Improving the management of acute aggression in state residential and inpatient psychiatric facilities for youths

The Maryland Youth Practice Improvement Committee for Mental Health, which includes academicians, clinicians, and policymakers, was convened by the Maryland State Mental Hygiene Administration to advise on approaches to improve mental health care for youths in state inpatient and residential facilities. This report describes the development of a guide to improve the management of acute aggression. The process included the identification of key stakeholders, a literature review on managing acute aggression and promoting staff behavioral change, and many debates among the Committee members. An external peer review critiqued the Guide for content validity and feasibility in routine practice. The therapeutic process, a model to direct clinical decision-making used in other medical fields, forms the theoretical framework. Three levels of aggression and corresponding treatment options were established. The Committee hopes that acute aggressive episodes requiring restrictive interventions can be reduced with the combination of careful planning, adequate resources, and sufficient training. When selecting an intervention, the safety of all individuals involved is of primary importance and a patient's past stated preferences should also be considered. This report concludes with a brief discussion of future plans for the implementation and evaluation of this protocol in clinical practice.     

Alternatives to the mental hospital: use of residential facilities for long-term psychiatric care.

We examine the use of the mental hospital and alternative residential facilities by 149 chronic psychiatric patients in Ontario. All major movements of patients since the time of first admission were recorded, including the number of episodes and duration of hospitalization and placement in alternative facilities and in the community. Clinical and social variables thought likely to influence use were correlated with duration, placement, and mobility. In spite of the lack of formal criteria for placement, relatively discrete and homogeneous populations were found in each facility and clear patterns of use could be distinguished. For many patients, their present placement represents their most typical setting and implies a particular route through the psychiatric services. We describe factors relating to different types of movements, and emphasize the continuing importance of the mental hospital in long-term psychiatric care.     

Discriminant validity of the MASQ in a clinical sample

A major weakness of the Mood and Anxiety Symptom Questionnaire (MASQ) is that its discriminant validity has not been demonstrated in a clinical population of anxiety and mood disorder patients. This paper, using 470 anxiety and mood disorder patients, assessed the discriminant validity of the MASQ. The MASQ subscales showed statistically significant discriminant validity, but their maximum ability to discriminate is low at 70%. Overall it was concluded that the MASQ had very weak clinical utility in differentiating anxiety and mood disorder patients, and gave rise to doubts as to the tripartite structure of the MASQ. When using the MASQ, future researchers should be mindful of its limitations when applied in a clinical population.     

Structured assessment of mental health status in psychogeriatrics: validity of the French HoNOS65+.

OBJECTIVE: To assess the reliability, validity, and feasibility of a French version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+). METHOD: Twenty mental health professionals completed the scale for 126 elderly patients. We assessed interrater reliability in inpatient and outpatient settings, together with construct and discriminant validity, as well as concurrent validity compared with several widely used clinical instruments. RESULTS: Excellent agreement among raters was observed in the outpatient subgroup (kappa range 0.77 to 1.00), whereas interrater reliability was modest in the inpatient subgroup (kappa values < 0.55). In cases where the patient-caregiver relationship lasted more than 1 month, the reliability of the scale improved. Construct validity analysis revealed no subscale structure. All items except "self-injury" displayed high concurrent validity (significant Spearman correlations with 8 other questionnaires). In terms of discriminant validity, the "cognitive impairment" (area under the curve [AUC] 0.91) and "depressive symptoms" (AUC 0.79) items showed high sensitivity and specificity values. CONCLUSION: Our results indicate that the French version of HoNOS65+ is a promising clinical assessment tool to evaluate mental disorders in the elderly in outpatient settings. We support its use in routine clinical practice, with the condition that a relatively long and individualized patient-caregiver relationship has been established.     

Discriminant validity of lateral sensorimotor tests in children

The discriminant validity of left- (LH) and right-hand (RH) sensorimotor measures from a comprehensive neuropsychological battery was tested using confirmatory factor analysis. A group of children (primarily learning disabled) was divided into analysis (n = 488) and cross-validation (n = 400) samples and the following measures were taken for both the LH and the RH Tactile Perception, Finger Agnosia, Fingertip Number Writing, Tactile Form Recognition, Finger Tapping, Grip Strength, Grooved Pegboard, and Mazes. RH- and LH scores from these tests, and scores from five WISC subtests (Information, Similarities, Vocabulary, Block Design, and Object Assembly) were analyzed in a series of four nested confirmatory factor models. Models distinguished between LH and RH skill factors, and/or between simple- and complex-skill factors. Models were compared using incremental fit ratios and chi 2 difference tests (Bentler & Bonnett, 1980). Model comparisons revealed little evidence for discriminant validity of LH and RH measures, but strong support for distinctions between measures of simple- and complex-skills. These findings were replicated in the cross-validation sample.     

The process of care in residential facilities

Background Although residential facilities (RFs) have largely replaced mental hospitals (MHs) in most developed countries for the long-term residential care of severely impaired patients, the process of care in RFs has not been well studied. The aim of this paper is to investigate the process of care in 265 RFs, representing 19.3% of all RFs in Italy, and to devise a classification of RFs based on process characteristics.Methods Structured interviews were conducted with the manager and staff of each RF. Residents were evaluated using standardized rating instruments.Results Most RFs had specific admission criteria, with one third having a waiting list that averaged about 3 months. There was no formal limitation to the length of stay in three quarters of RFs, and turnover rates were very low. Although a homelike atmosphere was found in many RFs, most facilities had restrictive rules on patients’ daily lives and behaviours. RFs carried out several external activities targeted at integrating patients within the local community. Standardized assessment instruments and written treatment plans were rarely used. A cluster analysis based on the levels of restrictiveness and the standardization of the process of care classified RFs into five groups that differed with respect to daily staff coverage, size, geographical distribution and proportion of former MH residents. No significant intercluster differences were associated with the current clinical and psychosocial characteristics of residents, or with several other outcome variables.Conclusions This study provides naturalistic evidence of the heterogeneity of the process of residential care on a large scale. Future efforts should focus on developing an empirical classification of RFs, as well as on national and international standards of care and staffing to address patients’ needs.The PROGRES Group includes: National Coordinators: G. de Girolamo, A. Picardi, P. Morosini (National Mental Health Project, National Institute of Health); Biostatistician: R. Micciolo (University of Trento); Regional Coordinators: P. Argentino, M. Casacchia, P. Ciliberti, G. Civenti, A. Colotto, G. Dell’Acqua, W. Di Munzio, G. Fagnano, A. Fioritti, N. Longhin, M. Miceli, M. Nicotera, M. Pisetta, R. Putzolu, E. Rossi, M. E. Rotunno, G. Borsetti, D. Semisa, R. Tomasi, P. Tulli, E. Zanalda; Researchers: C. Barbini, F. Basile, G. Bazzacco, R. Bracco, A. Calvarese, G. Canuso, E. Caroppo, L. Caserta, M. Colangione, S. Damiani, T. De Donatis, F. Di Donato, V. Di Michele, R. Esposito, M. Facchini, S. Ferraro, P. Fracchiolla, P. Gabriele, D. Gallicchio, G. Giardina, A. Greco, F. Grilletti, S. Guzzo, A. M. Lerario, M. R. Marinelli, C. Marino, E. Monzani, F. Picoco, L. Pinciaroli, C. A. Rossetti, P. Rubatta, G. Santone, F. Scorpiniti, V. Scrofani, M. Stefani, A. Svettini, A. Zaffarano, M. Cellini, A. Galli, K. Pesaresi, G. Pitzalis, L. Tarantino; Scientific Consultants: F. Amaddeo, I. Falloon     

Technician losses in public residential facilities.

A cross-organizational longitudinal survey was undertaken of state-operated residential facilities to gauge the extent to which technician-level work forces are affected by turnover and absenteeism. Twelve facilities participated in this study for a period of 9 months. Monthly turnover rates ranged from .6 to 4.9 percent, with a average of 2.4 percent. Turnover rates appeared to be influenced by the size, location, and staffing patterns of the individual institution. With respect to absenteeism, the average "lost time rate" was 6.7 percent. Various standards suggest that absenteeism exceeding 4.5 percent disrupts recommended staffing ratios. One may conclude that employee withdrawal, whether in the form of avoidable turnover or unscheduled absenteeism, represents a serious managerial problem for many institutions.     

Caregiver perceptions of psychotropic medication in residential facilities

Direct caregivers (designated as "psychopaedic nurses" in New Zealand) in two public residential facilities were surveyed regarding their perceptions, opinions, and knowledge of psychotropic drugs. Of 276 individuals contacted, 227 (82%) returned usable questionnaires. The results indicated that unit supervisors (charge nurses) and unit doctors were perceived as wielding most influence on decisions regarding psychotropic drugs, whereas caregivers based outside residential units were seen as having little influence. Aggressive/destructive behavior and, to a smaller extent, self-injurious behavior were seen as the most likely problem behaviors to lead to medication use. Subjective measures were generally favored for assessing drug effects although, in a hypothetical "ideal" situation, nurses gave increasing priority to more objective indices. Endorsement of behavior modification as an alternative to pharmacotherapy was generally high. A large majority of these caregivers (85%) expressed dissatisfaction with their training concerning psychotropic drugs. Finally, data were presented on drug topics about which respondents wanted to learn more and about changes they wished to see instated in their facilities. Our principal conclusion was that these data indicate a need for more education on a variety of social, pharmacological, and behavioral issues as they relate to medication use.     

Relationships between requests for psychiatric consultations and psychiatric diagnoses in long-term-care facilities

OBJECTIVE: The authors' objective was to investigate reasons for referral of elderly nursing home residents for psychiatric consultation and the relationship of these reasons for referral to psychiatric diagnoses. METHOD: They examined 197 nursing home residents consecutively referred to a consulting team in a university-affiliated mental health center. These patients represented all patients evaluated by the consulting team at six nursing homes over a 2-year period (Sept. 1, 1984, through Aug. 30, 1986). RESULTS: Reasons for referral were diverse but fell into seven broad clusters: behavioral problems; mood-related problems; consultations requested by involuntary treatment services, patients, physicians, or other referring agencies; psychotic features; physical signs; impaired activities of daily living; and other. Behavioral problems were most commonly cited and tended to be associated with dementia diagnoses. Mood-related reasons for referral were most strongly associated with diagnoses of affective disorders, and diagnoses of schizophrenia and adjustment disorder were each associated with two or more reasons for referral. However, reasons for referral were distributed widely across diagnostic groups and were relatively weak predictors of diagnoses. CONCLUSIONS: The results illustrate the variety of problems for which nursing home staff are willing to seek psychiatric consultation but emphasize the need for professional psychiatric evaluation to establish a diagnostic base on which treatment interventions can be built.     

Staffing of adult psychiatric inpatient facilities

Administrators who have studied the relationship between facility staffing levels and quality of care have been frustrated by problems in defining case load and organizational structure. To help eliminate ambiguity, the authors propose criteria for setting staffing levels for several types of inpatient wards in public psychiatric facilities, based on reporting, observation, and analysis of daily tasks performed by staff at an adult psychiatric center with 600 patients. Definitions of understaffing, minimal staffing, and optimal staffing are proposed.     

Conceptual and methodological issues in the comparison of inpatient psychiatric facilities

The authors compared the length of stay of acute admission patients at a mental health center and a nearby state hospital. The two facilities had significantly different length of stay distributions; the mean was not an adequate index to describe these patterns. Despite careful matching, patients at the state hospital were more disabled. Different patient characteristics were associated with length of stay at the two facilities, and these were also characteristics on which the patient populations differed at admission. The authors conclude that comparisons of hospitals, for example, on mean or median length of stay can be misleading unless the different functions, policies, and constraints of the facilities are taken into account.     

Self-preservation ability and residential fire emergencies

Perske's concept of risk from the perspective of fire safety was examined for approximately 46,000 developmentally disabled persons. The National Bureau of Standards measurement of self-preservation ability was used to define individual risk, resulting in the Evacuation Assistance Score. Environmental risk was measured by grouping residences according to fire safety standards described in the National Fire Protection Association's Life Safety Code. Results indicated that: (a) the Evacuation Assistance Score is best thought of as a single variable that measures any risk that might impede a resident's safe evacuation in a fire emergency, (b) the majority of the developmentally disabled individuals receiving services in New York were totally capable of self-preservation, (c) resident demographic characteristics were not strong predictors of Evacuation Assistance Scores, and (d) the match between individual and physical environment risk vulnerability was not strong.     

Mania in the Swedish Twin Registry: criterion validity and prevalence

BACKGROUND: In population surveys, the assessment of mania is commonly done by trained lay interviewers using structured diagnostic instruments: the validity of this approach has been questioned. We examined the criterion validity and prevalence of lifetime mania in a survey of Swedish twins conducted with interview methodology usually applied in psychiatric epidemiology. METHODS: 41 838 individuals in the Swedish Twin Registry were evaluated via a telephone interview that included the eight DSM-IV mania items, and these data were merged with inpatient hospitalization discharge diagnoses from two comprehensive national registries (the criterion). An algorithm with eight cut-points was used to diagnose lifetime mania, and compared by a receiver operator characteristic curve to the criterion. The algorithm requiring at least four positive items resembling a DSM-IV diagnosis. RESULTS: History of hospitalization for a psychiatric condition that included a manic episode was present for 0.7% of all living twins, and predicted non-response to the survey (OR = 0.5; 95% CI = 0.4-0.6). The incidence rate for first hospitalization was 2.1/10 000 year(-1). For > or =1 symptom (first cut-point), the prevalence, sensitivity and specificity were 3.6%, 39.0% and 96.6%; for > or = 4 symptoms (DSM-IV-like cut-point) 2.6%, 36.5% and 97.6%; and for eight symptoms 0.3%, 18.0% and 99.8%. Positive predictive values were, respectively, 5.5%, 7.0% and 29.8%. CONCLUSIONS: The performance of the telephone screening for mania by lay interviewers in terms of positive predictive power was not satisfactory; despite a high specificity, the false positive rate was high. The low population prevalence of mania, non-response bias, criterion choice and inherent limitations of the interviewing method are among the explanations. Assessment of a lifetime manic episode based on lay interviewer screening may yield misleading data.