A method for comparing two systems of acute 24-hour psychiatric care

A quasi-experimental method was developed to evaluate the cost-effectiveness of a public system of 24-hour acute psychiatric care in Santa Clara County, California, before and after a new treatment setting was introduced. The original system relied on a 54-bed psychiatric unit in a county general hospital; the new system consisted of a 20-bed unit in the general hospital plus a 45-bed nonhospital psychiatric health facility. The study demonstrated that the per diem cost of the psychiatric health facility was approximately 60 percent that of the original general hospital unit, but the average difference in cost per episode between the two systems was only about +25, primarily due to longer lengths of stay in the new system. In addition, patients treated in the new, combined system appeared sicker at discharge than those treated in the old system. The findings suggest the importance of simultaneously evaluating both cost and treatment effectiveness to make sure that one element does not dominate program direction at the expense of the other.     

Nonhospital alternatives for acute psychiatric care in California

In California multiple social forces and financial constraints are leading to the rapid development of local alternatives not only to state hospitals but to general hospital psychiatric units as well. Two dissimilar patterns of acute-care services are emerging: the use of skilled nursing facilities with additional staff to provide mental health services and the development of a wide range of primarily nonmedical facilities under the licensing category of "residential care facility." The author summarizes characteristics of both kinds of programs and describes how they draw on all available sources of revenue before using state and county mental health funds. He also describes Santa Clara County's plan for local acute-care services in which a 54-bed residential building and a 15-bed psychiatric unit in a county hospital will replace two county-hospital psychiatric wards.     

Consultative psychiatry in both private and public general hospitals

Most psychiatric patients obtain care in the nonpsychiatric units of general hospitals. Two groups of 100 psychiatric consultation patients in a private hospital setting and in a public hospital were compared. Significant differences were found. Patients in the public hospital were medically, psychiatrically, and socioeconomically more disabled. In the private setting, psychiatric consultants were usually seen as members of a treatment team. The public facility expected consultants to function as psychiatric triage officers. However, both patient groups had a similar frequency of psychiatric illness and had an equal need for psychiatric services.     

Integration of general hospital psychiatric services with freestanding psychiatric hospitals

General medical hospitals and freestanding psychiatric hospitals usually function independently. The authors review the relative strengths and weaknesses of the two settings and suggest a plan for a rational coordination of services. In an efficient integrated system, the general hospital would provide emergency psychiatric services and treat patients with combined medical and psychiatric conditions. The freestanding facility would offer inpatient and outpatient services, as well as partial hospitalization and transitional living arrangements, to psychiatric patients without medical complications. All facilities would share professional staff and data processing capabilities and would have common policies and procedures, reducing the cost of treatment and facilitating patient transfers.     

Long-term hospital treatment: A 25-year study

Findings from a 25-year study of admissions to a single long-term private psychiatric inpatient facility document a sharp decline in average age and an increase in concurrent diagnoses of substance abuse and personality disorders. In this case, long-term private inpatient care has survived the significant changes in mental health policy and funding practices of the past quarter century, but has shifted its focus from a more general psychiatric caseload to the seriously disturbed adolescent or young adult patient.There are numerous factors which determine every aspect of hospital treatment. Though some are easily determined, many are dimly defined and difficult to measure. At present, their effect on patient progress is obscure. These factors, discussed in some detail, may be internal and peculiar to an institution itself. A dialogue is initiated for the insight it furnishes about the changes that have occurred in hospital treatment.Presented at the Annual Meeting, American Society for Adolescent Psychiatry, San Francisco, California, May 6, 1989.     

上海综合医院精神卫生培训调查

目的：通过对上海市综合医院的临床医师所接受精神卫生培训以及开展精神卫生工作意向等进行调查．为探讨改善综合医院精神卫生服务现状提供研究依据。方法：采用自制调查问卷，在上海市二家分别设立和未设立精神卫生服务科室的三级甲等综合医院，分别对130名和107名临床医师进行了统一调查。结果：已开设精神卫生科室的医院在患者精神问题会诊率，临床医师在接受精神卫生培训，掌握精神卫生知识程度，以及对开展精神卫生服务的工作意向等方面均显著优于未开设精神卫生科室的医院。结论：需要提高各级综合医院的精神卫生服务的能力，在综合医院中设立精神卫生机构至关重要。     

Etiological explanation, treatability and preventability of childhood autism: a survey of Nigerian healthcare workers' opinion

Background  

The possibility that a significant proportion of the patients attending a general health facility may have a mental disorder means that psychiatric conditions must be recognised and managed appropriately. This study sought to determine the prevalence of common psychiatric disorders in adult (aged 18 years and over) inpatients and outpatients seen in public, private and faith-based general hospitals, health centres and specialised clinics and units of general hospitals.     

Transfers of hospitalized psychiatric patients under Medicare's prospective payment system

Medicare's reimbursement policy provides payment incentives for hospitals to transfer psychiatric patients to another acute-care facility, especially when the destination facility is exempt from Medicare's prospective payment system. The authors found, however, that transfers were relatively infrequent in 1985, accounting for only approximately 3.4% of all psychiatric hospitalizations under Medicare. The most common type of transfer was from a nonspecialized general hospital bed to a Medicare-exempt psychiatric unit within the same hospital. Given that increasing financial pressures may result in a rise in the number of transfers, the authors discuss potential reforms of Medicare reimbursement for these cases.     

Determinants of psychiatric hospitalization after attempted suicide

OBJECTIVE: This study investigated the characteristics of suicide attempters referred to psychiatric hospitals and the factors affecting such referral. METHOD: All 1198 consecutive suicide attempters treated in general hospital emergency rooms in Helsinki during a 12-month period were identified. Data on all health care contacts 1 year before the index attempt and on referrals to psychiatric hospitals after the attempt were gathered. RESULTS: We found that a quarter of patients were referred to psychiatric hospitals as inpatients after index suicide attempts. Factors predicting referral to psychiatric hospitals, compared to nonreferral, were older age, psychotic disorder, mood disorder, lack of alcohol consumption preceding the attempt, somatic illness, suicide attempt on a weekday, previous psychiatric treatment, psychiatric consultation and the hospital treating the suicide attempt. CONCLUSION: Although the clinical characteristics of patients attempting suicide are a major determinant of whether they are subsequently referred to psychiatric hospitals, the treatment practices of emergency room hospitals also influence treatment decisions.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

Psychiatric units in Brazilian general hospitals: a growing philanthropic field

BACKGROUND: Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. OBJECTIVE: To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. METHOD: A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. RESULTS: Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. CONCLUSION: The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.     

Planning mental health services: I. Background and key issues.

Planning mental health services is a complex task requiring an understanding of background developments and key issues related to mental health services. In Canada, the deinstitutionalization of patients attempted to shift the locus of care from provincial psychiatric hospitals to general hospital psychiatric units. This resulted in the isolation of provincial psychiatric hospitals, general hospital psychiatric units and community mental health programs, with little overall accountability for the services provided--three solitudes. To move toward the creation of responsible, integrated systems a number of issues must be addressed: target population(s); the roles of provincial psychiatric and general hospitals; community support services; continuity of care; co-morbidity; consumerism; and methods of integration. In the development of a comprehensive mental health plan, each issue should be recognized and decisions made which are in keeping with current knowledge. A companion report will survey Canadian initiatives in mental health planning and discuss approaches to many of the issues identified.     

Psychiatric hospitalization of senile,presenile and arteriosclerotic dementia patients in israel: A psychiatric case register study

Most dementia patients in Israel are cared for by non-psychiatric services. Psychiatric hospitals are generally reluctant to admit behaviourally disturbed dementia patients, unless it is for appropriate psychiatric reasons and for a transient period of time. We used national Psychiatric Case Register (PCR) data to examine the implementation of these criteria in a sample of 711 dementia patients (senile and arteriosclerotic). Results suggest that: (a) in about a third of senile patients and in nearly half of arteriosclerotics no primarily treatable, psychiatric symptoma-tology was diagnosed; (b)most admissions were not on a psychiatric emergency basis; (c)inpatient stay of dementia patients was longer than the average psychiatric admission. These patients were usually transferred to a non psychiatric facility or to a general hospital, or died in the psychiatric hospital. We conclude that the subject of psychiatric hospitalization of dementia patients in Israel needs substantial revision.     

Help seeking behaviour of psychiatric patients before seeking care at a mental hospital.

BACKGROUND: A wide range of professionals including psychiatrists, psychologists, general physicians, faith-healers and religious healers cater to the needs of mentally ill patients. Psychiatric facilities are available at general hospitals, office based practice and mental hospitals. Psychiatrists are preferred the least due to stigma. The present work reports on treatment options used by a group of psychiatric patients before visiting a mental hospital. AIM: To study the help seeking behaviour of patients visiting a mental hospital. METHOD: Patients attending psychiatric outpatient service at a mental hospital were asked specifically about various treatment facilities utilized by them before coming to the hospital and the reasons thereof. RESULTS: A wide range of services was used by the subjects varying from professional care to faith healers. Trust, easy availability and accessibility, recommendations by the significant others and belief in supernatural causation of illness were the important reasons for choosing a particular facility. Thus sociocultural factors appeared to influence the help seeking behaviour. CONCLUSION: A substantial number of patients suffering from severe mental disorders seek non-professional care. There is a need of studies in community to assess the help seeking behaviour of psychiatric patients and factors associated with it.     

Day hospitalization as a cost-effective alternative to inpatient care: a pilot study.

Two private day hospitals and an insurance company offering group health coverage to federal employees undertook a pilot study to determine if providing insurance coverage for day hospitalization on the same basis as for inpatient treatment was a feasible means of controlling the cost of psychiatric care. The study included 31 patients who otherwise would have been hospitalized; most had histories of severe psychiatric disorders and extensive treatment. Using the measure that the day hospital patients would have been in inpatient treatment for the same number of days, the authors estimate that the use of day treatment saved the insurer more than $255,000. They recommend that day hospitalization be reimbursed on the same basis as inpatient care if a day hospital can meet stringent criteria ensuring that it provides active, appropriate treatment, and they present a list of such criteria.     

Ect use in the public sector: California

Availability of ECT in the United States often has been greater in the private sector than in the public sector. This is especially true in California, where ECT is heavily regulated. In 1986, ECT was available at 29.6% of the public hospitals and 42.9% of the private hospitals with psychiatric units in California. Public hospital patients accounted for 8.5% of all ECT in the state, while private hospital patients accounted for 91.5%. Of the 88 patients unable to give informed consent, 34.1% came from public hospitals vs. 65.9% from private hospitals. Two university-affiliated county hospitals accounted for 43 of 52 patients (82.7%) treated in the 6 county hospitals with psychiatric units. White patients accounted for 92.4% of ECT, leaving minorities undertreated.Private patients have a greater degree of choice regarding changing physician or hospital if ECT is needed but unavailable. The choices for public patients are limited. Possible causes and potential solutions to this problem are discussed.A version of the paper was presented at the New Research Poster Session, American Psychiatric Association Annual Meeting, May 10, 1989, San Francisco, California.     

Psychiatric consultations in short-term general hospitals

We investigated the use of psychiatric consultations in short-term general hospitals using a national sample of 327 hospitals and examining the hospital experience of approximately 263,000 patients discharged from these hospitals. We found that the demographic characteristics of patients receiving psychiatric consultations in the national sample were roughly similar to those reported for patients receiving consultations in earlier, single-hospital studies. Rates of consultation were considerably lower, however: 0.9%, compared with a median rate of 3.3% reported in the literature. We also found that patients receiving psychiatric consultations used more hospital resources than other patients.     

Duration of inpatient treatment of various psychiatric disease categories. A follow-up study]

The frequency and duration of in-patient treatment in psychiatric and general hospitals was observed over an average 14-year period for 328 patients with different psychiatric diseases. Schizophrenics were more frequently admitted and spent longer in psychiatric institutions than all other diagnostic groups, but were admitted less frequently and for shorter periods to general hospitals. Patients suffering from organic mental illness and those with neurotic disorders had more frequent and longer periods of general hospital care. Drug dependent and neurotic patients were hospitalised more frequently and longer for psychiatric rather than for medical reasons in general hospitals. The total frequency and duration of psychiatric in-patient treatment was distinctly less frequent and of shorter duration for neurotic disorders as compared with schizophrenic or affective psychoses.     

2006年天津市精神科住院服务现状分析

目的了解天津市精神科住院服务现况。方法现况调查。使用天津市医疗机构精神卫生服务状况调查问卷调查天津市18个区县365家医疗机构2006年精神科床位的分布情况以及精神科住院服务的利用情况。结果 2006年天津市有21家医疗机构提供精神科住院服务,共拥有精神科医生497人,精神科护士876人,精神科床位4281张,按人口密度计算分别为4.76人/10万人、8.4人/10万人、4.11张/万人。全年总住院人次10449人次。精神卫生资源主要分布在中心城区、精神专科医院、三级医院,住院服务的利用主要在中心城区和精神专科医院。结论天津市精神科住院服务资源水平相对较高,但是精神科床位在全市的分布不均衡。     

General hospital psychiatry: Are its roles and functions adjunctive or pivotal?

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.