Involuntary commitment and detainment in adolescent psychiatric inpatient care

Objective  

To evaluate whether adolescents committed to psychiatric inpatient care are the most disturbed, and whether psychosocial factors other than psychiatric symptoms are associated with commitment to and detainment in psychiatric care among adolescents.     

Re-thinking acute psychiatric inpatient care

BACKGROUND: Reports of low staff morale and high levels of patient complaints suggest that acute psychiatric wards are not achieving their full therapeutic potential. AIMS: This paper reviews some of the 'therapeutic milieu' literature to identify ways of construing ward functioning so as to maximise therapeutic and minimise destructive processes within inpatient units. METHOD: Relevant papers are reviewed, providing an understanding that permits the inpatient clinician to consider and apply the pertinent concepts. RESULTS: Five key therapeutic functions of the ward environment are identified containment, support, structure, involvement and validation. Four destructive processes are described, relating to: the isolated patient; group phenomena; the contribution of staff; and structural manifestations in the ward. CONCLUSIONS: The inpatient ward can be construed as a 'whole', embodying a range of therapeutic functions, which may need rapid deployment and dismantling, as dictated by changes in ward conditions. The 'ward-as-a-whole' construct complements individualised models of patient care and the practical implications of such thinking could engender a greater sense of agency and job satisfaction in staff.     

Cost variation in child and adolescent psychiatric inpatient treatment

Publicly available costs data for child and adolescent psychiatric inpatient services do not allow links to be made with patients’ needs and outcomes. Without this information commissioners may reduce the role of inpatient services on the basis of budgetary impacts alone. This study estimates the support costs before, during and after an inpatient admission and explores the associations between costs, needs and outcomes. A detailed prospective cohort study of eight child and adolescent units was undertaken in which participants were assessed at referral, admission, decision to discharge and 1 year later. Mean admission costs were ￡24,120, although the range was wide. Associations were found between costs and patients’ global impairment, age and exclusion status. Support costs after admission were similar to pre-admission costs, but there was some evidence to suggest that services were better targeted. Moves in England to develop national tariffs for inpatient psychiatric episodes should be based on the likely cost of the episode of treatment rather than costs per day, and good commissioning requires more information on the predictors of such costs.     

Psychopathology of adolescent detained versus psychiatric inpatient females

Several studies have shown high rates of psychopathology among female adolescents in detention. Although rates of mental health problems have been called alarming, it is unknown whether mental health needs in females in juvenile justice differ substantially from those of females in mental health care. Therefore, this study compared adolescent females in detention with inpatient adolescent females. For this purpose, a sample of 256 detained females (mean age 15.4 ± 1.3) was compared to 45 psychiatric inpatient females (mean age 15.8 ±1.4). Socio-demographic characteristics, mental health history and psychiatric problems were investigated using file-information and self-report questionnaires. Compared to detained females, inpatients more often showed internalizing problems and dissociation, whereas externalizing problems prevailed in girls in detention centers. Females in detention more often came from an ethnic minority group, while females in mental healthcare more often received mental healthcare previously and had parents with higher employment. This study confirms that mental health needs of girls in mental healthcare and in detention are high. However, non-mental health related factors were different as well - i.e. socio-economic factors - and are likely to influence the involvement with either service sector.     

The changing face of adolescent inpatient psychiatric treatment

Widespread changes in the criteria and resources for psychiatric inpatient treatment of adolescents present enormous challenges and demand serious and far-reaching adaptive efforts. Among these efforts may be a redesigning of the inpatient treatment milieu to accommodate different patient populations for whom different models of treatment and therapeutic strategies are necessary. This paper describes the redesigning and successful integration of an adolescent inpatient unit at a private psychiatric hospital to include separate treatment tracks for three different patient populations. An intensive/reconstructive treatment track provides the long-term inpatient treatment of youth with treatment-refractory personality disorders who have the clinical justification and resources for therapy that aspires to effect structural personality change. An acute crisis intervention track provides short-term inpatient treatment with an adaptation-oriented and highly focused approach to patients who have had limited previous treatment, are confined to short lengths of stay by financial constraints, or for whom regression should be discouraged. Finally, a psychosocial skills treatment group conducts longer term inpatient treatment for neurobiologically impaired patients. Psychotic, severely developmentally disturbed, profoundly abused patients, and those with extremely primitive personalities characterized by an abundance of deficits cannot tolerate the emotional and interpersonal intensity of a reconstructive treatment approach, but can benefit from a supportive, developmental, ego-building strategy.     

Incidents of violence in psychiatric inpatient care

During a period of 18 months a systematic inventory of aggressive incidents was made on two psychosis wards at the psychiatric department of Danderyd Hospital, Stockholm, Sweden. The Staff Observation Aggression Scale (SOAS) for recording and assessing aggressive incidents was used. Staff subjected to violence or threat of violence was interviewed using a semi-structured questionnaire. In one part of the study, a somewhat reduced variant of the same questionnaire was used but this time staff answered anonymously. Aggressive incidents were distributed over the 24 h, but had two distinct peaks - morning and evening. Aggressive incidents most often occur with patients with some kind of a psychotic diagnosis, most often schizophrenic psychoses. The female staff was more exposed to violence than male. Female patients are also more violent to female staff than to male staff. There is a significant difference in the emotional reactions of female and male staff after aggressions. In the staff, men are more often frightened while women tend to get surprised. Still, staff members of both genders feel insulted and angry. The "research" interviews were experienced as therapeutic discussions by the staff.     

Patient satisfaction with inpatient psychiatric care

The aim of the study was to investigate the influence of personality traits, diagnosis and perceived coercion on patient satisfaction with inpatient psychiatric care. The study was performed as a cross-sectional study on 7 inpatient wards in southern Sweden. A cohort of 50 psychiatric inpatients evaluated satisfaction with care and also made ratings on a personality questionnaire. Patients with a higher level of the trait aggressive nonconformity were significantly less satisfied with the ward's physical and psychosocial environment, the treatment design and the treatment program. The phenomenon of acquiescence was not related to the reported level of satisfaction. Analyses of patient satisfaction according to diagnostic groups showed that patients with affective disorders had significantly better satisfaction than patients with a diagnosis of schizophrenia. Patients who perceived that they were involuntarily admitted were measured as being significantly less satisfied with the care in all areas. It is concluded that, to attain a higher specificity in analyses of variation in patient satisfaction, focus may be put on situational and setting factors of the care delivered along with specific patient characteristics. Risk groups, which require great attention in the development of quality assessment and quality assurance policies, are patients with schizophrenia and patients who perceive coercion in connection with inpatient psychiatric treatment.     

Trends in acute psychiatric inpatient care in Massachusetts

This report presents the preliminary results of a longitudinal study of acute psychiatric hospitalization in the Commonwealth of Massachusetts for fiscal years 1994 to 2000. The study was a secondary analysis of data obtained through the Commonwealth's mandated case-mix reporting system, covering 42 acute psychiatric facilities and 119,284 patients. Results include a 58.4 percent increase in the patient population, accompanied by declines in both length of stay and readmission rates; increases in the number of diagnoses of depression and in the number of patient deaths; and shifts to an older population increasingly supported by Medicaid and Medicare, especially managed care programs.     

Consumer satisfaction with an adolescent inpatient psychiatric unit.

OBJECTIVE: To explore factors influencing the satisfaction of patients, parents, and referring clinicians who used the services of an adolescent inpatient psychiatric unit, and to explore how levels of satisfaction related to the patient's symptomatic and functional improvement during the admission. METHOD: All 105 adolescents, their families, and the referring community clinicians who used an inpatient service over a 1-year period were asked to rate the patient's symptoms and functioning on admission, at discharge, and 4 months after the patient's return to the community. We obtained satisfaction ratings at discharge, and consumers were asked to rate helpfulness of the ward experience at 4 months postdischarge. Ward psychiatrists provided Children's Global Assessment Scale (CGAS) ratings and diagnoses over the course of the inpatient stay. RESULTS: Most of the patients (83%) improved during their admission. Consumer satisfaction ratings correlated with improvement of self-identified problems and with the perceived usefulness of discharge recommendations. Satisfaction did not, however, correlate with the patient's symptomatic and functional progress. Interaction with ward staff was an important source of both positive and negative experiences. CONCLUSION: Our study indicates that inpatient psychiatric staff should attend closely to the consumer's perception of difficulties and the need for practical discharge recommendations.     

Regional variation in patterns of inpatient psychiatric care

Regional variation in both average length of stay and number of beds per 100,000 population is described for inpatient psychiatric care in the United States during 1983. The greatest differences were between the Northeast and Mid-Atlantic regions, on the one hand, and the Pacific and Southwest regions, on the other. Medical centers of the U.S. Department of Veterans Affairs (VA), whose policies are largely centrally determined, followed the same regional trends. Regional average length of stay, particularly in public sector mental health care organizations, was higher in regions with more occupied beds per 100,000 population.     

Personality disorder and pathways to inpatient psychiatric care

Background The impact of personality disorder on pathways into psychiatric care is unknown. Aim To examine associations between personality disorder status, length of pathway into inpatient psychiatric care, and involvement of the criminal justice service in the pathway into care. Method The Structured Clinical Interview for DSM-IV personality disorders (SCID-II) and a modified WHO Pathways Encounter Form were administered to a sample of 153 consecutive inpatients admitted to acute wards in one inner London borough over a 4-month period. Diagnosis, socio-demographic variables, social support and substance misuse were also ascertained. Results The presence of personality disorder was not associated with significant differences in the number of carers, time spent along the pathway, or probability of criminal justice system involvement. However, all three personality disorder clusters were significantly associated with increased use of Accident and Emergency (A & E) services. Conclusion Given the high levels of contact with A & E services, casualty staff should receive improved training in the assessment and management of patients with personality disorders. Improved detection of personality disorder within A & E departments could lead to earlier diversion to mental health services and a consequential improvement in the planning of subsequent treatment.     

Residents' perceptions of inpatient psychiatric care

Psychiatric care on an inpatient unit entails the exposure of a patient to a multitude of experiences. It is generally intended that these experiences will be of benefit to the patient. A psychiatric clinician who functions in such a setting has a major responsibility for making decisions about the kinds of experiences to which any patient will be subject. He must also try to orchestrate the impact of these experiences in a way that will be of maximum benefit to the patient. This decision-making process must inevitably be influenced by the clinician's beliefs with respect to how much patients will benefit from these various experiences. These beliefs can be viewed as a set of expectations or as an ideology derived from many sources. In the course of his training, a clinician reads, learns from teachers, and deals with a variety of clinical materials and situations. Out of these emerges that analgam of experience, faith, and knowledge upon which he can draw when a decision is to be made. While reports by Myers and Rosen¹ and by Rubenstein and Laswell² have touched on this issue, relatively little is known about the patterns of beliefs held by psychiatric clinicians. In a previous report³ we described residents' perceptions of the benefit derived from psychiatric hospitalization.In this study we attempt (1) to assess the beliefs of psychiatric residents regarding what aspects of hospital care benefit patients, (2) to measure these beliefs at the beginning and at the end of a period of clinical training and experience, and (3) to compare these general beliefs or stereotypes against more individualized judgments of what it is that patients actually do benefit from.     

Treatment patterns in inpatient depression care

This study aimed to identify latent patterns of treatment combinations in inpatient depression care. A secondary analysis of routinely collected data on inpatient depression treatment from 2133 patients was conducted. Exploratory latent class modeling was used to identify distinct classes of treatment combinations based on antidepressant medication, psychotherapeutic interventions, and additional treatments. The classes were compared with regard to patient characteristics and treatment outcomes. Eight different classes of inpatient treatment combinations could be identified: 22.8% of the patients were treated with a combination labelled “standard modern antidepressants”, 14.6% with “standard tricyclic antidepressants”, 12.2% with “high intensity innovative strategies”, 12.1% with “standard selective‐reuptake‐inhibitors”, and 11.6% with “low intensity”, 9.6% with “somatic”, 8.8% with “high intensity traditional”, and 8.3% with “high intensity psychosocial” care, respectively. Patients treated with different patterns of interventions differed statistically significantly regarding demographic and clinical characteristics. Responder rates ranged from 68.4% to 86.6% across treatment classes. The presented attempt of empirical modeling of a complex multifactorial intervention by means of latent class analysis proved to be a promising way of capturing the complexity of routine inpatient depression treatment. The identified classes of treatment combinations may provide relevant information for a re‐evaluation and improvement of inpatient depression treatment strategies. Copyright © 2015 John Wiley & Sons, Ltd.     

Suicide attempts by psychiatric patients in acute inpatient, long-stay inpatient and community care

Background: This study examined rates of and risk factors associated with suicide attempts by psychiatric patients under active care. It was especially focussed on the relative rates across three standard treatment settings: acute inpatient care, long-stay inpatient care and community-based care. Methods: A total of 12,229 patients in 13,632 episodes of care were rated on the Health of the Nation Outcome Scales (HoNOS) Item 2. For the purposes of the current investigation, a score of 4 was deemed to indicate a suicide attempt. Results: Incidence densities per 1000 episode days were 5.4 (95% CI = 4.8–6.1) for patients under care in acute inpatient settings, 0.6 (95% CI = 0.5–0.8) for patients under care in long-stay inpatient settings, and 0.5 (95% CI = 0.5–0.6) for patients under care in community-based arrangements. Predictors varied by treatment setting. Risk was elevated for personality disorders across all settings: 22.7 attempts per 1000 episode days (95% CI = 17.2–30.0) in acute inpatient care; 2.1 (95% CI = 1.0–4.5) in long-stay inpatient care; and 2.3 (95% CI = 1.7–3.0) in community-based care. This effect remained after adjustment for demographics. Conclusion: Rates of suicide attempts among psychiatric patients are a major issue facing contemporary mental health care systems, and risk factors vary across different treatment settings. Accepted: 8 October 1999