The effect on diagnostic rates of assigning patients to ethnically focused inpatient psychiatric units

OBJECTIVE: The authors examined whether assigning patients from three ethnic groups-blacks, Latinos, and Asians-to three psychiatric inpatient units that provided culturally appropriate treatment to those groups would affect rates of diagnosis of various psychiatric disorders. METHODS: Retrospective administrative data for 5,983 inpatients at a large urban community hospital with several ethnically focused units were examined. The data represented 10,645 admissions between 1989 and 1996. Chi square analyses and Stuart-Maxwell tests of symmetry and homogeneity were used to assess the relationship between matching patients to ethnically focused units and the rates of major psychiatric illnesses among Asian, black, and Latino patients compared with whites. RESULTS: Ethnic differences in diagnostic rates were consistent with the results of previous studies. Black patients had more diagnoses of psychotic disorders and fewer diagnoses of affective disorders than other ethnic minorities or whites, and Latino patients had more nonspecific diagnoses. Matching inpatients to ethnically focused units did not have a marked effect on patterns of diagnoses among black patients, but an association was observed for Latino patients, particularly those who had only one admission. No significant diagnostic differences were found between Asian patients and whites, irrespective of whether the Asian patients had been ethnically matched to a specialty focus unit. CONCLUSIONS: The effect of referring inpatients with serious mental illnesses to an ethnically focused psychiatric unit varied by ethnic group, probably because each specialty unit functioned differently, depending on the needs of its particular patient population.     

Substance abuse-related mortality among middle-aged male VA psychiatric patients

OBJECTIVE: This study evaluated mortality and causes of death over a seven-year period among middle-aged male psychiatric patients with and without co-occurring substance use disorder. METHODS: This cohort study examined mortality among 169,051 male Vietnam-era veterans ages 40 to 59 treated for psychiatric disorders by the U.S. Department of Veterans Affairs (VA) between April and September 1998. Demographic variables, diagnoses, and prior hospitalizations were obtained from VA electronic medical records. Mortality status was obtained from VA benefits records. Cause-of-death data were purchased from the National Death Index for a random sample of 3,383 decedents. Mortality among psychiatric patients with and without diagnosed co-occurring substance use disorders was compared by logistic regression, with controls for demographic factors, psychiatric and medical diagnoses, and prior hospitalizations. Causes of death for psychiatric patients with and without co-occurring disorders were compared by chi square analyses. Results were compared to age- and race-matched norms for the U.S. population. RESULTS: The risk-adjusted probability of dying was 55% higher among psychiatric patients with co-occurring substance use disorders than among those without substance use disorders (OR=1.58-1.69). Overdoses and substance abuse-linked illnesses accounted for 27.6% of deaths among psychiatric patients with co-occurring substance use disorders, compared with only 8.8% of deaths among other psychiatric patients. CONCLUSIONS: Substance use disorders strongly contributed to premature death among male psychiatric patients. Secondary prevention is needed to reduce substance misuse and improve medical care for substance-related illnesses among psychiatric patients with co-occurring substance use disorders.     

Discharge curve among psychiatric patients after admission and risk factors associated with long stay based on "patient survey"]

The "Reform Vision of Mental Health Services" (2004) announced the basic policy for the transition from hospital based to community based care, and set up numerical objectives, such as the average proportion remaining hospitalized in the first year after admission and the incidence rate of discharge among psychiatric patients hospitalized for more than one year. Using data from the "Patient Survey" performed in 2002 by the Ministry of Health, Labour and Welfare, we estimated discharge curves for each mental disorder during the first year after admission and assessed the effects of variables, i.e., diagnosis, sex, age, hospital type, and residential area, on remaining hospitalized after one year from admission and the incidence rate of discharge among psychiatric patients hospitalized for more than one year. The estimated number of discharged psychiatric patients was 27,974 in September, 2002, and 86% of them were discharged less than one year after admission. The incidence rate of discharge (per 100 person-year) in the first year was 314.8, but the rate after the second year sharply decreased to 19.9. Patients with dementia, mental retardation, and schizophrenia tended to stay for a long period in hospital, and proportions remaining hospitalized after one year from admission were 27.0%, 16.4%, and 14.6% respectively. Based on multivariate analysis using the weighted Poisson regression model, risk factors associated with an increased chance of remaining hospitalized after the first year included a long length of continuous hospitalization, diagnoses of dementia, mental retardation, and schizophrenia, male, older age, and being in a mental hospital. On the other hand, as to the incidence rate of discharge after one year, a long length of continuous hospitalization and being in a mental hospital were related with a long stay, but other variables were slightly different. Being female, patients aged 45-54 years old, and diagnoses of epilepsy and schizophrenia were associated with a long stay. These results clarify the present situation of discharge among psychiatric inpatients and indicate the important variables associated with discharge to prevent new long hospital-stay cases in Japan.     

Psychiatric and medical diagnoses as risk factors for mortality in psychiatric patients: a case-control study

On the basis of a case-control study, the authors conclude that former psychiatric inpatients are more likely than control subjects to die of both natural and unnatural causes within 2 years of discharge. Patients who committed suicide were more likely to have had a diagnosis of affective disorder (unipolar depression) or alcoholism. Those who died of natural causes were more likely to have been admitted with medical diagnoses; no specific psychiatric diagnoses were associated with these deaths. It is doubtful that medical illnesses caused psychiatric syndromes such as depression in these inpatients. Psychiatric and medical illnesses combined may increase a patient's likelihood of seeking psychiatric help and entering the hospital.     

Does racial bias influence psychiatric diagnoses assigned at first hospitalization?

BACKGROUND: Research on racial bias in psychiatric diagnosis has largely been limited to studies of admission diagnoses assigned to chronically ill patients. This study tests whether racial bias influences diagnoses assigned to patients at discharge from their first psychiatric hospitalization. METHODS: In a county-wide sample of patients with psychosis, hospital diagnoses were compared with research diagnoses formulated using structured interviews and strict adherence to DSM-III-R. Symptom patterns were also examined. RESULTS: Racial differences were observed in the distribution of both hospital and research diagnoses. Using research diagnoses as the gold standard, the sensitivities and specificities of hospital diagnoses were similar by race (for blacks the sensitivity and specificity of schizophrenia was 0.33 and 0.91, and for whites, 0.43 and 0.89). The only suggestion of possible bias was that more blacks were discharged without a definitive diagnosis (38.7% of blacks vs. 26.3% of whites, chi(2) = 5.80, df = 1, p = 0.02). CONCLUSIONS: We did not observe the expected racial bias in the assignment of diagnoses of schizophrenia and affective disorders. While there was evidence that hospital clinicians had more difficulty diagnosing black patients, the low concordance between hospital and research diagnoses for both black and white patients demonstrates the need to better understand the clinical diagnostic process for all patients with psychotic disorders at their first hospitalization.     

Young chronic patients and substance abuse

The prevalence of substance abuse was investigated in 100 young chronic patients consecutively admitted to a long-term private psychiatric hospital. Data were obtained from diagnostic research interviews with each subject at admission. Half of the subjects had concurrent diagnoses of psychiatric disorder and substance abuse. One-third of the dual-diagnosis patients began using substances before the onset of a diagnosable psychiatric disorder, and they more often had a diagnosis of schizophrenia. Half of the dual-diagnosis patients abused three or more drugs. Implications of the findings for treatment and community management of dual-diagnosis patients are discussed.     

Criminality and aggression among psychotic in-patients: frequency and clinical correlates

OBJECTIVE: Violence is common among patients with psychoses. The aim of the study was to examine relations between diagnoses, crimes, demographic variables and aggressive behaviour during admission to hospital. METHOD: During 14 months 257 patients were consecutively referred to a unit with high staff/patient ratio. They were assessed for clinical symptoms at admittance and discharge. Also legal status, coercive measures, criminality and sentences were examined. RESULTS: Of the 257 patients, 38% were found in the police register and 33% had been prosecuted. Those patients committed 2525 crimes, including 292 acts of violence. Problems during admittance were related more to positive symptoms at admittance than to earlier criminality. CONCLUSION: Criminality rate is high among patients with functional psychoses. Many patients, especially women, had never been evaluated by a forensic psychiatrist. The psychiatric services have to consider the importance of preventing psychotic relapses and thereby also preventing violence and criminality.     

The setting of psychiatric care for medicare recipients in general hospitals with specialty units

This study examined the patient and hospital characteristics associated with whether patients with psychiatric disorders were treated on the psychiatric unit or on medical wards after admission to general hospitals with psychiatric units. Medicare data for 169,798 beneficiaries who had psychiatric disorders and were admitted to general hospitals with psychiatric units were used to estimate logistic regressions of the probability of treatment on the unit. Results showed that beneficiaries who had more than one psychiatric diagnosis (except for substance use disorders), state buy-in coverage such as Medicaid, or previous psychiatric hospitalizations or who had ever been eligible for Medicare through disability were more likely to be treated on the unit. Those who were older, admitted through the emergency department, or had greater medical morbidity or primary diagnoses other than schizophrenia or bipolar or major affective disorders were less likely to be treated on the unit.     

Psychiatric morbidity in disintegrative psychosis and infantile autism: A long-term follow-up study.

In order to study the validity of disintegrative psychosis (DP), the authors compared 13 patients given this diagnosis in childhood with a control group of 39 patients with infantile autism (IA) matched for sex, age, IQ and social class on measures of psychiatric morbidity. Almost the same proportion of the two groups had been admitted to a psychiatric hospital during a 22-year follow-up period. However, there was a slight tendency (statistically nonsignificant) for the DP group to utilize the psychiatric health care system more frequently than the IA group. They had more admissions and stayed longer in hospital than patients with IA suggesting that they had more psychiatric symptoms than the IA group. The original IA diagnoses were confirmed fairly consistently during the follow-up period, while the DP group was given more heterogenous diagnoses. No diagnosis of schizophrenia was made in either group.     

Unexplained transient hyperphosphatemia is more common in acute psychiatric disorders than in acute medical-surgical conditions

Increased serum inorganic phosphorus associated with elevated serum calcium has been demonstrated to coincide with the onset of agitation and mania in periodic psychoses and bipolar disorders. We tested the hypothesis that unexplained transient hyperphosphatemia (UTHP) is more common in patients with psychiatric disorders than in controls with medical or surgical conditions. We studied 100 patients admitted to a psychiatric ward and 100 controls admitted to a medical-surgical ward. All subjects (patients and controls) underwent acute admission to the same general hospital. The serum phosphorus was measured upon admission and, if elevated, followed during the hospital course. Twenty patients (20%) with psychiatric disorders had unexplained hyperphosphatemia compared with four medical-surgical controls (4%). UTHP occurred in six patients with psychiatric disorders and no controls. Hypophosphatemia did not occur in subjects with psychiatric disorders. This study shows an increased incidence of UTHP in acutely ill, hospitalized patients with psychiatric disorders relative to acutely ill, hospitalized controls with medical-surgical conditions. These data extend previous findings by linking UTHP to acute psychiatric disturbances across varied psychiatric diagnoses independent of hypercalcemia. Potential explanations include trazodone administration and transient hypocalcemia.     

Race, Schizophrenia, and Admission to State Psychiatric Hospitals

The relationships among race, diagnoses of schizophrenia, mood disorder, and admission to state psychiatric hospitals were examined in this study. Two hypotheses and two research questions represented these relationships. Data were analyzed from a sample of 2,311 individuals who had hospital admissions in Indiana during an 8-year period. In comparison with the general population, African Americans were found to be overrepresented among inpatients with diagnoses of schizophrenia. African Americans were four times more likely than White inpatients to receive a diagnosis of schizophrenia. Accountability tools to address issues of differential hospitalization rates and overdiagnosis of schizophrenia are discussed.     

Six-year outcomes in first admission adolescent inpatients: clinical and cognitive characteristics at admission as predictors

Persistent functional disability is common after even a single psychiatric admission in people with schizophrenia or bipolar disorder, but less is known about other conditions and about adolescent onset patients. This study examined clinical symptoms and cognitive performance at the time of the first admission for the prediction of 6-year outcomes. First admission adolescent patients with a variety of psychiatric diagnoses were assessed with comprehensive clinical ratings of psychopathology, a neuropsychological assessment, and received clinical diagnoses while experiencing their first psychiatric admission. They were contacted 6 years after discharge and examined with a structured assessment of psychiatric symptoms and functioning. Despite the low levels of overall impairment at follow-up, at least 20% of the variance in depression, psychosis, poor peer relationships and poor school attendance 6 years after the hospital admission were predicted by information collected during the hospitalization. Attentional deficits during admission predicted the presence of psychosis at follow-up more substantially than psychotic symptoms during admission, as well as predicting risk for relapse. Attentional deficits during a first psychiatric admission predicted risk for manifesting psychosis at 6-year follow-up to a more substantial degree than either a psychosis diagnosis or psychotic symptoms at admission. In contrast to psychosis, depression at follow-up was predicted by admission symptomatology, but not by cognitive deficits.     

Total population-based study of the impact of substance use disorders on the overall survival of psychiatric inpatients

Background: Patients with severe mental illness have a shortened lifespan, and substance use disorder (SUD) is an especially important diagnosis in this respect. There have been no studies comparing directly SUD to other diagnoses in a nationwide cohort. Aims: To directly compare differences in mortality rates of psychiatric inpatients with a discharge diagnosis of SUD versus other psychiatric diagnoses. Methods: A register-based study was made of all patients admitted to psychiatric hospitals in Iceland between 1983 and 2007. Patients were grouped according to discharge diagnoses. Survival with respect to SUD was compared using Cox-proportional hazard ratio, excluding those with an organic mental disorder. Furthermore, the survival of patients with SUD and co-morbid diagnoses was evaluated. Results: A total of 14,281 patients (over the age of 18 years) were admitted to a psychiatric hospital in Iceland during the study period, with a total of 156,356 years of follow-up. For both men and women, a diagnosis of SUD conferred similar mortality as a diagnosis of schizophrenia without SUD, while individuals with a diagnosis of a mood disorder or “other disorders” had significantly lower mortality than SUD. For men with SUD, a co-occurring mental disorder was associated with an increased risk of dying, however, this was not found for women. Conclusions: SUD was the psychiatric diagnosis that had the highest mortality rate among psychiatric inpatients, in both men and women. An additional psychiatric diagnosis on a pre-existing SUD diagnosis did increase the risk for men but not women.     

Admission pattern and diagnostic stability among unipolar and bipolar manic-depressive patients

The instability of the diagnoses in a psychiatric register causes practical problems when groups of probands with specific diagnoses are selected for further studies. A cohort of 3,062 first admissions with at least one manic-depressive admission was followed for 5-7 years. 623 had at least one admission for mania and were considered bipolar. The percentage of patients who changed their diagnoses was highest at first readmission; at each later readmission about 10% of the bipolars and 25% of the unipolars changed from manic-depressive psychosis and a similar number changed from other diagnoses to manic-depressive psychosis. Compared with the diagnostic distribution of all register cases, reactive psychoses were more frequent than expected as former diagnoses and schizophrenia as later diagnosis. Neuroses and character deviations were frequent alternative diagnoses among unipolars, not among bipolars. The consequences of different selection criteria for the composition of proband groups are discussed.     

Mortality among discharged psychiatric patients in Florence, Italy

OBJECTIVE: Psychiatric disorders involve an increased risk of mortality. In Italy psychiatric services are community based, and hospitalization is mostly reserved for patients with acute illness. This study examined mortality risk in a cohort of psychiatric inpatients for 16 years after hospital discharge to assess the association of excess mortality from natural or unnatural causes with clinical and sociodemographic variables and time from first admission. METHODS: At the end of 2002 mortality and cause of death were determined for all patients (N=845) who were admitted during 1987 to the eight psychiatric units active in Florence. The mortality risk of psychiatric patients was compared with that of the general population of the region of Tuscany by calculating standardized mortality ratios (SMRs). Poisson multivariate analyses of the observed-to-expected ratio for natural and unnatural deaths were conducted. RESULTS: The SMR for the sample of psychiatric patients was threefold higher than that for the general population (SMR=3.0; 95 percent confidence interval [CI]=2.7-3.4). Individuals younger than 45 years were at higher risk (SMR=11.0; 95 percent CI 8.0-14.9). The SMR for deaths from natural causes was 2.6 (95 percent CI=2.3-2.9), and for deaths from unnatural causes it was 13.0 (95 percent CI=10.1-13.6). For deaths from unnatural causes, the mortality excess was primarily limited to the first years after the first admission. For deaths from natural causes, excess mortality was more stable during the follow-up period. CONCLUSIONS: Prevention of deaths from unnatural causes among psychiatric patients may require promotion of earlier follow-up after discharge. Improving prevention and treatment of somatic diseases of psychiatric patients is important to reduce excess mortality from natural causes.     

Race and inpatient psychiatric diagnoses among elderly veterans

OBJECTIVE: Limited data exist on differential rates of psychiatric diagnoses between ethnocultural groups in the elderly population. The purpose of this study was to examine more closely the issue of race and rates of psychiatric diagnoses among elderly inpatients. METHODS: The national sample included 23,758 veterans age 60 or over admitted in 1994 to acute inpatient units in Department of Veterans Affairs (VA) hospitals. Psychiatric diagnosis determined inclusion in one of six diagnostic groups: cognitive, mood, psychotic, substance use, anxiety, and other disorders. The study also assessed rates of psychiatric diagnoses among patients admitted to psychiatric units only and by age group and treatment setting, such as the size of the hospital and whether it had an academic affiliation. RESULTS: Compared with elderly Hispanic and Caucasian patients, a significantly higher proportion of elderly African-American patients were diagnosed as having cognitive disorders and substance use disorders, and a significantly lower proportion were diagnosed as having mood and anxiety disorders. Hispanic and African-American patients had significantly higher rates of psychotic diagnoses than Caucasian patients. For all diagnoses except cognitive disorders, these differential rates were also found among patients admitted to psychiatric units only. Age and treatment setting appeared to moderate some of the differences in diagnostic rates, except for mood disorders. In every analysis performed, the rate of mood disorder diagnoses among elderly African-American patients was less than half the rate among elderly Caucasian patients. CONCLUSIONS: The findings suggest that elderly African-American veterans admitted to VA inpatient units have strikingly lower rates of mood disorder diagnoses. Future studies should examine the contribution of both patient and provider factors to these differences.     

Survival time after last hospitalization among suicide victims in northern Finland

Psychiatric patients exhibit increased suicide risk shortly after hospitalization, but little is known about patients who are discharged after treatment for physical illness. Information on all suicides over a period of 13 years in northern Finland as well as information from hospital registers were used to examine the interval between the last hospitalization and the suicide. On the basis of discharge diagnoses of physical or psychiatric illnesses, three groups were distinguished. Among victims with psychiatric disorders, survival time was shorter than among those without such a history, even if the last admission was for a physical condition. Clinicians should note the putative suicide risk among somatic patients at discharge, especially among those with a psychiatric history.     

Self-poisoning with medications in adolescents: a national register study of hospital admissions and readmissions

ObjectiveTo examine characteristics of hospital admissions and risk factors associated with rehospitalization for self-poisoning with medications in adolescents aged 10–19 years.MethodThis study used data from the Norwegian Patient Register from 2008 to 2011. The main outcome was hospital readmission within the observation period. A complementary log–log regression model was used to assess the effect of characteristics at index hospital admission on readmission.ResultsOf 1497 patients, 76.4% were females and 89.8% were aged 15–19 years. At their first hospital admission, about one third received a secondary psychiatric diagnosis. Females (47.5%) were registered with an E-code for intentional self-harm more often than males (33.7%), and females were more often than males discharged to further treatment (27.8% vs. 21.5%). As many as 18.4% were rehospitalized for self-poisoning by medications. Significant predictors for hospital readmission were female sex [hazard ratio (HR)=2.4, 95% confidence interval (CI) 1.7–3.6], discharge to further treatment (HR=2.3, 95% CI 1.8–2.9) and psychiatric secondary diagnoses (HR=1.5, 95% CI 1.2–1.9).ConclusionThis national study demonstrated significant sex differences in adolescents treated in hospital for self-poisoning with medications. Psychiatric secondary diagnoses had a strong predictive effect on readmission, which indicates the importance of psychiatric/psychosocial assessment of adolescents who are admitted to hospital for self-poisoning with medications.     

Effects of diagnosis and context on dangerousness

The authors extensively reviewed the medical records of 253 patients hospitalized on a locked, university-based psychiatric unit. They found that schizophrenic and manic patients were more likely than patients with other diagnoses to be assaultive before admission. In the hospital, however, manic patients were the most likely to be assaultive. The results of this study show that the risk of violence among different diagnostic groups of patients varies according to context and is moderated by situational variables. These findings have implications for the assessment of dangerousness before and during hospitalization.     

Violence,self-harm,victimisation and homelessness in patients admitted to an acute inpatient unit in South Australia

OBJECTIVES: To measure the incidence of traumatic and potentially socially disruptive events prior to admission to a psychiatric hospital. METHOD: One hundred and nineteen patients were interviewed and further information was obtained from case notes. Data were collected concerning rates of violence, self-harm, threats of violence or self-harm, physical assault and homelessness. RESULTS: The patients' mean age was 35 years, 70% were male and 77% were currently single. More than half were legally detained. The most common diagnoses were substance abuse disorders, schizophrenia and related psychoses and mood disorders. Eighteen per cent of patients were physically violent at the time of admission. They were more likely to have a diagnosis of substance abuse. Significantly more men (30%) than women (8%) made threats of violence. Eighteen per cent of patients had physically harmed themselves. Significantly more women (70%) than men (40%) had threatened to harm themselves. Eight per cent of patients had been physically assaulted prior to admission. Twenty-seven per cent of patients were homeless. CONCLUSION: These patients were severely disabled with high rates of comorbidity. Socially disruptive behaviours were common, and almost a quarter of the patients were homeless. This study highlights the need for development of targeted services in the community.