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PubMed1992

Need-for-treatment criteria for involuntary civil commitment: impact in practice.

There has been considerable discussion in the literature on the differences between criteria for involuntary commitment that are based on dangerousness and criteria based on need for treatment. A number of states have adopted clinical criteria, and other state legislatures are actively considering them. Some libertarians argue that dangerousness is constitutionally required if a person is to undergo the loss of liberty involved in commitment. Citing widely publicized data from the state of Washington, they predict that a return to clinical criteria would result in a deluge of inappropriate commitments. Some clinicians counter that use of clinical criteria would result in selection of a much more appropriate clinical population and point to research indicating that strict observation of the need-for-treatment provisions of the APA model commitment statute would actually decrease the number of commitments. The author examines state hospital admission and census data from eight states that added need-for-treatment criteria to their commitment codes between 1975 and 1990 and argues that the data indicate that there is little reason to believe that such changes would result in the deluge of admissions predicted by the critics.

Ambulatory Care↗
PubMed1992

Conservatorship for gravely disabled psychiatric patients: a four-year follow-up study.

OBJECTIVE: The authors examined the conservatorship process in California by studying a group of psychiatric patients for whom conservatorship was sought; their goal was to determine its effectiveness both during and after the period of conservatorship. METHOD: The subjects were 60 county psychiatric hospital inpatients 18-60 years old for whom temporary (30-day) conservatorships were obtained and who were followed for 4 years. The patients' courses over the 4 years were assessed in terms of whether 1-year conservatorships were obtained, stability (number and length of psychiatric hospitalizations, arrests, serious physical violence, and homelessness), and presence or absence of family support. RESULTS: The patients proved to be a severely mentally ill and disabled group. Thirty-five (58%) were granted a 1-year conservatorship sometime during the 4-year study period, and 25 (42%) were not. Both family support and conservatorship appeared to be related to the patients' stability. When one or both were present, there was a significantly greater likelihood of stability. CONCLUSIONS: The authors believe that for a considerable number of chronically and severely mentally ill individuals, conservatorship would play an important role in their clinical management and treatment by helping to eliminate their chaotic life styles, their cycle of admission and discharge from hospitals and jails, and/or their living on the streets, particularly when family support is absent.

Adolescent↗
PubMed1992

The psychotherapist as witness for the prosecution: the criminalization of Tarasoff.

The "duty to protect" doctrine heralded by the Tarasoff decision seeks to prevent physical harm to third parties by psychiatric patients. Recent court cases have mandated the testimony of a criminal defendant's psychotherapist both about the Tarasoff warning itself and about confidential treatment information that was associated with the warning. One court further ruled that some clinical sessions were not psychotherapy and therefore were not afforded the protection of psychotherapist-patient privilege. The continuing erosion of confidentiality has resulted in psychiatrists and other mental health professionals becoming prosecution witnesses at the criminal trials of their own patients.

California↗
PubMed1993

Profiles and predictors of assaultiveness for different psychiatric ward populations.

OBJECTIVE: The authors examined associations between patient-related characteristics and assaultiveness on six different psychiatric wards to determine 1) the relative contributions of demographic, disorder-related, and diagnostic variables to prediction of assaultiveness and 2) how ward composition and type of victim affect prediction of assaultiveness. METHOD: Hospital records of 1,025 inpatients residing in psychiatric wards within a 6-month time frame were reviewed for evidence of assaultiveness. Data on all 260 assaultive patients and a sample of 136 of the nonassaultive patients were analyzed with multiple regression to predict assaultiveness scores for each ward and each victim category. RESULTS: The findings indicated high rates of assaultive patients and assaults on fellow patients. Multiple regression results produced different predictors of assaultiveness for different wards but not for different categories of assault victim within each ward. Overall, age and sex consistently failed to predict assaultiveness, whereas greater assaultiveness was significantly associated with a greater proportion of time hospitalized since first admission. The most powerful unique predictors of assaultiveness scores were diagnostic distinctions derived from data on coexistent diagnoses. The most assaults were by acute patients whose diagnoses excluded organic mental disorder but included either bipolar disorder or personality disorder and longer-stay patients whose exclusive diagnosis was organic mental disorder. CONCLUSIONS: This identification, albeit modest, of risk factors for assaultiveness on different wards nevertheless provides information fundamental to the management policies of psychiatric institutions. The findings caution against aggregating different ward populations for research on assaultiveness and endorse the usefulness of coexistent diagnoses for predicting assaultiveness.

Bipolar Disorder↗
PubMed1998

Management of threats of violence under California's duty-to-protect statute.

OBJECTIVE: This is the first study to assess clinical practices under one of the new duty-to-protect statutes, some version of which has been passed in many states. In 1985, California enacted a statute enabling psychotherapists to limit their liability when a patient makes a serious threat of violence by 1) making reasonable efforts to warn the victim of the threat and 2) notifying local police. METHOD: The authors examined all duty-to-protect notifications over a 5-year period in San Francisco by reviewing police and court records. RESULTS: Police received only 337 notifications, typically made by nondoctoral staff members at public facilities such as psychiatric hospitals and crisis clinics. Patients most commonly directed their threats toward family members. Of the patients who made threats resulting in notifications, 51% had prior arrest records, and 14% had subsequent arrests. Only 52% of the patients who made threats were civilly committed. CONCLUSIONS: The findings suggest that 1) clinicians rarely discharge the duty to protect in the manner specified by the law, 2) many patients whose threats result in notifications have extensive involvement with the criminal justice system, and 3) family intervention may have clinical relevance in many duty-to-protect situations.

Adolescent↗
PubMed2006

Patient casemix classification for medicare psychiatric prospective payment.

OBJECTIVE: For a proposed Medicare prospective payment system for inpatient psychiatric facility treatment, the authors developed a casemix classification to capture differences in patients' real daily resource use. METHOD: Primary data on patient characteristics and daily time spent in various activities were collected in a survey of 696 patients from 40 inpatient psychiatric facilities. Survey data were combined with Medicare claims data to estimate intensity-adjusted daily cost. Classification and Regression Trees (CART) analysis of average daily routine and ancillary costs yielded several hierarchical classification groupings. Regression analysis was used to control for facility and day-of-stay effects in order to compare hierarchical models with models based on the recently proposed payment system of the Centers for Medicare & Medicaid Services. RESULTS: CART analysis identified a small set of patient characteristics strongly associated with higher daily costs, including age, psychiatric diagnosis, deficits in daily living activities, and detox or ECT use. A parsimonious, 16-group, fully interactive model that used five major DSM-IV categories and stratified by age, illness severity, deficits in daily living activities, dangerousness, and use of ECT explained 40% (out of a possible 76%) of daily cost variation not attributable to idiosyncratic daily changes within patients. A noninteractive model based on diagnosis-related groups, age, and medical comorbidity had explanatory power of only 32%. CONCLUSIONS: A regression model with 16 casemix groups restricted to using "appropriate" payment variables (i.e., those with clinical face validity and low administrative burden that are easily validated and provide proper care incentives) produced more efficient and equitable payments than did a noninteractive system based on diagnosis-related groups.

Activities of Daily Living↗
PubMed2006

Firearm laws, patients, and the roles of psychiatrists.

OBJECTIVE: Persons with mental illness and/or substance abuse are frequently perceived by the public to be dangerous. This has resulted in an increase in state legislation restricting their ability to purchase, possess, register, obtain licensure, retain, and/or carry a firearm of any sort. The purpose of this article is to educate clinicians about the impact of firearms statutes and restrictions for their patients. Many state statutes mandate that treating psychiatrists report such gun possession to state justice or police departments. Psychiatrists may also have a statutory role in an appeals process. METHOD: The firearms statutes of the 50 states, the District of Columbia, and Puerto Rico and the Federal National Firearms Act were surveyed, with particular attention paid to the ability of persons with mental illness and/or alcohol or substance abuse to obtain firearms. The results were tabulated. RESULTS: These statutes are not uniform. They vary in their definition of mental illness, the type and duration of gun restriction, reporting practices, the confidentiality of medical information, and the immunity of clinician reporters and appeals processes. CONCLUSION: Clinicians would be wise to familiarize themselves with the provisions of the relevant statutes in their particular states. This will allow them to identify the consequences to their firearm-possessing patients, understand their own roles and obligations -- if any -- and better consider potential clinical and ethical issues for particular patients.

Dangerous Behavior↗
PubMed2002

A hazardous profession: war, journalists, and psychopathology.

OBJECTIVE: War journalists often confront situations of extreme danger in their work. Despite this, information on their psychological well-being is lacking. METHOD: The authors used self-report questionnaires to assess 140 war journalists, who recorded symptoms of posttraumatic stress disorder (PTSD) (with the Impact of Event Scale-Revised), depression (with the Beck Depression Inventory-II), and psychological distress (with the 28-item General Health Questionnaire). To control for stresses generic to all journalism, the authors used the same instruments to assess 107 journalists who had never covered war. A second phase of the study involved interviews with one in five journalists from both groups, using the Structured Clinical Interview for Axis I DSM-IV Disorders. RESULTS: The rates of response to the self-report questionnaires were approximately 80% for both groups. There were no demographic differences between groups. Both male and female war journalists had significantly higher weekly alcohol consumption. The war journalists had higher scores on the Impact of Event Scale and the Beck Depression Inventory. Their lifetime prevalence of PTSD was 28.6%, and the rates were 21.4% for major depression and 14.3% for substance abuse. War journalists were not, however, more likely to receive treatment for these disorders. CONCLUSIONS: War journalists have significantly more psychiatric difficulties than journalists who do not report on war. In particular, the lifetime prevalence of PTSD is similar to rates reported for combat veterans, while the rate of major depression exceeds that of the general population. These results, which need replicating, should alert news organizations that significant psychological distress may occur in many war journalists and often goes untreated.

Adult↗
PubMed2001

Clinical factors related to admission and release decisions in psychiatric emergency services.

OBJECTIVE: The purpose of the study was to identify important clinical variables that influence admission and release decisions in psychiatric emergency services. METHODS: Physicians at four urban psychiatric emergency services rated 465 patients on ten clinical dimensions, including depression and psychosis. Information on five other variables-age, gender, ethnicity, diagnosis, and previous inpatient admission-were extracted from the patients' charts, as was information on case disposition. RESULTS: Logistic regression produced a model with five variables that significantly predicted admission or release. In order of importance, they were level of danger to self, severity of psychosis, ability to care for self, impulse control, and severity of depression. The model explained 51 percent of the variance in case disposition and correctly classified 84 percent of the cases. CONCLUSIONS: Guidelines addressing the variables that should be considered in making disposition decisions in psychiatric emergency services should be developed. The study found five variables that should be considered for inclusion.

Adult↗