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PubMed1991

New York State's system of managing insanity acquittees in the community.

New York State's Insanity Defense Reform Act of 1980 outlined specific procedures for conditional release to the community of persons found not guilty of a criminal offense by reason of insanity. To assess how well the procedures were working, the authors examined data on all clients placed on conditional release in the state between 1980 and 1987. The majority of the 331 clients so identified had been found to be dangerously mentally ill and were subsequently released to the community after extensive periods of involuntary inpatient treatment. The most common condition for community release was participation in a treatment program. While in the community, 22 percent of the clients were arrested, and 5 percent had their conditional releases revoked and were recommitted. The authors compare the New York program with similar programs elsewhere. They believe the key features of a successful program include centralized responsibility, a uniform system of treatment and supervision, and a network of community services.

Adult↗
PubMed1992

A mobile crisis program: collaboration between emergency psychiatric services and police.

An emergency psychiatry-mobile crisis program was established in 1987 in Charleston, South Carolina, linking professionals from the mental health center, the university, and the local police department. The program has two goals: to provide emergency psychiatric services to persons in the community and to train psychiatric residents in crisis intervention. Mental health staff act as consultants to the police in some situations, and in others the police provide security. The authors describe the development of the collaboration with police and important features of the program. Three cases illustrate how such collaboration can be of mutual benefit and can save lives.

Adult↗
PubMed1993

Initial evaluation of reorganized hospitalization services in a community mental health center.

OBJECTIVE: Two locked inpatient units at an inner-city community mental health center were reorganized as a hospitalization service consisting of a 22-bed intensive care inpatient unit, an acute-treatment day hospital for 20 patients, and a 23-bed transitional residence program. Levels of functioning of hospitalized patients treated before and after the reorganization were compared to determine if the reorganized program as a whole was more effective clinically than the two inpatient units had been. METHODS: The authors retrospectively compared levels of functioning at discharge of random samples of 10 percent of patients treated in the ten months before the reorganization (N = 66) and 10 percent of the intensive care and day hospital patients treated in the same ten calendar months afterward (N = 78). They also compared data on episodes of seclusion and restraint and on patient flow in the two time periods. RESULTS: The mean functional level of intensive care and day hospital patients treated in the reorganized service was significantly higher than the level of inpatients treated before. The mean duration of episodes of seclusion, but not of restraint, decreased significantly. Total service admissions and readmissions increased from 493 to 603. CONCLUSIONS: The reorganized service encouraged patients to function at higher levels. However, such a program must be affiliated with a diversified and well-functioning outpatient service that can divert some potential inpatients to appropriate alternative treatments and help move patients out of the day hospital-residential program when they are stabilized.

Activities of Daily Living↗
PubMed1994

The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence.

OBJECTIVE: Previous research on violence and mental disorder has typically focused on the relationship between diagnosis and risk of violence or between symptoms within a particular diagnostic category and risk of violence. The authors' goal was to evaluate whether the pattern of symptoms associated with short-term risk of violence varies depending on patients' diagnoses. METHODS: Subjects were 330 patients with a variety of diagnoses who were hospitalized on a university-based, locked psychiatric inpatient unit. At hospital admission, physicians rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated whether patients became violent during hospitalization by completing the Overt Aggression Scale at the end of each shift. RESULTS: Assaultive patients had different symptom patterns than nonassaultive patients. Symptoms patterns varied significantly across diagnostic groups, and the symptom patterns associated with violence also varied significantly across diagnostic groups. Higher levels of hostile-suspiciousness, agitation-excitement, and thinking disturbance were generally associated with violence, although these symptoms were less predictive of assaultiveness among schizophrenic patients than among patients in other diagnostic groups. CONCLUSIONS: Symptom profiles represent a useful level of analysis for understanding the relationship between violence and psychopathology. However, the value of particular symptom profiles as indicators of imminent violence varies with diagnosis.

Acute Disease↗
PubMed1994

Enforcing the Fair Housing Amendments Act to benefit people with mental disability.

Housing is integral to successful community care for many people with mental disabilities. To try to eliminate discrimination in access to housing for people with physical or mental disability and to support their right to live in the community of their choice, Congress enacted the Fair Housing Amendments Act of 1988. The author examines representative court cases that have applied the act to restrictions related to people with mental disabilities; they include cases testing restrictions applicable only to mentally disabled people, restrictive covenants, failure to make "reasonable accommodation," state and municipal laws that predate the 1988 act, and exclusion because of dangerousness to others. To date, the courts have been receptive to the use of the act in challenging laws and practices that create barriers for people with mental disability.

Community Mental Health Services↗
PubMed1994

Psychiatric and social reasons for frequent rehospitalization.

OBJECTIVE: The authors attempted to identify factors that commonly contributed to the decision to rehospitalize patients who made heavy use of mental health services. METHODS: The case notes of 50 patients with frequent readmissions to the South Australian Mental Health Services over a three-year period were examined to identify which of 15 factors most frequently contributed to hospital readmission. RESULTS: Lack of insight or denial of illness was cited in 62.2 percent of the patients' 442 total admissions, followed by relationship problems (61.1 percent), suicidal ideation (44.8 percent), and noncompliance with medication (43.2 percent). When the 15 factors were combined into four major categories, social factors were found to contribute to 38.9 percent of admissions, followed by factors related to psychiatric and physical illness (31.1 percent), dangerousness to self or others (20.3 percent), and substance abuse (9.7 percent). CONCLUSIONS: The substantial contribution of social factors to the readmission of patients to acute mental health services is strong evidence that the mental health system must provide appropriate targeted resources and assertive, continuous case management to avoid social crises. Issues surrounding drug and alcohol abuse among heavy users of services must be actively addressed.

Adult↗
PubMed1994

Involuntary community treatment of people who are violent and mentally ill: a legal analysis.

Three major legal mechanisms exist for providing involuntary community treatment to people who are violent and mentally disabled: outpatient commitment, preventive commitment, and conditional release from a hospital. In most states, predicted deterioration is either the explicit or the de facto criterion for involuntary community treatment. However, the constitutionality of this standard has been the subject of considerable debate, centering on whether involuntary treatment in the community requires a showing of imminent dangerousness and an overt act of dangerousness and whether a person who is not dangerous solely because of treatment may be committed. The author suggests that the predicted deterioration standard is constitutional, but only if it is accompanied by limitations on the duration of commitment and proof that involuntary treatment is necessary to prevent danger to self or others. The author also discusses whether a person committed under the predicted deterioration standard has the right to refuse treatment and whether persons hospitalized after being committed to involuntary community treatment should receive a hearing.

Commitment of Persons with Psychiatric Disorders↗
PubMed1995

Who will pay for involuntary civil commitment under capitated managed care? An emerging dilemma.

Involuntary civil commitment in managed care settings may create conflicts between providers and payers. Providers may determine that a patient, particularly one who presents a risk to self or others, must be confined beyond the period reimbursed by the payer. Court decisions have upheld clinicians' ethical obligations to provide care in these situations. In addition, civil commitment may be used to shift costs of long-term care to another provider. The author explores these issues and suggests six strategies that providers can use to address them. They include avoiding negotiations with payers over individual patients' care by ensuring that contracts with payers address civil commitment and patients at risk of harming themselves or others, identifying and creating services and social supports to reduce the necessity for commitment and allowing creative use of benefits, adopting formal risk assessment protocols to standardize the process for all patients and and clinicians, conducting research on the use of civil commitment and coercion in managed care settings, ensuring that incentives do not exist in states' Medicaid managed care programs to use civil commitment to shift costs, and holding discussions with treatment staff about the growing encroachment of financial considerations into treatment decisions.

Adult↗
PubMed1995

Factors associated with admission to public and private hospitals from a psychiatric emergency screening site.

OBJECTIVE: The study examined factors associated with admission to public and private hospitals from a mental health care emergency screening system operating under a longstanding mandate to maximize use of private inpatient treatment. METHODS: For 206 patients evaluated at the mental health emergency screening site over a two-and-a-half-month period, data were collected on demographic and clinical characteristics, admission history, services received during the emergency encounter, system variables such as time the patient spent at the emergency screening site, number of admission sites asked to accept the patient, and all reasons cited by providers for refusing to admit the patient. Logistic regression was used to develop a model of factors most likely and least likely to be associated with private hospitalization. RESULTS: Overall, 60 percent of the sample was refused admission by one or more providers, and 55 percent, who were not accepted by and private hospital, became public patients. Private hospital admission was associated with patient or family involvement in referral and disposition, private or Medicaid insurance, a presenting problem of depression or suicidality, and longer time spent at the emergency screening site. Public admission was associated with no insurance, a past history of major public hospitalization, current or past history of assaultiveness, a presenting problem of aggression, and lack of any discharge site. CONCLUSIONS: Private providers are reluctant to admit patients who have characteristics associated with public hospitalization. In the restructuring of health care, a more fully privatized system will likely be called on to absorb such patients. Their care, treatment, and impact on the system should be carefully monitored and evaluated.

Adult↗