the VA Connecticut Healthcare System (N=36,385) were merged with state Department of Correction data. Logistic regression models were used to identify risk factors for incarceration. RESULTS: Bivariate analysis showed that incarceration rates were higher for VA patients with psychiatric disorders and with substance use disorders than for those without such diagnoses, but there were no significant increases in likelihood of incarceration over these years of extensive closures. In multiple logistic regression analysis only diagnoses of substance use disorders and major depression were independently associated with an increased likelihood of incarceration, whereas schizophrenia, personality disorders, and co-occurring psychiatric and substance use disorders were not independently associated with increased likelihood in multivariate analysis. CONCLUSIONS: Alcohol and drug problems appeared to account for much of the risk of incarceration among hospitalized veterans during the study period. Unlike in previous studies, schizophrenia and related psychotic disorders were not independently associated with an increased risk of incarceration.     

Injury risk in young psychiatric outpatients

BACKGROUND: Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients. SUBJECTS AND METHODS: Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation. RESULTS: Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation. CONCLUSION: Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.     

Service system finance: implications for children with depression and manic depression.

An estimated 6.2% of children in the United States satisfy the criteria for a depression diagnosis, but approximately half of this group do not receive necessary treatment. Thus it is important to consider potential barriers to use through service system finance.This article reviews three major types of changes affecting access: parity legislation, managed care, and public contracting. How these developments will affect children with depression and manic depression (DMD) is unclear.To better understand the potential effects on children with DMD, this review uses new data from the Medical Expenditure Panel Survey to describe the service use patterns of this population. These children have higher levels of expenditures, higher rates of inpatient use, and higher rates of Medicaid payment than do other children with mental health diagnoses; they also are overrepresented among the costliest cases of mental illness in children.Children with DMD pay a relatively low out-of-pocket share, suggesting that parity efforts focusing only on copayments and deductibles will have little effect on the absolute out-of-pocket burden for these children. Because children with DMD are overrepresented among high utilizers of health services, health care rationing arrangements or techniques, such as utilization review and capitation, may place this population at particular risk.     

Depression among general hospital patients in Greece

We estimated the prevalence of depression in 150 medical and surgical inpatients. Forty-three patients (29%) scoring at 14 or above on the Beck Depression Inventory (BDI) were classified as depressed. An excess of women and white-collar workers and more stressful life events during the last 12 months were found among the depressed patients. Of the 21 BDI items, 6 differentiated the 43 medical-surgical depressed patients from a group of 43 psychiatric inpatients with a diagnosis of primary or secondary depression (Feighner's criteria). Medically ill depressed patients scored higher in social withdrawal, work inhibition and irritability but lower in loss of libido, sleep disturbance, and lack of satisfaction. Our results show rates of depression in a medical inpatient population in Greece comparable with those in other studies. The use of BDI may help assessment of depression in general hospital patients.     

Admissions of elderly patients from English-speaking and non-English-speaking backgrounds to an inpatient psychogeriatric unit.

OBJECTIVE: The aim of this study was to compare differences between elderly patients from non-English-speaking backgrounds (NESB) and English-speaking backgrounds (ESB) admitted to an acute psychogeriatric unit. METHOD: Sociodemographic and clinical variables were collated from inpatient files for a 12-month period and analysed according to NESB and ESB status. The 1996 Australian Census data were used for comparison of catchment area representation of different ethnic groups. RESULTS: With a few exceptions, admission rates for elderly patients from NESB reflected the representation of that ethnic group in the catchment area population figures. No significant differences were found between the two groups for mean age, length of stay and previous admissions to the unit. Patients from NESB were less likely to be admitted voluntarily and less likely to be diagnosed with affective disorder. These differences were more marked for males, who were more likely to be diagnosed with dementia. CONCLUSIONS: These findings suggest that further investigation is required into the accessibility of psychiatric hospitalisation for elderly patients from NESB. Under-recognition of disorders such as depression and reluctance to accept necessary inpatient management are two possible factors that should concern mental health service providers for the ethnic elderly. A subsequent analysis will examine if differences also exist between elderly patients from NESB and ESB who receive community-based psychiatric treatment. Implications for mental health service provision for the elderly from NESB are discussed.     

Depressive disorders: treatment patterns and costs of treatment in the private sector of the United States

The purpose of this paper is to examine the treatment patterns and costs of treatment for depressive disorders in the private sector of the United States. Based on the 1987–1989 calendar year MEDSTAT claim data, 40,898 patients were identified with a principal diagnosis of depressive disorder. Among a list of CPT-4 code procedures, individual psychotherapy had the highest frequency of usage followed by individual visits. Compared to individual psychotherapy, group/family psychotherapy had a much lower frequency of usage. Very few diagnostic episodes had laboratory work. In inpatient settings, costs of physician procedures and laboratory services were 2 times greater for patients with major depression or bipolar disorder than for patients with depression not otherwise specified (NOS) or dysthymic disorder. As expected, costs varied widely per episode. As the severity of illness increased, the cost variation became wider.     

Coercion and restrictions in psychiatric inpatient treatment.

To find out to what extent coercion and restrictions are used in psychiatric inpatient treatment and with which patient characteristics the use of coercion is associated. To this end, the hospital records of 1,543 admissions (six-month admission samples) to the psychiatric clinics in three Finnish university towns were evaluated by retrospective chart review. The study clinics provide all psychiatric inpatient treatment for the working-age population in their catchment areas. Use of coercion and restrictions was recorded in a structured form. Coercion and restrictions were applied to 32% of the patients. Mechanical restraints were used on 10% of the patients, and forced medication on 8%. Compared to international statistics the figures in the current study are high.     

Patterns of psychiatric hospital service use in Finland: a national register study of hospital discharges in the early 1990s

We were interested in studying the possible concurrent changes in the psychiatric inpatient population during a rapid phase of deinstitutionalisation, and severe economic recession with a record level unemployment rate, and after the amendment of the mental health legislation. Although there were 4540 fewer beds in the psychiatric hospitals in 1993 compared to 1990, the rate of patient admissions remained the same. There was a significant increase in readmissions (P < 0.001) to the psychiatric hospitals, and particularly in multiple (three or more) readmissions among new inpatients (P < 0.001). The prevalence of inpatients with major depression increased by 0.2/1000 in the whole cohort and by 0.12/1000 among first-timers from 1990 to 1993 (P < 0.001). In addition, the rate of involuntary admissions decreased significantly (P < 0.001). Accepted: 2 September 1997     

Gender differences in the psychopathology of depressed inpatients

Abstract. In the last few years there has been increased scientific effort to describe the gender–specific psychopathological features of depression. Until now these studies have not been entirely conclusive, which could be the result of methodological difficulties. This report investigates sex differences in the symptom presentation in an inpatient population: 104 female and 113 male patients suffering from a depressive episode according to ICD–10 were admitted to the inpatient treatment at the Department of General Psychiatry in Vienna. A psychopathological rating according to the standardized documentation system of the AMDP (Association for Methodology and Documentation in Psychiatry) was performed at admission and discharge. At admission into the hospital women tended to show more affective lability (p = 0.025), whereas men had higher scores in affective rigidity (p = 0.032), blunted affect (p = 0.002), decreased libido (p = 0.028), hypochondriasis (p = 0.016) and hypochondriac delusions (p = 0.039). At discharge from the hospital women had significantly higher scores in dysphoria (p = 0.010), while men were more prone to have compulsive impulses (p = 0.030). Although our results were obtained in a selected sample of inpatients at a university hospital, they are indicative of psychopathological differences between men and women in the core symptoms of depression. These differences may influence diagnostic practice and gender specific treatment of depression.*Both authors contributed equally     

Child and adolescent inpatient units in medical schools: staffing patterns, length of stay, and utilization rates

This study examines staffing patterns, lengths of stay, and utilization rates in medical school-based psychiatric hospital treatment of children and adolescents. Results of surveys taken in 1984 and 1988 show that lengths of stay decreased during these four years, but utilization rates and number of beds tended to remain the same or increase. As economic pressures force hospitals to consider reducing staff, it is important to establish baseline data to evaluate and plan staffing patterns for child and adolescent inpatient units.     

Clinicians' assessments of bipolar disorder and substance abuse as predictors of suicidal behavior in acutely hospitalized psychiatric inpatients.

BACKGROUND: Suicide is a major risk for those with bipolar disorder, a risk amplified by comorbid substance abuse in some, but not all, previous studies. To further explore the relationships of substance abuse, suicide, and bipolarity as they present in clinical practice, we analyzed standardized clinical data from a large acute psychiatric inpatient service. METHODS: Standardized clinical evaluations of 7819 patients with diagnoses of bipolar depression (n=990), bipolar mania (n=948), unipolar depressive episode (n=3626), or schizophrenia-schizoaffective disorders (n=2255) were analyzed to evaluate the relationship between current substance-use problems, substance-induced symptoms, and a current suicide crisis, as well as lifetime suicide attempts, with logistic regressions adjusting for age, gender, and ethnicity. RESULTS: Across the combined groups, current substance-use problems were significantly associated with a lifetime suicide attempt (odds ratios [ORs] 1.6-2.5) and to a lesser degree to the admission suicide crisis (ORs 1-2.2). Among bipolar (depressed/manic) patients, but not other diagnostic groups, those with both current substance-use problems and substance-induced symptoms had even higher rates of a recent suicide crisis (ORs 1.5-3.1) and of a lifetime attempt (ORs 2.5-3.4). CONCLUSIONS: In bipolar patients, substance use disorder doubled and substance use disorder plus substance-induced symptoms tripled the suicidal risk. Implications for future research are discussed.