Recent treatment history vs clinical characteristics in the prediction of use of outpatient psychiatric services

Background The use of outpatient psychiatric services has been shown to be a complex function of sociodemographic, clinical, and pathway variables. The relative contribution of each variable or groups of variables in explaining the variability in the use of outpatient psychiatric services, however, remains poorly documented. Methods The subjects (N=382) were all patients admitted to an outpatient psychiatric clinic serving mostly a minority and low-income population. The charts of the patients were reviewed for sociodemographic, clinical, and pathway variables and the number of outpatient visits. The pathway variables studied were source of referral and most recent psychiatric treatment service used. Both bivariate and multivariate statistics were used to analyze the data. Results Pathway variables were better predictors of the number of outpatient visits than clinical variables after controlling for sociodemographic variables. Conclusion Patients recently hospitalized may be sicker or have fewer social supports and therefore require more outpatient visits. Recent treatment history stands out as an important variable in the prediction of the number of outpatient mental health visits. More research is needed to examine the influence of pathway variables on treatment decisions.     

Use of coercion in psychiatric care as narrated by patients,nurses and physicians

The patterns of use of outpatient services during a 1-year follow-up in seven psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorized psychiatry. One-year treated incidence cohorts were used. Three main patterns of outpatient care emerged at the service system level. First, in two of the services the outpatient care was dominated by emergency contacts. In four of the services the outpatient care was dominated by scheduled contacts, and most of the patients had no emergency outpatient contacts at all. In one of the services a remarkably large number of (38%) the patients had no outpatient contact at all. In addition to the characteristics of the psychiatric services, the following variables predicted the use of emergency outpatient services: self-referral, no inpatient care and no planned outpatient contacts during the follow-up, diagnosis of adjustment disorder or functional psychosis, and being on sick leave. The following variables predicted several scheduled outpatient contacts during the follow-up: no inpatient care and two or more emergency outpatient contacts during the follow-up, female gender, age less than 65 years, no previous inpatient care, and diagnosis of non-organic psychosis, neurosis, or personality disorder.     

Inpatient and outpatient psychiatric services: substitutes or complements?

Patients at risk for psychiatric hospitalization make only limited use of outpatient services, although clinical research has demonstrated that outpatient treatments and home care can be as effective as inpatient psychiatric treatment in treating certain mental health problems. The substitution of ambulatory services for inpatient care has in part been limited because insurers have restricted outpatient mental health benefits to control utilization. The authors critically review evidence from the economic and clinical literatures to determine the extent to which outpatient psychiatric treatment substitutes or complements inpatient treatment. To encourage clinically effective substitution of outpatient for inpatient services, further research is needed to identify the patient populations for whom substitution is possible and the treatment and environmental conditions in which it is most likely to be successful.     

Personality correlates of outpatient mental health service utilization

OBJECTIVE: The present paper investigated the relationships between several personality constructs and the use of outpatient mental health services. METHODS: Respondents were from the National Comorbidity Survey (NCS) Part II data set and included those with a past-year mood, anxiety, alcohol/substance use disorder (n=1750). Bivariate logistic regressions were used to examine associations between participants' self-reports of personality traits and outpatient mental health service utilization. Similar multivariate analyses were used to investigate these associations after adjusting for sociodemographic variables and the presence of psychiatric disorders and their comorbidity. RESULTS: The bivariate and multivariate analyses revealed significant positive associations between outpatient mental health service utilization and both Powerful Others Locus of Control and Self-criticism. CONCLUSIONS: These findings suggest that personality traits may play a role in treatment seeking behaviors for mental health problems over and above the presence of psychiatric disorders alone. The assessment of relevant personality constructs has the potential to inform and improve treatment outreach efforts.     

Determinants of psychiatric inpatient admission to general hospital psychiatric wards: an epidemiological study in a region of central Italy

Objective: To determine which factors contribute to the decision to admit individuals to psychiatric wards in general hospitals. Method: Data on 1,379 individuals undergoing psychiatric evaluation in eight emergency rooms in a region of central Italy were collected. A logistic regression analysis was used to evaluate the likelihood of psychiatric admission considering the independent effects of demographic, social, and clinical factors and of the history of psychiatric treatment. Results: The adjusted odds ratio for psychiatric admission significantly increased with the following variables: severity of symptoms; presence of paranoid states and schizophrenic psychoses, affective psychoses and acute psychotic conditions (with neurotic disorders used as reference); a history of outpatient treatment; the presence of a staff member of a community mental health facility upon presentation at the emergency room; and the availability of beds in the psychiatric ward. Conclusion: The independent effect played by the presence of a staff member of a community mental health facility is of particular interest, suggesting the existence of a collaborative relationship between inpatient and outpatient services. Accepted: 11 December 1998     

The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case‐register study

ObjectivesThe general practitioners'' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross‐boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions.MethodsWe compared a local and a centralized model of mental health care. Service utilization over a 5‐year period was studied.ResultsFindings suggest that a local institution‐based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all.ConclusionLocal inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network‐oriented treatment philosophy.     

Survey of patient satisfaction in adult psychiatric outpatient clinics.

A client satisfaction survey was undertaken in two adult psychiatric outpatient clinics. The anonymous self-report questionnaire covering demographic, setting and satisfaction with service variables was endorsed by 203 participants. The mean age of the subjects was 42.5 +/- 19 years, with a small majority (58.6%) of females. Overall satisfaction with psychiatric care was high (79.8%). None of the demographic or setting variables correlated significantly with satisfaction. Psychoeducation was significantly correlated with level of satisfaction with services. These findings further emphasize the importance of psychoeducation by service providers in mental health.     

Current need versus treatment history as predictors of use of outpatient psychiatric care

The authors conducted a study of treatment utilization and outcome on a sample of 116 psychiatric outpatients at a Veterans Administration (VA) hospital. Utilization and outcome measures were obtained at a follow-up interview 18 months after a baseline assessment. Comparisons between patients with high and low rates of utilization revealed negligible relationships between use of services and severity of illness, clinical change, or demographics. However, previous use of VA outpatient and inpatient psychiatric services and VA psychiatric disability rating predicted utilization of psychiatric care during the study. The authors conclude that use of VA outpatient psychiatric care may reflect patients' help-seeking history more than their current clinical need.     

The nature of help-seeking during psychiatric emergency service visits by a patient and an accompanying adult

Utilization rates for urban psychiatric emergency services remain high, and the decision to seek care in this setting is poorly understood. Three hundred individuals accompanying patients to a psychiatric emergency service were interviewed about their help seeking and choice of treatment setting. Twenty-three of the interviewees (7.7 percent) were caregivers accompanying patients with severe and persistent mental illness. They were significantly more likely than other interviewees to know the difference between psychiatric emergency services and services offered by other outpatient providers. More than half reported that the patient they accompanied was intermittently noncompliant, which required visiting either a walk-in service during a moment when the patient was cooperative or a facility equipped to provide involuntary treatment.     

Predictors of Receiving Aftercare 1, 3, and 18 Months After a Psychiatric Emergency Room Visit

This study used logistic regression to predict the receipt of aftercare within one, three, and eighteen months of an emergency room visit for individuals with a severe mental illness. Two psychiatric history variables (had previous psychiatric admissions and was currently receiving outpatient treatment) and one system responsiveness variable (was not admitted at the index emergency room visit) predicted receiving aftercare at all three points in time. In general, variables measuring a client's psychiatric history and the responsiveness of the treatment system appear to be better predictors of the receipt of aftercare than client background variables.     

Household crowding and compliance with outpatient treatment in patients with non-affective functional psychoses in São Paulo, Brazil

Background: Compliance with outpatient treatment can reduce the use of psychiatric inpatient services by people with severe mental disorders. In developing countries, socio-economic factors may be associated with compliance with outpatient treatment. Methods: A 2-year prospective cohort study was conducted of 99 patients with non-affective functional psychoses who were discharged from hospital. Standardized assessments were used for psychopathology, social functioning and use of psychiatric services. Results: Forty-two patients (42.4%) missed all outpatient appointments for at least 2 consecutive months. Household crowding was the only variable associated with poor compliance, patients living in very crowded homes being more than twice as likely to show poor compliance as those living in less crowded homes. Conclusions: In large urban centres in developing countries, strategies to improve compliance with outpatient treatment targeted towards those living in overcrowded households may reduce use of psychiatric beds. Accepted: 4 November 1999     

High and long-term users of the mental health services

Summary Residents of South-Verona who contacted the mental health services in 1983 were traced and followed for a period of 1 year, utilizing a psychiatric case register. Single consulters and long-stay inpatients were excluded from this cohort. A score of service consumption (with subscores for inpatient, day-patient and outpatient care) was calculated for each patient admitted to the study. Seven percent of the patients seeking care in 1 year were high users, having received inpatient as well as day and outpatient care. Using another criterion in classifying the patterns of care, the same sample was divided into long-term and non-long-term users, the former being 9% of the original cohort. The two criteria were then combined to generate four patterns of use of mental health services (high usersand long-term users, neither high nor long-term users, high users only, long-term users only).Using log-linear analysis, a strong association was found between the pattern of service use and diagnosis, occupational status and previous psychiatric contacts. No significant higher-order interaction emerged between these three variables and the pattern of service use.     

An alternative model for psychiatric service delivery for people with intellectual disabilities in a vocational rehabilitation center

The prevalence of mental illness in the intellectually disabled (ID) population is high. Because of their special characteristics, such as involvement of multiple carers (family, social services, protected housing staff, vocational instructors), linguistic limitations and the need for a familiar and steady environment, these patients require special therapeutic consideration. In Israel, as in many other countries, people with ID (PWID) receive psychiatric services from general psychiatric outpatient clinics and hospitals; their treatment is generally not specifically tailored to their needs, and hence often suboptimal. In this article we will review some models of psychiatric service delivery for PWID and present an alternative model that we have developed. Our service has been operating since December 1998; it is based upon cooperation between the municipal social services and the local psychiatric outpatient clinic, and is provided in a vocational rehabilitation center where most mild to moderate ID individuals in our area, the city of Bat Yam, are employed. During the first five years (1999-2004) of the operation of the service, 42 people (about half the total number of clients passing through the vocational rehabilitation center during this period) were examined by the psychiatrist; 37 of them (88%) had at least one psychiatric diagnosis. There were especially high rates of adjustment disorder (26% of all principal diagnoses) and of behavior disorder (24% of all principal diagnoses). This model for psychiatric service delivery for PWID in a vocational-rehabilitation center, based as it is on cooperation between the different care agencies, facilitates more accurate psychiatric diagnosis and hence the provision of more appropriate treatment, which in practice usually consists of a combination of pharmacological and behavioral treatment together with educational programs and support for families and staff. Based on our positive experience with this model, we believe that it is the most suitable framework of treatment for adults with dual diagnosis, and that it should be adopted in other areas.     

Coexisting psychiatric disorders in a New Zealand outpatient alcohol and other drug clinical population

OBJECTIVE: To describe the extent of psychiatric disorder and mental health service utilization in a representative outpatient alcohol and other drug (AOD) treatment sample in New Zealand. METHOD: A total of 105 patients were randomly recruited from two outpatient AOD treatment services in New Zealand and completed a diagnostic interview within the first 2 months of treatment. Axis I psychiatric diagnoses were made using the computerized Composite International Diagnostic Interview (CIDI-Auto), and were supplemented by the South Oaks Gambling Scale (SOGS) and the conduct disorder and antisocial personality disorder section of the Diagnostic Interview for Genetic Studies (DIGS). RESULTS: Seventy-four per cent of the sample had a current non-substance or gambling axis I disorder, with a lifetime rate of 90%. The most commonly diagnosed of these coexisting psychiatric disorders were major depressive episode (34%), social phobia (31%) and posttraumatic stress disorder (31%). Past contact with mental health services was common, while contact at the time of baseline assessment was uncommon. CONCLUSIONS: Coexisting psychiatric disorder was the rule and not the exception in this sample. AOD patients are clearly part of the larger population of mental health patients. AOD services need to be capable of comprehensive assessment and treatment planning, which includes coexisting psychiatric disorders, and should work toward better integration with other mental health services.     

Post-inpatient Attrition from Care “As Usual” in Veterans with Multiple Psychiatric Admissions

Disengagement from outpatient care following psychiatric hospitalization is common in high-utilizing psychiatric patients and contributes to intensive care utilization. To investigate variables related to treatment attrition, a range of demographic, diagnostic, cognitive, social, and behavioral variables were collected from 233 veterans receiving inpatient psychiatric services who were then monitored over the following 2 years. During the follow-up period, 88.0 % (n = 202) of patients disengaged from post-inpatient care. Attrition was associated with male gender, younger age, increased expectations of stigma, less short-term participation in group therapy, and poorer medication adherence. Of those who left care, earlier attrition was predicted by fewer prior-year inpatient psychiatric days, fewer lifetime psychiatric hospitalizations, increased perceived treatment support from family, and less short-term attendance at psychiatrist appointments. Survival analyses were used to analyze the rate of attrition of the entire sample as well as the sample split by short-term group therapy attendance. Implications are discussed.     

The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.     

Assessing the needs for care of non-psychotic patients

Summary Recent psychiatric epidemiological studies using standardized interviews in the community have yielded high rates of non-psychotic disorders. The implications for service provision in terms of treatment and planning remain unclear. No methodology exists to link the individual needs for care and services to problems associated with disorders. The Needs for Care Assessment Schedule (NFCAS) is a relatively new procedure for assessing the needs of long-term mentally ill patients, mostly psychotic and attending psychiatric services. We report here a trial application of a modified version of the NFCAS on a sample of 39 non-psychotic patients, most of whom were attending psychiatric outpatient services. The results show that the modified procedure requires further refinement to achieve acceptability and reliability. Some improvements are suggested for refining items and for the collation of others. The difficulties encountered underline the key issues in developing such technology: specifying the threshold for recognizing the problems, detailing the interventions considered appropriate, defining the model or care and specifying the composition of the research team.     

Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study.

OBJECTIVE: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital. METHOD: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures. RESULTS: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized. CONCLUSIONS: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.     

The role of the certified social worker in England's social services.

With the reorganization of England's social services into a single unified system, the professional called the certified qualified social worker is playing a key role in the administration and delivery of community services. The author describes some of the worker's activities and also presents an overview of hospital, day treatment, and outpatient services for adult psychiatric patients in the county of Warwickshire. One of the most effective programs is a system of voluntary group homes, operated by an area council of churches, for former psychiatric inpatients.     

The Nordic Comparative Study on Sectorized Psychiatry: continuity of care related to characteristics of the psychiatric services and the patients

The problem addressed in this paper is how continuity of care is related to characteristics of psychiatric services, previous events in a patient's pattern of care and patient characteristics. The present paper is a part of a Nordic Comparative Study on Sectorized Psychiatry in seven catchment areas in four Nordic countries. One-year-treated-incidence cohorts were used. Each patient was followed for 1 year after the first contact with the psychiatric service. Continuity of care was measured by the time from discharge from hospital to the first subsequent day-patient or outpatient contact. Notable findings were large differences in the continuity of care in the seven services, high proportions of discharges without any aftercare contacts and long time lags between discharges and aftercare contacts in most of the catchment areas. A Cox regression analysis revealed that aftercare following hospitalisation seems to be more probable if the outpatient services are located geographically close to the patients, if the hospitalisation lasted between 2 and 4 weeks, if there was a community care contact shortly before the hospital admission and if the patient is not retired and not divorced. Staff resources were not related to continuity of care. Accepted: 14 March 1998