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Objective: The authors' goal was to compare distribution of diagnoses, length of stay, and readmission rates for every 16th patient admitted to the St. Louis County Insane Asylum (now St. Louis State Hospital) between 1886 and 1904 with those for every 16th patient admitted to the hospital between 1978 and 1980., Methods: A sample of 369 cases was drawn from the archival admission records, and 380 cases were selected from recent admissions. Descriptive data from the archival records were used to make DSM-III diagnoses. Data on length of stay and number of readmissions were collected from case records., Results: The historical sample had fewer cases of major mental illness, longer mean lengths of stay, and fewer mean readmissions than the modern sample., Conclusions: Differences in the clinical characteristics of the two samples may be explained by differences between the two periods in treatment philosophies, admitting policies, and presence of alternative resources for accommodating long-term chronic patients.

Objective: The goals of the study were to examine the composition, operation, and purpose of ethics committees in state mental hospitals, to determine whether committees were accessible to patients and family members, and to identify frequently addressed ethical issues., Methods: In June 1992 a 41-item survey questionnaire was mailed to chief executive officers of 204 state-operated general psychiatric inpatient facilities. Survey items asked about the facility's attributes, composition of the ethics committee, how the committee functioned, and the issues it addressed., Results: A total of 145 facilities from 46 states responded to the survey, for a response rate of 71 percent. Nearly half the facilities had ethics committees, most of which were recently established. Physicians accounted for the plurality of committee membership, followed by nurses and administrators. Although several facilities gave patients access to committee meetings, few patients or their family members actually attended these meetings. Issues such as patients' danger to others, resuscitation policies, and scarce resources were frequently addressed by many committees but were never addressed by others., Conclusions: Although many state mental hospitals have established ethics committees in the past few years, these committees may not meet patients' needs because of inadequate representation by patient advocates and family members. Numerous concerns were heard by committees, but no obvious patterns of pressing issues were revealed.

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.

Objective: The authors' aim was to determine whether clozapine was associated with a decrease in state hospital bed-days for patients with chronic schizophrenia., Methods: Patients were started on clozapine in a state facility and were followed while taking the medication for 1.5 years (N = 172), two years (N = 86), and 2.5 years (N = 53). Patients' number of bed-days before starting clozapine was compared with those during the follow-up period., Results: Bed-days were reduced by an average of 132 days per year after 1.5 years, 166 days per year after two years, and 201 days per year after 2.5 years (p < .001). During the final 180 days of each follow-up period, only 23 to 30 percent of patients were continuously hospitalized, compared with 56 to 64 percent before clozapine. Forty to 57 percent of patients had no hospital days at all during the last 180 days of follow-up., Conclusions: Based on hospital costs of $250 per patient per day, this reduction in bed-days could result in gross savings of about $33,000 per patient per year at 1.5 years, $41,500 per patient per year at two years, and $50,250 per patient per year at 2.5 years. Hospital patients are conspicuous targets for clozapine funding, since bed-days represent an easily measured expense. Nevertheless, community treatment should be an even higher priority, since most chronic mentally ill persons are outpatients.

The number of state hospital beds nationwide has been reduced to 40 per 100,000 population; in California, nonforensic state hospital beds have decreased to 8.3 per 100,000. The main effects of this reduction are becoming more evident. Most seriously affected have been the new generation of chronically and severely mentally ill persons who have reached adulthood since deinstitutionalization. Those who need intermediate or long-term hospitalization and cannot receive it may become even more desperate and psychotic; may avoid treatment entirely; and may turn to drug abuse and become homeless or incarcerated in jail. Moreover, the small number of long-stay beds can lead to a breakdown in the public mental health system and attempts to avoid responsibility for persons who need both acute and long-term hospitalization. This avoidance can be manifested by raising admission criteria for acute treatment or shifting responsibility to other systems. The authors recommend providing intermediate and long-stay hospitalization to the extent needed.

Objective: High doses of neuroleptic medication are still administered to many patients, although many studies have shown the effectiveness of low-dose strategies. The purposes of the study were to determine whether and in what ways high-dose patients differed from patients on regular dosages and whether the higher dosages were more effective., Methods: In a case-control study at two large state hospitals, 38 high-dose patients were compared with 29 regular-dose patients., Results: The high-dose patients had a persistent course of illness, with severe chronic symptoms resulting in hospitalizations of much longer duration than those of the regular-dose patients. The high-dose patients evidenced more regressed functioning and were more violent. To control these behaviors, clinicians increased neuroleptic dosages., Conclusions: The high-dose patients represented a subgroup of chronic regressed and violent patients. Clinicians prescribed high dosages and continued to use them despite a lack of clear evidence that such treatment is effective.

Objective: To help predict changes in patterns of service delivery, the total number of inpatient admissions to specialty mental health organizations and the number of elderly persons (over age 65) admitted were projected in five-year intervals between 1990 and 2010., Methods: One set of projections is based on 1986 rates of use and their coefficients of variation. A second, more accurate, set is based on 1990 rates derived from logarithmic projections of trends from 1980 to 1986 and the coefficients of variation for the 1986 rates., Results: Projections based on 1990 rates show an increase of more than 25 percent in the total number of inpatient admissions to all specialty mental health organizations between 1986 and 2010 and an increase of more than 40 percent in elderly admissions. Nonfederal general hospitals are expected to have the largest increases in the number of total admissions, and state and county mental hospitals the smallest. The greatest percentage growth in total admissions will occur in private psychiatric hospitals. For elderly persons, inpatient admissions to Veterans Affairs medical centers will show the largest percentage increase, and admissions to state and county mental hospitals the smallest. By 2010 the majority of elderly admissions (67.6 percent) will be to nonfederal general hospitals., Conclusions: Plans to cope with increased demand for inpatient services should take into account the potential economic consequences of the forecasted changes as well as their effects on allocation of and access to services.

Objective: Patients who visited a psychiatric emergency service were studied to determine whether repeat visitors, who consume a disproportionate share of services, could be identified by demographic and diagnostic characteristics., Methods: Data were obtained from a semistructured diagnostic interview given to all 16,257 persons who made 29,214 visits to an urban psychiatric emergency service in Pittsburgh, Pennsylvania, from 1985 to 1989. Patients were categorized into four groups based on the number of visits in the five-year period. Patients in group 1 made a single visit, while those in group 2 averaged less than one visit per year; those in group 3 made one or two visits per year, and those in group 4, more than two visits per year., Results: Groups 3 and 4 constituted 5.1 percent of the sample but made 27.1 percent of the total visits. Repeat users were significantly more likely to be male, younger, unmarried, unemployed, and nonwhite and to have diagnoses of schizophrenia, other psychotic disorders, and personality disorders., Conclusions: Repeat users of psychiatric emergency services appear to have demographic and diagnostic characteristics that may permit their early identification. For such patients, implementation of alternative management strategies, such as intensive case management, may reduce their use of services.

Objective: Characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 were studied to examine changes in the demographic profile of the patient population and in principal sources of payment for hospitalization over the study period., Methods: Information on patients' demographic characteristics and principal payment sources was obtained from a nationally representative data base compiled about every five years by the National Institute of Mental Health., Results: Among schizophrenic patients admitted between 1970 and 1986, the proportion of African-American males increased. By 1986 patients were less likely to pay for care through private insurance or their own resources. They were more likely to receive Medicare and to lack medical insurance. Medicare use increased largely among white patients, and medical indigency largely among African-American patients., Conclusions: Changes in the characteristics of schizophrenic patients admitted to state hospitals between 1970 and 1986 may be related to changes in nosology, in the prevalence of schizophrenia, and in the types of patients likely to be admitted to state hospitals. The increase in the number of medically indigent patients accentuates the need for more adequate finding of state hospitals.

Objective: The purpose of the study was to determine the prevalence of personality disorders among a large population of persons seeking treatment in a public psychiatric facility and to examine the role of personality disorders in the clinical conditions of persons frequenting such facilities., Methods: Clinical and demographic data were retrospectively examined for 18,179 adults who visited a walk-in clinic of a public psychiatric facility between 1983 and 1989. Patients who received a diagnosis of personality disorder were compared with those who did not., Results: A total of 2,344 patients (12.9 percent) were diagnosed as having a personality disorder, a lower prevalence rate than generally found in treatment populations. The most frequent diagnoses were atypical, antisocial, and borderline personality disorders. Compared with other subjects, those with a personality disorder were significantly more likely to be men, to be 35 years old or younger, to have a higher level of social impairment, and to have more symptoms and more severe symptoms., Conclusions: The relatively low prevalence rate was attributed in part to underdiagnosis, largely due to the need for making rapid assessments in a public intake setting. The authors conclude that clinicians in such facilities may be likely to diagnose personality disorders when patients with certain axis I disorders such as substance use, affective, and adjustment disorders present with an overall greater level of symptomatology and social impairment.

Treatments applicable to the frequently rehospitalized psychiatric patient--the so-called revolving-door patient--have been poorly delineated. One subgroup of these patients includes those for whom recidivism has become a way of life; they may be said to suffer from "hospitalphilia." Neither refractoriness to treatment nor noncompliance with medications explains their frequent admissions. The author presents ten clinical principles to guide treatment planning for this subgroup of patients. The principles emphasize cooperation between the patient and the treatment agencies in creating a comprehensive, consistent, and enforceable plan to reduce unnecessary hospitalizations. Four treatment strategies based on the principles are outlined: unlimited access to hospitalization, a chit or voucher system, a rationing system, and an approach centered on the patient's expressed ability to avoid hospitalization.

A total of 196 nonspecialty state hospitals in the U.S. each identified one patient--referred to as the hospital's "worst" recidivist--admitted to the hospital in 1987 who had the most lifetime admissions to that hospital. Persons admitted for mental retardation or substance abuse detoxification were excluded. The mean age of the recidivists was 42.2 years; their mean age at first admission was 24.7. The number of admissions per patient ranged from five to 121, with a mean of 31. Compared with the national population of state hospital admissions, significantly larger proportions of recidivists had diagnoses of schizophrenia, bipolar disorder, and personality disorder. More research is needed to determine actual community tenure of patients who receive revolving-door care and whether alternative approaches would be more effective.

Fifty-three long-stay patients on the back wards of a large psychiatric hospital in London were assessed to determine their suitability for other placements after the hospital was closed. The general and deviant behavior subscales of the REHAB Scale were used in the assessment. A wide range of scores indicated that these patients varied greatly in basic living skills. Associations were investigated between patients' scores and somatic problems, fluctuations in mental state, and adverse reactions to change, which affect patients' ability to live in the community. Of 14 patients whose scores indicated a potential for discharge, two had significant deviant behaviors, seven had fluctuating mental states, and two were known to react adversely to change. Although the REHAB Scale is useful, results show that placement decisions should not be based on scores alone. Flexible services that take into account fluctuations in patients' functioning are required.

The relationship between patient-staff ratio and the prevalence of patient incidents, such as assaults, fighting, suicides, falls, and abuse of patients by staff, was examined at an urban inpatient psychiatric center. Stepwise logistic regression was used to analyze 5,375 shifts in 14 high-incident wards representing five types of inpatient services; sample periods from three different years were examined. At least one incident occurred during 411 shifts (7.6 percent). More incidents occurred on the day shift and on two specific wards, confirming previous findings of a relationship between incidents and time of day as well as patient characteristics and milieu. However, no relationship between patient-staff ratio and the occurrence of incidents was found. This finding suggests that small increases in the number of ward staff may not reduce the number of patient incidents.

In Maryland a six-month fiscal incentive to promote nursing homes' acceptance of chronic patients discharged from state psychiatric hospitals was evaluated after one year. During the fiscal year of the incentive program, such placements (N = 182) increased an average of 38 percent from previous years. Of 163 patients whose placements were evaluated, 22 were returned to the state hospital during the six-month period that the incentive was in place. Ten of the 22 were returned within 30 days of placement. Contrary to expectation, the return rate did not rise after the incentive was discontinued; four patients were returned during the second six months of the study period. Most returns during the first six months were due to patients' physical and verbal threats. The results supported the use of short-term fiscal incentives and emphasized the importance of intensive supportive interventions with chronic mentally ill patients early in the nursing home placement.

Eighty-eight of 143 hospitals in New York State providing psychiatric inpatient treatment responded to a mailed questionnaire designed to determine the size of three subgroups of chemical abusers--alcohol abusers, drug abusers, and polychemical abusers--among inpatients with psychiatric diagnoses, as well as the availability of services for these patients. Data for New York City and its metropolitan area were analyzed separately. In 1987 almost one-third of psychiatric admissions both in and outside the metropolitan area had comorbid chemical abuse disorders. Seventy-five percent of patients in the metropolitan area with comorbid chemical abuse had a drug abuse disorder; in rural areas 88 percent of patients with chemical abuse disorders abused alcohol. Both hospital- and community-based aftercare services, especially in the metropolitan area, were less available to psychiatric patients with chemical abuse than to patients without these disorders.

Demographic and diagnostic intake data on about 10,000 patients at a public psychiatric facility were used to assess whether information recorded on various DSM-III axes could predict the frequency of patients' psychiatric hospitalizations over a follow-up period. Compared with patients who had been hospitalized only once or not at all, patients with three or more hospitalizations during the study period were more likely to be single and black and to come from lower social classes. They were more likely to have an axis I diagnosis of an alcohol-related disorder, a substance use disorder, or a psychotic disorder. When samples from the patient groups were matched on key demographic variables and primary axis I diagnosis, the multiaxial resources of DSM-III were not helpful in predicting future use of hospitalization. The results reinforce the importance of axis I diagnosis and demographic characteristics in assessing course and prognosis.

Several factors increase the psychiatric inpatient's risk of falling, including side effects of medications and mental disorders that decrease awareness of environmental hazards. In this study, rates of falling were determined for a cohort of 4,156 psychiatric inpatients over 34 months. A total of 494 falls occurred among 376 patients. Thirty-five percent of the patients who fell required medical or nursing intervention. Forty-eight percent of the falls occurred in the over-60 age group. When other results were adjusted for age, neither gender nor diagnosis was found to increase the risk of falling, except for depressed patients under 20 years old, who were at less risk, and psychotic patients in their 60s, who were at greater risk. The authors discuss the costs of falls and preventive efforts instituted in their setting.

Characteristics of adolescents discharged from a psychiatric residential treatment center were examined to create a model for predicting patient discharge against medical advice (AMA). Subjects were 81 adolescents in two consecutive cohorts discharged between 1983 and mid-1988 (N = 49 and N = 32). In both groups 41 percent of the discharges were AMA. Logistic regression analysis found that an equation based on three factors--history of juvenile court involvement, unsupportive family attitude toward treatment, and diagnosis of conduct disorder--was 69 percent accurate in predicting discharge status in group 1 and 81 percent accurate in predicting discharge status in group 2. A positive correlation between rates of staff turnover and AMA discharge was noted.

The literature on violence by psychiatric inpatients provides some evidence that rates of violence may be increasing over time and that they are higher in the United States than in other nations. This review examines the extent of inpatient violence and describes the individual, situational, and structural factors with which it is associated. Individual factors include acute illness, psychosis, drug abuse, age, and history of violence. Situational variables include overcrowding, provocation, staff inexperience, and management tolerance of violence. Structural factors include changes in mental health policy that have made dangerousness a frequent criterion for commitment and a shortage of treatment resources. The author concludes that violence is the result of an interaction between the various types of factors and is not simply an expression of individual pathology.

Notwithstanding the large-scale deinstitutionalization of the elderly, psychogeriatric patients continue to make up a significant portion of patients in U.S. state hospitals. This paper reports pilot data from a national survey assessing the current status of geriatric populations in state hospitals. Elderly patients still account for one-fifth of state hospital patients, and two-thirds of state hospitals still have separate geriatric units. The data suggest that, while deinstitutionalization of the elderly may be continuing in many state hospitals, in more than one-third of state hospitals the geriatric census is on the rise. Tentative hypotheses suggesting further research are discussed.

Methodological and practical difficulties have limited the growth of knowledge about outcome of psychiatric hospital treatment. The authors report on outcome at hospital discharge for 103 long-term and 93 short-term patients treated at the C. F. Menninger Memorial Hospital, part of an ongoing follow-up study of hospital treatment. Discharge outcome is based mainly on ratings of symptoms, global functioning, and therapeutic alliance as well as on patients' reports of satisfaction. At discharge both long- and short-term patients were found to have low levels of symptoms (based on the Brief Psychiatric Rating Scale) and a relatively adequate level of functioning (in the 51-to-60 range on the Global Assessment Scale) and to have been highly satisfied with treatment.

Assessments at hospital admission of patients' potential for violence often rely on limited information, such as the patient's mental status, because detailed clinical and historical information may not be readily available. This study examined the relationship between symptoms at admission as measured by the Brief Psychiatric Rating Scale and later violence of 127 psychiatric inpatients. Patients who showed higher levels of thinking disturbance, hostile-suspiciousness, and agitation-excitement at the time of admission were at greater risk of becoming assaultive during the hospitalization. The findings suggest the usefulness of specific symptom profiles for identifying acute psychiatric patients at risk for violence.

In early 1988 a discharge assessment team surveyed the records of 421 extended-care patients at Washington's Western State Hospital to facilitate planning for patients who were able to move out of the hospital. The group as a whole manifested serious problem behaviors, both current and past. Less than 40 percent of the patients needed continued state hospital care, but most who could be discharged to the community would require intensive residential supervision and support. The authors review linkages between two kinds of residential treatment programming that exists for this population, a network of community residential treatment facilities operated by private providers and community mental health centers and a hospital-based transitional program called the Program for Adaptive Living Skills. Linkages between these programs have proved useful in the residential placement of extended-care patients.

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.

The economic and political forces of the 1980s will have a profound effect on state hospitals. The total number of these facilities is likely to decline, although their utilization will probably remain high. Their staffing will most likely remain low and their total budgets relatively stable. The extent of judicial advocacy that characterized the role of the courts in the last decade will be somewhat diminished in the 1980s. Most state hospitals will be forced by the insufficiency of community alternatives to provide primary and secondary care as well as tertiary care to be catchment areas they serve.