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Objective: This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital., Method: The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures., Results: During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized., Conclusions: This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.

Objective: The purpose of this study was to examine rehospitalization rates of people receiving risperidone or clozapine who had been discharged from state psychiatric hospitals in Maryland., Method: Rehospitalization status was monitored for all patients discharged from state psychiatric facilities on a regimen of either risperidone or clozapine between March 14, 1994, and Dec. 31, 1995. Patients were followed up with respect to readmission until Dec. 31, 1996. Time to readmission was measured by the product-limit (Kaplan-Meier) formula. Risk factors associated with rehospitalization were examined., Results: One hundred sixty patients were discharged on risperidone, 75 having the diagnosis of schizophrenia. The patients with schizophrenia were more likely to be readmitted than the 85 patients with other mental disorders. Recidivism rates for schizophrenic patients discharged on risperidone versus those discharged on clozapine were not significantly different over the 24-month study period. However, no patient who received clozapine and remained discharged for more than 10 months (N = 49) was readmitted, while the readmission rate for risperidone-treated patients appeared to be steady up to 24 months. At 24 months 87% of the clozapine-treated patients and 66% of the risperidone-treated patients remained in the community. No clinical or demographic variables were found to predict rehospitalization., Conclusions: This study demonstrates that the rehospitalization rates of patients taking the second-generation antipsychotics risperidone and clozapine are lower than those in previously published reports of conventional antipsychotic treatment.

Objective: The purpose of the study was to gather baseline data on physician caseloads, particularly psychiatric caseloads, at public mental hospitals., Method: A 26-item survey was sent to medical directors of public mental hospitals in the United States and its territories. Questions focused on hospital demographics, programs, and medical staffing. Survey data were analyzed and descriptive statistics were determined., Results: Of 295 surveys mailed, 195 (66%) usable surveys were returned. The hospitals had a mean bed capacity of 347 (SD=301, range=10-1,926), a mean current patient population of 321 (SD=277, range=7-1,815), and 950 mean annual admissions (SD=891, range=3-5,100). Acute care was the most common treatment program (81%), followed by long-term care (71%). A wide range of psychiatric caseloads by type of program existed, with approximately equal mean and median amounts., Conclusions: The caseloads reported were, overall, reasonable and expected by the type of treatment program. The range of caseloads, however, included extremely high outliers that raise concerns about the quality of care delivered.

Objective: Professional skepticism and concerns regarding diagnostic reliability hinder research in dissociative disorders and multiple personality disorder. The reported frequency of multiple personality disorder in different psychiatric settings ranges from 2.4% to 35%. The authors conducted a replication study of multiple personality disorder ascertainment in women admitted to a state hospital over a 5.5-month period., Method: Responses to the Dissociative Experiences Scale and to the Dissociative Disorders Interview Schedule were obtained, along with data on length of stay, county of admission referral, admission commitment status, and discharge diagnoses, for 176 female inpatients in a state hospital. Of 421 women representing 483 consecutive admissions, 121 were discharged before they could be assessed for study, 64 were excluded, 60 declined to participate, 176 enrolled in the study, and 175 completed the research procedures., Results: Twenty-one women (12%) met criteria for multiple personality disorder based on the Dissociative Disorders Interview Schedule; these women were significantly younger than the women without multiple personality disorder. Scores on the Dissociative Experiences Scale of the women with multiple personality disorder (mean = 59.5, SD = 19.6) were significantly higher than the scores of women without multiple personality disorder (mean = 22.5, SD = 20.1), but considerable overlap occurred. There was no significant difference between groups in length of stay or admission status., Conclusions: The authors conclude that 1) the wide variability in multiple personality disorder detection is partially due to site-specific ascertainment biases and 2) despite its apparent usefulness for screening purposes, the Dissociative Experiences Scale requires more comprehensive evaluation before it can be applied broadly.

Objective: A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals., Method: Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations., Results: Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations., Conclusions: Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

Objective: By focusing on the functioning of a state hospital throughout its existence, the author provides a historical perspective on the nature and causes of "revolving door" admissions., Method: Northampton State Hospital was chosen as a prototype, and data on characteristics of patients and patterns of hospital utilization were analyzed from three 10-year periods: 1880-1889, 1930-1939, and 1980-1989. The data for the first two time periods came from the hospital's admission and discharge logbooks and its annual reports; the material for the most recent decade was obtained from unpublished yearly reports generated by the hospital's medical records department., Results: The hospital operated very differently in each of the decades analyzed, but only in the 1980s was recidivism a major finding. This was not, as has often been thought, due to problems or populations unique to the state hospital in the 1980s nor to the fact that in earlier eras the state hospital rarely discharged patients. The once-large asylum has been replaced by a facility rapidly admitting and discharging patients, many of whom have accumulated more than 10 lifetime admissions, in a pattern of care not previously noted., Conclusions: State hospitals have functioned in different yet questionable ways throughout their history. Their current role of providing a revolving-door pattern of care to a considerable population is rooted in a contemporary shift in ideology. This role for state hospitals appears to make no more sense than did their earlier role as neglected and neglectful asylums, and it should be reevaluated.

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.

Objective: The authors examined the propositions that a revolving state hospital door is an inevitable consequence of deinstitutionalization and that enhancing resources for community-based care can limit this phenomenon., Method: They analyzed the recidivism patterns of state hospital patients in a region of Massachusetts where, because of a federal court consent decree, the level of funding for community programs was more than twice as high as it was in other regions in the state and compared the pattern of recidivism in this region with that observed in the other areas of the state., Results: Despite the fact that the average daily state hospital census in the resource-rich region was only half that of the other regions, longitudinal data on hospital use showed that the readmission patterns were similar in all state regions., Conclusions: The authors suggest that attributes of serious and persistent mental illness may have more effect on hospital readmission patterns than service system variables.

During 1979-1989, the long-stay population in Massachusetts state psychiatric hospitals declined and then moderately increased, although to far below its initial 1979 level. The increase toward the end of the period was due to a growing number of patients admitted, an increase in the proportion of these new patients who were retained for 1 year or longer, and a decrease in discharges of long-stay patients, especially those hospitalized for 20 or more years. The last factor was particularly important and was due to the fact that the number of these very-long-stay patients had become so small by 1983 that the effect of their continued discharge on the total long-stay population was minimal. The authors point out that more community services, not more hospital beds, may be needed. They recommend that states assess the clinical needs of the long-stay population before determining how to allocate their resources to address this phenomenon.

On the basis of the principle that patients have the right to be treated in the least restrictive setting appropriate to their needs, all 368 patients at Northampton State Hospital (Massachusetts) were discharged over a 10-year period. Three-quarters were discharged to community settings. Half of the patients were never rehospitalized, but many others continued to display patterns of recidivism. On the assumption that socially dysfunctional behavior would improve after discharge, the funded community system emphasized assessments, residential placements, and crisis intervention and deemphasized treatment. The findings raise many questions about the efficacy and wisdom of attempting to serve an entire state hospital population in the community.

A 1978 consent decree affecting one region of Massachusetts mandated a drastic reduction of census at its state hospital, where considerable deinstitutionalization had already occurred over the prior two decades. The transfer of patients from hospital to community was to be accomplished through the unprecedented expansion of community resources. This second-generation deinstitutionalization effort achieved substantial census reduction but less than was envisioned. It was most effective in discharging geriatric and mentally retarded patients but far less effective with longterm and new chronic patients, many of whom continue to require repeated hospitalizations despite the availability of a comprehensive array of community-based services.

The arrest rates of nearly 2,000 psychiatric patients released from psychiatric centers in 1968 and those of nearly 2,000 patients released in 1975 were compared with the arrest rates of a group of 5,000 patients studied 25 years earlier. In general, arrest rates among the two recent samples were considerably higher than general population rates, primarily because of the large proportion of patients previously arrested. Other characteristics related to subsequent arrest were age and admitting diagnosis. One additional finding was that the number of patients with prior arrests had increased markedly over the years.

In 1979, the state of Washington broadened its criteria governing the involuntary commitment of the mentally ill. This study examined the impact of the revised law on involuntary and voluntary admissions and on the type of patient admitted to state hospitals in Washington. The short-term effect of the law was an abrupt increase in involuntary commitments, with a concomitant but not offsetting decline in voluntary admissions. Although the law resulted in a substantial change in admissions policy, it does not appear to have altered the type of patient admitted to state mental hospitals in Washington.

The Lanterman-Petris-Short Act in California has been acclaimed for protecting the civil rights of the mentally ill and curbing unnecessary involuntary psychiatric hospitalization. Its passage, however, has not prevented an increase in the rate of involuntary admissions to state hospitals and a marked decrease in the rate of voluntary admissions. This has greatly changed the functions and problems of state hospitals. In local as well as state hospitals large numbers of people continue to become involuntary psychiatric patients. In many cases this results from gaps between the law and its implementation. It appears that professionals, the courts, families, and society generally feel a continuing need for social control of the mentally ill.

In 10 of the 13 cases the author examined, after passage of a state statute affecting involuntary admission to state psychiatric hospitals the percentage of involuntary admissions changed significantly in the direction intended by the legislature. The findings support the hypothesis that state laws significantly influence involuntary admission rates and, consequently, clinical practice. The findings also demonstrate that legislative intent in the late 1960s and early 1970s supported restriction of involuntary hospitalization and that a move toward liberalization of its use occurred in the late 1970s. The author recommends greater involvement by psychiatrists in the formulation of legislation that has an influence on their clinical work.

Filed against the state of Massachusetts in 1977, Brewster v Dukakis involved the claim that psychiatric patients living in state hospitals or at risk of being hospitalized in these facilities have a right to treatment in community settings. The decree that emanated from the suit resulted over a 5-year period in a tenfold increase in state expenditures for community mental health services, a 48% decline in the state hospital census, and a 15% drop in the state hospital admission rate in the region of the state targeted by the suit. Factors that facilitated this outcome are described, as well as the dangers and limitations of exclusive reliance on the judicial process to promote the development of community services.

This report identifies and quantifies the multiple manifest and latent functions of the state mental hospital, using data collected by the National Institute of Mental Health. The data reveal a complex institution providing over 500,000 episodes of care for acute and chronic, voluntarily and involuntarily admitted inpatients and 300,000 episodes of care for the most seriously disturbed and disadvantaged outpatients. In addition, state hospitals employ over 200,000 individuals and train over 3,300 professionals each year. The diversity and significance of these functions, as well as the failure of other institutions to supplant them, account for the endurance of the state mental hospital.

Of the 270 patients who had been hospitalized at least 1 year in Maryland public psychiatric facilities in 1976, 15% remained 7 years later. The authors' data provide evidence that a new long-term population is not accumulating in Maryland.

The authors examine the development and characteristics of a "new" long-term population in the public mental health system in Maryland. The findings do not substantiate concern over a large increase in the number of chronic patients in state hospitals in the next several years.

During the past decade and a half, readmissions increased substantially as a proportion of all admissions to state mental hospitals, and the absolute number of readmissions appeared to rise. These trends were interpreted widely, but incorrectly, as reflecting an accelerated rate of return to the hospitals by discharge patients. Most of the rise in the readmission percentage in New York State mental health facilities was due to a drop in first admissions, and the apparent increase in the number of readmissions was entirely accounted for by several statistical artifacts. There was no appreciable increase in the rate of patients' rehospitalization within given periods of time after their release.

The authors investigated the factors relating to the observation that in a large state hospital, there is an age-related increase in the ratio of patients with a DSM-II diagnosis of paranoid schizophrenia to those with a diagnosis of nonparanoid schizophrenia. Elderly inpatients (N = 1,518) treated over a 5-year period were studied and the hypotheses of proportionately greater numbers with late onset of paranoid conditions, longer lengths of stay for recently admitted paranoid patients, and changing diagnosis over time were tested and rejected. The data suggest that the buildup among the elderly of those diagnosed under DSM-II to have paranoid conditions is due to patients admitted well before age 54. The authors discuss the reasons for the poor prognosis of this group.

The authors report data on the social and clinical characteristics of patients who received ECT in public or private psychiatric facilities in New York State during 1972 and 1977. The findings indicate that the predominant use of ECT is in the private psychiatric sector and that, in both private and public facilities, it is administered primarily to white, middle-aged women with depressive conditions.