Receipt of preventive medical services at psychiatric visits by patients with severe mental illness

The authors used data from the National Ambulatory Medical Care Survey from 1992 to 1999 on 3,198 office visits to explore the extent to which psychiatrists provide clinical preventive medical services to patients with severe mental illness. Preventive services were provided during 11 percent of the visits. A multivariate analysis showed that preventive services were more likely to have been provided for patients with a chronic medical condition, for patients who were also seen by a nurse or other health provider during the visit, in rural areas, and during longer visits. Preventive services were less likely to have been provided during visits to health maintenance organizations and visits that took place later in the study period.     

Alcohol dependence among patients admitted to psychiatric emergency services

We assessed the prevalence of alcohol dependence among patients examined in the psychiatric emergency service of a general hospital. We compared socio-demographic data and psychiatric status of patients with and without alcohol dependence. One-hundred and four consecutive patients received by the psychiatric emergency service of Bichat-Claude Bernard Hospital (Paris, France) were assessed. Diagnosis of alcohol dependence, acute alcohol intoxication, and antisocial personality was determined according to DSM-IV criteria. Other psychiatric disorders were identified using a structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Prevalency rate of alcohol dependence was 37.5% among patients examined by the psychiatric emergency service. Alcohol-dependent patients were more often men than women and more often unemployed than non-alcohol-dependent psychiatric emergencies. They presented more dysthymia, acute alcohol intoxication, and antisocial personality than non-alcoholic patients followed by the psychiatric emergency service. Attempted suicide was as frequent in alcohol-dependent patients (23%) as in other patients (29%). Alcohol-dependent patients consumed alcohol more often when alone, and their alcohol consumption began more frequently in the morning. Patients seen in a psychiatric emergency service must be identified as a population at risk for alcohol dependence (37.5%). Alcohol-dependent patients are more often men and have a higher rate of unemployment. They present significantly more often dysthymia and acute alcohol intoxication associated to alcohol dependence.     

Use of general medical services by VA patients with psychiatric disorders

OBJECTIVE: Patients with psychiatric disorders, particularly those with severe mental illnesses, have high rates of undetected and untreated medical problems and substantially elevated mortality rates due to medical illness. The authors sought to develop a better understanding of the demographic, medical, and psychiatric characteristics of this population to inform efforts to improve the medical care of these persons. METHODS: Using Department of Veterans Affairs (VA) databases, the authors examined use of medical services by 175,653 patients who were treated in Southern California and Nevada during fiscal year 2000. Multivariate regression models were used to examine factors affecting receipt of any medical care and the number of medical visits. RESULTS: Patients with psychiatric diagnoses had fewer medical visits than other VA patients; the largest differences were seen for patients with severe mental illnesses. Patients who were younger and male had few visits. Patients with diabetes or hypertension who had been diagnosed as having schizophrenia, bipolar disorder, or an anxiety disorder had substantially fewer visits than those who did not have these psychiatric diagnoses. Patients older than 50 years were less likely to have any medical care if they had a diagnosis of a substance use, depressive, bipolar, or anxiety disorder or posttraumatic stress disorder. CONCLUSIONS: Use of medical care varies by psychiatric diagnosis. Young adults with schizophrenia and posttraumatic stress disorder and adults of all ages with bipolar disorder have an especially high risk of not receiving general medical services. Interventions to improve medical care may need to be tailored to the population being targeted.     

Service expectations and clinical characteristics of patients receiving psychiatric emergency services

Previous studies suggest that patients use medical emergency departments for nonurgent care. However, relatively little has been published about the use of psychiatric emergency services. Eighty-two patients who visited the psychiatric emergency department in a free-standing psychiatric hospital during July 2003 participated in a self-report survey about patients' expectations. Almost all respondents had acute psychiatric needs on presentation to the psychiatric emergency department, and 45 (75 percent) had urgent needs that required inpatient or partial hospitalization. However, there was considerable mismatch between some patients' expectations and the types of services available. Patients' use of this psychiatric emergency department was generally consistent with the department's mission, but many respondents endorsed a need for a service that was not available, such as family therapy. These findings suggest the importance of efforts to educate the public about how to obtain mental health services.     

The psychiatric clinical specialist''s impact on psychiatric emergency services

Psychiatric emergency services have evolved into more comprehensive programs during the past two decades. With this evolution other disciplines have gained access to the services and integrated their expertise and philosophy into the daily care of patients. Nursing has been an integral part of this process and contributed its perspective in nursing care. This paper outlines the development of psychiatric emergency services with a special emphasis on the contribution of nursing specialists who have developed their role within the psychiatric emergency service.

What has been unique about the nursing contribution is the attention to individualizing patient care and modifying treatment approaches to meet the patients' needs and interests in psychiatric treatment. Additionally, nursing has complemented the physician's role by developing expertise in assessment that is both psychologically and biologically oriented. Nursing's future contribution to psychiatric emergency services should address mechanisms for tracking patients who enter the psychiatric emergency service system with an emphasis on linkage with other programs or resolution of the crisis episode.     

Mortality among psychiatric patients referred to the mental health services in Valencia

The rate of survival and causes of mortality in a cohort of 2103 psychiatric patients registered on a psychiatric case register and followed up for 7 years are compared with those of a general population sample (n = 2382) randomly extracted from the municipal census in Valencia (Spain). Using multivariate analysis by Cox regression, patients suffering organic psychoses and those diagnosed with drug abuse or dependency exhibited a greater risk of death than the general population for the total causes of death; no interaction was found between sociodemographic variables and psychiatric pathology. In terms of the causes of death, and controlling for the effect of age and sex, organic psychoses involved a greater risk of death due to cardiovascular and respiratory causes, and a greater risk of non-natural deaths than the general population. Schizophrenia and related conditions, the abuse of alcohol/other drugs, and neurosis/personality disorders all presented a higher risk of death from liver disease. The major affective disorders involved a greater risk of death due to suicide or accidents. The study concludes with a discussion of the possible explanations of these results. Accepted: 5 August 1997     

Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services

We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population.     

Delivering clinical preventive services is a systems problem

A steadily increasing number of research trials and prevention advocates are identifying the practice environment as the main source of both problems and solutions to the improved delivery of clinical preventive services. Although these sources are correctly focusing on office systems as solutions, there is a tendency to focus on only parts of a system and to relate this to just one or a few related preventive services. However, the effort required to set up and maintain an office system makes it difficult to justify doing so for a single clinical activity. The process and system thinking of Continuous Quality Improvement (CQI) theory suggests that there may be both efficiency and effectiveness advantages to the concept of all clinical preventive services being served by a single system with many interrelated component processes. Such a system should be usable for all age groups. This system and its literature base are described. The feasibility of applying this concept is being tested in a randomized controlled trial in 44 primary care clinics in Minnesota and Wisconsin.     

Mortality among psychiatric patients

The mortality of all patients seen at the Department of Psychiatry, the General Hospital in Lund, Sweden during 1962 was studied for the years 1962–1968. The number of deaths was 260. The expected number of deaths in a corresponding sample of the general population was 159. The mortality was significantly increased in both men and women. The ratio between observed and expected mortality was highest in the younger age groups. The overmortality was due mainly to an increased number of suicides, accidents and nervous and circulatory diseases in the men and suicide and cancer in women. The patients who died were compared with a randomized subsample of psychiatric patients sill alive at the end of the observation time. The items chosen for comparison were social and medical factors previously found to be related to mortality. The purpose was to try to recognize high risk groups within the psychiatric population. Divorced persons were more common among those who died than among controls, and more males who died were living along, unemployed or invalid pensioners. Mortality seemed to be independent of type of care in 1962 in terms of hospitalization and out-patient contact. Differences found in psychiatric services by those who had died and controls before and after 1962 were of low significance. The one outstanding psychiatric diagnosis among those who died was the organic brain syndrome. Alcoholism was more common among men who died accidental deaths compared with controls. More than 50% of the patients who committed suicide had previously attempted suicide. A high proportion of those who died were hospitalized in somatic wards and sent to the psychiatric out-patient department for psychiatric assessment. Common reasons for referral were recently attempted suicide and pain, often of unknown origin.     

Predictors of violent behavior among acute psychiatric patients: clinical study

Aim:  Violence risk prediction is a priority issue for clinicians working with mentally disordered offenders . The aim of the present study was to determine violence risk factors in acute psychiatric inpatients.
Methods:  The study was conducted in a locked, short-term psychiatric inpatient unit and involved 374 patients consecutively admitted in a 1-year period. Sociodemographic and clinical data were obtained through a review of the medical records and patient interviews. Psychiatric symptoms at admission were assessed using the Brief Psychiatric Rating Scale (BPRS). Psychiatric diagnosis was formulated using the Structured Clinical Interview for DSM-IV. Past aggressive behavior was evaluated by interviewing patients, caregivers or other collateral informants. Aggressive behaviors in the ward were assessed using the Overt Aggression Scale. Patients who perpetrated verbal and against-object aggression or physical aggression in the month before admission were compared to non-aggressive patients, moreover, aggressive behavior during hospitalization and persistence of physical violence after admission were evaluated.
Results:  Violent behavior in the month before admission was associated with male sex, substance abuse and positive symptoms. The most significant risk factor for physical violence was a past history of physically aggressive behavior. The persistent physical assaultiveness before and during hospitalization was related to higher BPRS total scores and to more severe thought disturbances. Higher levels of hostility–suspiciousness BPRS scores predicted a change for the worse in violent behavior, from verbal to physical.
Conclusion:  A comprehensive evaluation of the history of past aggressive behavior and psychopathological variables has important implications for the prediction of violence in psychiatric settings.     

Receipt of aftercare services by problem types: Psychiatric,psychiatric/substance abuse and substance abuse

In the present study, a cohort of patients discharged from two state psychiatric hospitals were categorized into three groups: psychiatric, psychiatric/substance abuse and substance abuse. Patterns of service receipt postdischarge and the differential impact of service use on rehospitalizations and community tenure were analyzed. The psychiatric group were more receptive to contacting community mental health aftercare agencies and when they did connect, they received, on the average, greater amounts of service than the other two groups.This study was funded by grants from the Ohio Department of Mental Health, Office of Program Evaluation and Research.     

Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services

OBJECTIVE: The study identified clinical and sociodemographic characteristics of patients making multiple visits to a psychiatric emergency service. METHODS: Information was obtained for patients visiting a hospital psychiatric emergency service in Montreal from 1985 to 2000. Profiles were determined for four groups: one visit, two visits, three to ten visits, and 11 or more visits. To determine whether the profile for those with 11 or more visits was generalizable, data for patients visiting the main site and three other such services from 2002 to 2004 were similarly analyzed. RESULTS: At the main study site (1985 to 2000), patients with single visits accounted for 36% of the 29,569 visits. The 292 patients with 11 or more visits accounted for almost 21% of total visits. Timing of the visit-time of day and day of the week-did not differentiate between groups. However, time itself was important in identifying patients with 11 or more visits: use of 30-month observation periods resulted in identification of only 8% of this group. Patients with 11 or more visits were more likely to be diagnosed as having schizophrenia and as having a comorbid diagnosis and were generally younger at the index visit and more economically impaired than those in the other groups. Overall, and at two of the three other sites, schizophrenia was overrepresented in the highest user group. CONCLUSIONS: Most visits to the psychiatric emergency service were made by frequent users who had distinctive profiles, which are potentially useful for developing clinical strategies to reduce the impact of this patient group on this service.     

Suicide among Swedish psychiatric patients

Summary The study concerns mortality by suicide among psychiatric patients. The sample consisted of all patients, 20 years and over, who were treated at the Psychiatric Department in Lund, Sweden during the year 1962. The Swedish Central Bureau of Statistics publishes annual lists on mortality with coded data concerning causes and date of death for all deceased persons registered in Swedish parish registers. By examining these mortality lists for the years 1962 to 1967 the psychiatric patients, who had died by suicide during this period, could be located. Out of the total number of 3.006 patients, 46 died by suicide during these years. The expected number of suicides for a corresponding sample from the general population was 4.34. The suicides occurred fairly evenly throughout the 1962–67 period, there being no significant decreasing tendency with the passage of time. In 8 out of 29 male suicides and 10 out of 16 female suicides, the suicide occurred within three months after the last contact with the department. The sex-difference was significant. Hanging was the most frequent method in men and poisoning in women.

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Zusammenfassung Die Untersuchung bezieht sich auf die Mortalität durch Suizid bei psychiatrischen Patienten. Die Stichprobe umfaßt alle Patienten im Alter von 20 Jahren und darüber, die in der psychiatrischen Abteilung von Lund in Schweden im Jahre 1962 behandelt wurden. Das schwedische statistische Zentralbüro veröffentlicht jährlich Listen über Mortalität. Diese enthalten in kodierter Form Angaben über die Ursachen und das Datum des Todes für alle im schwedischen Gemeinderegister als verstorben aufgeführte Personen. Durch die Untersuchung dieser Sterberegister aus den Jahren 1962–67 konnten die psychiatrischen Patienten ausgemacht werden, die während dieser Zeit wegen Suizids verstorben waren. Im Laufe dieser Jahre starben von einer Gesamtzahl von 3006 Patienten 46 durch Suizid. Die für eine entsprechende Stichprobe aus. der Allgemeinbevölkerung erwartete Anzahl von Suiziden lag bei 4.34. Die Suizide erfolgten gleichmäßig innerhalb der Periode von 1962–67; es gab im Laufe der Zeit keine signifikant rückläufige Tendenz. Bei 8 von 29 männlichen Suizidenten und bei 10 von 16 weiblichen Suizidenten ereignete sich der Suizid innerhalb von drei Monaten nach dem letzten Kontakt mit der Abteilung. Der Geschlechtsunterschied war signifikant. Bei den Männern war die häufigste Methode das Erhängen, bei den Frauen das Vergiften.

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Résumé Ce travail étudie la mortalité par suicide parmi les patients psychiatriques. L'échantillon était constitué par tous les patients, de 20 ans et plus, en traitement au département psychiatrique de Lund, Suède, pendant l'année 1962. Le Bureau suédois central des statistiques publie chaque année des listes de mortalité comportant des données codifiées sur les causes et la date de la mort pour tous les décès des personnes enregistrées dans les registres communaux suédois. En examinant ces listes de mortalité pour les années 1962 à 1967, on a pu situer les patients psychiatriques qui étaient morts par suicide durant cette période. Sur un total de 3006 patients, 46 s'étaient suicidés pendant ces années-là. Pour un échantillon correspondant de la population générale, le nombre de suicides était de 4.34. Les suicides sont répartis assez régulièrement sur la période 1962–1967: ils n'o'nt pas eu tendance à diminuer de façon significative avec le temps. Dans 8 des 29 cas de suicide hommes et dans 10 des 16 cas de suicide femmes, le suicide a eu lieu dans les 3 mois après le dernier contact avec le département. La différence entre les sexes était significative. La pendaison était le moyen le plus fréquent chez les hommes, l'empoisonnement chez les femmes.

     

Coordination of services for outpatients under concurrent medical and psychiatric care

The proportion of outpatients with concurrent medical and psychiatric problems is high and is expected to increase, but coordination of services has not been satisfactory. The medical and psychiatric records of 28 patients under regular psychiatric and medical care were abstracted, for a total of 323 visits, to ascertain issues related to assessment and coordination of care. Results indicate that psychiatric therapists and primary-care providers do not perform satisfactorily in assessing medical and psychiatric problems, respectively, and in initiating coordination of their patients' health care. The implications of these findings for the training, education, and supervision of staff are discussed.