Long-term consequences of the reformation of psychiatric care: a 15-year follow-up study

Although there are a great many epidemiological studies of psychiatric diseases and the outcomes of controlled rehabilitation programmes, there is a shortage of studies of routine psychiatric care. This study is a retrospective cohort study of the total number (n=138) of patients receiving inpatient care at a psychiatric rehabilitation clinic in J?nk?ping during 1984. The follow-up period is 15 years, 1984-98. The group had a considerable amount of inpatient care, but this decreased dramatically during the time of investigation. Positive indications were that there were no suicides during the last 5 years of the period and that the number of registered crimes showed a marked decrease from 1992. Negative indications were low levels of work and occupation and few social contacts.     

Utilization of psychiatric inpatient care in Greece: a nationwide study (1984-1996)

This report examines the trends in the utilization of psychiatric inpatient care for the period 1984-1996, when the implementation of the psychiatric reform programme was initiated in Greece. Admissions in public mental hospitals declined by 7.2%. However discharges have been increased by 30.6% with a parallel decrease of the length of stay by 53.7% followed by an increase in discharges of patients diagnosed as suffering from schizophrenia and affective psychoses by 61.1% and 123.8% respectively. In the private sector a remarkable reduction in both admissions and discharges was noticed. Admissions in psychiatric departments of general hospitals for the same years have been increased by 1054.1%. It seems that the recent deinstitutionalization process resulted in increasing trends in the discharges of patients suffering from psychoses. Additionally, a substantial increase in the number of extramural psychiatric services and rehabilitation places between 1994-1996 was observed. The demand for the mental health care services expressed as the urbanization index was found to be related with mental health professionals and the extramural units ratios. The higher degree of urbanism is, the greater the number of extramural services exist. The models explained variance reached 50.6%.     

Does case management reduce the rehospitalization rate?

It was expected from deinstitutionalization that outpatient care could replace hospital care. But many empirical studies proved that the number of admissions to psychiatric hospitals rose when community-based care developed. This might be due to the lack of coordination and cooperation of extramural services. The concept of case management therefore originated in the last few years. In this study the effect of case management on the rehospitalization rate is examined by analyzing the data of 4 social-psychiatric services responsible for defined catchment areas. During the evaluation period of 2.5 years, 162 patients dismissed from psychiatric hospitals were referred to those services. For each of these index patients a matched control patient was identified, each identical in diagnosis, sex, age, living conditions and number of previous inpatient episodes. The results of a survival analysis show that there are no significant effects of case management on the rate of rehospitalization nor on the length of time in hospital in case of a rehospitalization.     

Are Psychiatrist Characteristics Associated With Postdischarge Suicide of Schizophrenia Patients?

Information on the relationship between characteristics of mental healthcare providers, including hospitals and psychiatrists, and postdischarge suicide is scanty. This study aims to identify the risk factors for suicide among schizophrenia patients in the 3-month postdischarge period. The study cohort comprised all patients with a principal diagnosis of schizophrenia discharged from psychiatric inpatient care from 2002 to 2004 who committed suicide within 90 days of discharge. The control cohort consisted of all surviving schizophrenia patients discharged from psychiatric inpatient care in the same period and were matched to cases for age, gender, and date of discharge. There were 87 and 348 cases in the study and control cohorts, respectively. For suicide cases, death most frequently occurred on the first day after leaving the hospital (16.1%). The adjusted hazard ratios for committing suicide during the 90-day postdischarge period were 2.639 times greater for patients without previous psychiatric admission than for those hospitalized more than 3 times in the year preceding the index hospitalization. The adjusted suicide hazard for schizophrenia patients treated by male psychiatrists was significantly higher than for patients treated by female psychiatrists, by a multiple of 5.117 (P = .032). The adjusted suicide hazard among patients treated by psychiatrists over age 44 years was 2.378 times (P = .043) that for patients treated by psychiatrists aged younger than 35 years. Risk factors related to psychiatric hospitalization, including number of psychiatric admissions in the previous year and length of stay, together with gender and age of the psychiatrist providing inpatient care, are identified.     

Psychiatric inpatient care in the VA: before, during, and after DRG-based budgeting

OBJECTIVE: The authors examined the impact of budgeting based on diagnosis-related groups (DRGs) on inpatient psychiatric care in Department of Veterans Affairs (VA) medical centers. DRG-based budgeting was implemented by the VA in 1984 and suspended in 1988. METHOD: Computerized discharge abstracts were obtained for all episodes of VA inpatient care occurring from 1980 through 1989. The number of discharges per year, number of unduplicated patients treated, mean length of stay, total number of bed days of care per unique patient per year, readmission rates, and number of episodes of care per operational bed were determined for psychiatric and nonpsychiatric (medical-surgical) hospitalizations occurring before, during, and after DRG-based budgeting was in effect. RESULTS: In the case of VA psychiatric care, DRG-based budgeting was associated with more episodes of care, shorter lengths of stay, higher readmission rates, and more episodes of care per occupied bed. DRG-based budgeting had similar effects on medical-surgical care, although an increase in the number of episodes of care was not observed. During the first year after this funding mechanism was suspended, changes in both psychiatric and medical-surgical care that were related to DRG-based budgeting were slowed and, in some cases, reversed. CONCLUSIONS: Both psychiatric and medical-surgical inpatient care in the VA were sensitive to changes in funding mechanisms. These changes were generally similar to those observed in psychiatric care provided by non-VA hospitals reimbursed under Medicare's DRG-based prospective payment system.     

The use of coercive measures in adolescent psychiatric inpatient treatment: a nation-wide register study

Purpose

To evaluate the extent and trends in the use of seclusion/restraint in psychiatric inpatient treatment of adolescents aged 12–17?years in Finland.

Methods

The National Hospital Discharge Register data comprising all psychiatric inpatient treatment periods of 12- to 17?year-olds in Finland during the period 1996–2003 was used. Time trends, regional variation and patient characteristics related to the risk of being subjected to seclusion/restraint in psychiatric inpatient treatment are reported.

Results

The average prevalence of use of seclusion and restraint was 1.71/10,000/year over the study period. Use of seclusion/restraint in adolescent psychiatric inpatient care first increased, peaking in 1999–2001, and then decreased. The decrease occurred after stricter legislative control of use of seclusion/restraint was introduced in 2002, despite that involuntary treatment periods did not decrease. Considerable regional variation was seen in the use of seclusion/restraint. A greater proportion of girls than boys were secluded/restrained. Seclusion/restraint was most common in schizophrenia, mood disorders and conduct disorder.

Conclusions

Legislative control had the desired immediate impact on the use of seclusion/restraint in adolescent psychiatric inpatient care. Legislative control is, however, not strong enough to ensure homogenous practices across the country, as there is many-fold regional variation in figures for using seclusion and restraint.     

Changes in psychiatric inpatient treatment of children and youth in general hospitals: 1980-1985

Changes in the prevalence of inpatient psychiatric treatment of children and youth in short-term general hospitals between 1980 and 1985 were investigated. During that period, the locus of treatment of mental illness among children and youth shifted dramatically away from specialized facilities to general hospitals without psychiatric units. Among general hospitals without psychiatric units, the number of inpatient psychiatric episodes treated increased dramatically, patients' average length of stay almost doubled, and the total days of care provided more than tripled. The increased care was paid for primarily by Medicaid and commercial insurance. Total days of care for drug and alcohol problems among children and youth in general hospitals decreased substantially. The results suggest that general hospitals may be relying on psychiatric treatment to supplement revenues that were limited by Medicare's prospective payment system, which became effective during the period under study.     

Inpatient care and its outcome in a specialist psychiatric unit for people with intellectual disability: a prospective study

The outcome of treatment in care units has been thought to reflect the effectiveness of treatment. There have been only a few studies describing inpatient care and its outcome in patients with intellectual disability and psychiatric symptoms. The present study describes the psychiatric inpatient treatment in the specialist psychiatric unit of the Special Welfare District of South-west Finland and the need for aftercare among people with intellectual disability and psychiatric disorders (n = 40). As an outcome measure of care, the level of psychiatric symptoms was evaluated either with the Brief Psychiatric Rating Scale (BPRS) or with the Diagnostic Assessment for the Severely Handicapped (DASH) scale; self-reports (visual analogue scale) were also used. Patients’ psychotic symptoms were reduced significantly on the BPRS during inpatient care and aftercare, but non-psychotic symptoms were reduced significantly only during aftercare. For one patient, the psychiatric symptoms were reduced significantly during inpatient care on the DASH scale, while the psychiatric symptoms remained the same for three patients. Patients and their primary carers considered the patient’s psychiatric condition to have improved significantly during inpatient care, but not during aftercare. The specialist unit filled the gap in the care of people with intellectual disability and psychiatric problems in Southwest Finland. It is concluded that psychotic patients particularly benefit from the inpatient care in the specialist psychiatric unit. The care in the unit should include support for primary carers. All patients’ outpatient treatment should also be re-evaluated. The present study poses two important questions. Firstly, could these treatment outcomes have been achieved with other interventions? Secondly, what are the necessary services for people with intellectual disability?     

Trends in psychiatric hospitalisation of people with schizophrenia: a register-based investigation over the last three decades

The number of psychiatric beds has declined considerably in many countries over the past decades. Long-term studies on the impact of these health care changes for the severely mentally ill, however, are still scarce. This epidemiological study investigates the use of inpatient psychiatric services by people with schizophrenia, compared to that by people with other mental disorders. We used psychiatric register data of the Swiss canton Zurich to establish the annual treatment prevalence in the period 1977-2004. For patients with psychoses, the length of inpatient episodes decreased by half. The annual number of inpatient admissions doubled. The proportion of schizophrenia patients, which accounted for 36%-41% of all inpatient treatments up to 1993, dropped to 20% in 2004, while that of other psychoses remained about the same (8%-10%) throughout the study period. This contrasts with a 2-3 fold increase in other patient groups. The annual treatment prevalence for people with schizophrenia declined from 7.3 to 2.2 per 10000 population since the 1990s and affected patients of all ages and of both sexes equally. The treatment prevalence for other psychoses remained virtually unchanged (1.3 per 10000). For all other mental disorders, there was an up to twofold increase. The study suggests that the downsizing of psychiatric hospitals has resulted in a far-reaching redistribution of overall inpatient treatment resources. The considerable decrease in inpatient treatment for people with schizophrenia emphasizes the need to further investigate the current state of coverage for and the appropriateness of health care available to this patient group.     

Has the attempt to reduce psychiatric inpatient treatment been successful in Finland?

The deinstitutionalisation process in Finland's psychiatric healthcare did not start until the late 1980s. Our aim is to evaluate how the use of psychiatric inpatient treatment was associated with deinstitutionalisation given the changes in the modality of treatment ideology (years 1987--1991) as well as being due to economic pressures (years 1991--1995). Special emphasis is given on the inpatient treatment of schizophrenia and other psychotic disorders.Data was retrieved using the national hospital discharge register of all treatment periods in psychiatric hospitals and treatment periods due to psychiatric disorders in other hospitals. Three years (1987, 1991, and 1995) were compared. Four healthcare districts in northern Finland were studied. Resource use was measured by number of treatment periods and inpatient days in relation to population. Psychiatric inpatient treatment was reduced in 1987--1991, when resources in community care increased. During the period of economic pressures (1991--1995), when community care resources no longer increased, inpatient treatment started to rise again. Over the whole period, psychiatric treatment in primary care institutions increased.Reduction of psychiatric beds results in increasing inpatient treatment in non-specialist institutions, especially when community care fails to serve the patients. In the future it is important to evaluate whether the quality of care remains in the standard of specialised services when treatment shifts away from the specialist level.     

Health care utilization in children and adolescents with psychiatric disorders

Objective

Mental illness is increasing among young people and likewise the request for health care services. At the same time, somatic comorbidity is common in children and adolescents with psychiatric disorders. There is a lack of studies on health care use in children and adolescents, and the hypothesis was that children and adolescents with psychiatric disorders use more primary-, and specialized somatic health care compared to children without psychiatric disorders.

Methods

In this retrospective population-based register study, all individuals aged 3–17 years living in Västra Götaland region in Sweden in 2017 were included (n = 298,877). Linear and Poisson regression were used to compare health care use during 2016–2018 between children with and without psychiatric diagnoses, controlling for age and gender. The results were reported as unstandardised beta coefficient (ß) and adjusted prevalence ratio (aPR) respectively.

Results

Having a psychiatric diagnosis was associated with more primary care visits (ß 2.35, 95% CI 2.30–2.40). This applied to most diagnoses investigated. Girls had more primary care visits than boys. Likewise, individuals with psychiatric diagnoses had more specialized somatic outpatient care (ß 1.70, 95% CI 1.67–1.73), both planned and unplanned (ß 1.23, 95% CI 1.21–1.25; ß 0.18, 95% CI 0.17–0.19). Somatic inpatient care was more common in those having a psychiatric diagnosis (aPR 1.65, 95% CI 1.58–1.72), with the diagnoses of psychosis and substance use exerting the greatest risk.

Conclusions

Psychiatric diagnoses were associated with increased primary-, somatic outpatient- as well as somatic inpatient care. Increased awareness of comorbidity and easy access to relevant health care could be beneficial for patients and caregivers. The results call for a review of current health care systems with distinct division between medical disciplines and levels of health care.     

Time trends in mental health care utilization in a Dutch area, 1976–1990

This paper concerns time trends in mental health care utilization in a Dutch area from 1976 to 1990. In general, there was an increase in the use of psychiatric services during the study period, both in terms of the number of new patients (per 1000 population) and in terms of the amount of care utilized per patient. When only intramural services were taken into account the number of new psychiatric patients remained approximately constant, but the number of patients in care at a certain point in time (point prevalence) showed a rising trend. For most part, the increase in inpatient point prevalence rates could be ascribed to the increase in the elderly population (75 years or more). In addition to the proportional increase of the ageing population, a growing amount of psychosocial problems and broadening of the concept of illness were tentatively assumed to be related to the increase in mental health care utilization. Unlike some other countries, deinstitutionalization hardly occurred in the Netherlands. Accepted: 19 August 1997     

Health care utilization by older patients with coexisting dementia and depression

OBJECTIVE: Few studies have examined the course of coexisting dementia and depression. The purpose of this study was to compare elderly patients who had coexisting dementia and depression with elderly patients who had either disorder alone in terms of their utilization of inpatient and outpatient services. METHOD: The study group included 7,115 veterans aged 60 years or older who had been discharged from Department of Veterans Affairs inpatient units in 1992 with diagnoses of major depression, dementia, or both. Outcome measures were analyzed for a 2-year period following the index hospitalization for each diagnostic study group. RESULTS: Patients with coexisting dementia and depression had significantly more psychiatric inpatient days than the other two study groups and more medical inpatient days and nursing home readmissions than patients with depression alone. Patients with coexisting dementia and depression had significantly more total inpatient days than the other two groups. Notably, patients with coexisting dementia and depression did not utilize more outpatient resources than the other study groups; in fact, they had significantly fewer medical, psychiatric, and total visits than patients with depression alone. CONCLUSIONS: The findings suggest that patients with coexisting dementia and depression are high utilizers of inpatient services, with a course of illness that may resemble dementia in terms of nursing home and inpatient medical care utilization and depression in terms of inpatient psychiatric care utilization; however, these patients utilized significantly fewer outpatient resources than the group with depression alone. Aggressive outpatient treatment approaches might reduce utilization of inpatient care for patients with coexisting depression and dementia.     

Trends in mental health services for people with intellectual disability in residential care in Israel 1998-2004

Persons with intellectual disability (ID) have more mental health problems than the general population and utilize psychiatric service to a greater extent. This study was conducted to look at trends over time in the number of psychiatrists recruited, psychiatric medication and hospitalization for persons with ID in residential care in Israel. Data was extracted for the 1998-2004 period from the annual surveys conducted of medical service in all residential care centers in Israel by the Office of the Medical Director. Results showed an increase in psychiatrists working with this population, from 1.08 psychiatrist per 1,000 study population in 1998 to 2.23 in 2004, psychotropic medication also increased from 45% to 52% over the same period, but psychiatric inpatient hospitalization decreased from 5.48 to 4.99 per 1,000 study population. It is concluded that there has been an improvement in psychiatric service to this residential care population over the study period, but there is a need for a formal subspecialty in psychiatry, training and research.     

Characteristics and outcome of delirium in psychiatric inpatients

Abstract Delirium, a transient organic psychiatric syndrome, is a common psychiatric diagnosis. It is associated with increased rates of morbidity and mortality in medical-surgical inpatients. There have been few reports describing the risk factors and prevalence of delirium among psychiatric inpatients. The purpose of the present study was to investigate the rate of delirium, the reasons for admission, the clinical features, the etiologies and the mortality during a 2 year follow-up in psychiatric inpatients admitted to a general hospital during a 3 year period. The results show that the rate of incidence of delirium in psychiatric and geriatric (age 65 years) inpatients was 1.4 and 9.6% respectively. The most common cause of delirium was adverse effects of medication. The inpatient mortality (5.9%) was lower compared with reported mortality rates in medical-surgical inpatients. However, there was a high mortality rate during the 2 year follow-up period (39.4%), especially in older patients. The high mortality during follow-up stressed the importance of after-discharge care in these patients.     

Effectiveness of a High End Users Program for Persons with Psychiatric Disorders

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A pre-post study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.     

Predictors of Rehospitalization in High-Utilizing Patients in the VA Psychiatric Medical System

233 high-service-utilizing (HSU) psychiatric patients were recruited during an inpatient psychiatric treatment. They completed a questionnaire related to their treatment beliefs and were tracked via computerized medical records over 2 years. During the follow-up period, 79.8% were readmitted for additional inpatient psychiatric treatment. Survival analysis techniques were used to examine patients’ rates of readmittance during the follow-up period. Number of previous year inpatient psychiatric days served as a significant predictor of readmittance status and time to readmission. The survival plot was split by previous-year inpatient days to examine the effect of this variable on readmission. Implications of findings are discussed.     

A comparison of the performance of for-profit and nonprofit U.S. psychiatric inpatient care providers since 1980

OBJECTIVE: The authors synthesized evidence from a systematic review of the literature reporting substantiated performance differences between private for-profit and private nonprofit psychiatric inpatient care providers in the United States since 1980. They also compared reported differences in performance between nonprofit and for-profit inpatient psychiatric care providers with reported differences between nonprofit and for-profit providers of other types of health care. METHODS: Studies were located by means of computerized bibliographic searches and follow-up searches of studies cited in the articles located in the computerized search. The analysis included peer-reviewed studies that compared the performance of for-profit and nonprofit health service providers, including inpatient psychiatric services, in the areas of access, quality, cost-efficiency, and amount of charity care on the basis of quantitative data collected after 1980. The studies were classified in one of three categories according to the study conclusion: for-profit superiority, nonprofit superiority, or no difference or mixed results. RESULTS: Almost all studies (with one exception) found that the nonprofit psychiatric providers performed as well as or better than their for-profit counterparts. The proportion of studies reporting performance superiority of nonprofit versus for-profit psychiatric inpatient providers was greater than the proportion of studies reporting the same conclusion for providers of all other types of health care taken together. CONCLUSIONS: On the basis of data collected since 1980, nonprofit psychiatric inpatient care providers in the United States had superior performance on access, quality, cost-efficiency, and amount of charity care, compared with for-profit providers. Caution is warranted in pursuing public policies that permit or encourage the replacement of nonprofit psychiatric inpatient care providers with for-profit providers of these services.     

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994–2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.     

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994-2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.