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Objective: This study aimed to explore the transmission of COVID-19 in a U.S. state psychiatric hospital setting., Methods: Symptomatic and asymptomatic patients were tested throughout a large psychiatric hospital to determine penetrance. The hospital followed initial Centers for Disease Control and Prevention (CDC) guidelines., Results: Seventy-eight percent (N=51 of 65) of tested patients in the building where the first positive patient was housed (building zero) tested positive for COVID-19. Eighty-eight percent (N=14 of 16) of tested asymptomatic patients in building zero were positive, compared with 12% (N=6 of 51) of randomly selected asymptomatic patients in a sample from the rest of the hospital., Conclusions: A high percentage of patients can become positive for COVID-19 despite following initial CDC guidelines. As such, use of masks by all patients in close-quarter settings prior to the first positive case appears warranted. Recent CDC guidelines align with this strategy.

Objective: We investigated clinical and demographic variables to better understand their relationship to hospital length of stay for patients involuntarily committed to California state psychiatric hospitals under the state's incompetent to stand trial (IST) statutes. Additionally, we determined the most important variables in the model that influenced patient length of stay., Methods: We retrospectively studied all patients admitted as IST to California state psychiatric hospitals during the period January 1, 2010 through June 30, 2018 (N = 20 041). Primary diagnosis, total number of violent acts while hospitalized, age at admission, treating hospital, level of functioning at admission, ethnicity, sex, and having had a previous state hospital admission were evaluated using a parametric survival model., Results: The analysis showed that the most important variables related to length of stay were (1) diagnosis, (2) number of violent acts while hospitalized, and (3) age of admission. Specifically, longer length of stay was associated with (1) having a diagnosis of schizophrenia or neurocognitive disorder, (2) one or more violent acts, and (3) older age at admission. The other variables studied were also statistically significant, but not as influential in the model., Conclusions: We found significant relations between length of stay and the variables studied, with the most important variables being (1) diagnosis, (2) number of physically violent acts, and (3) age at admission. These findings emphasize the need for treatments to target cognitive issues in the seriously mentally ill as well as treatment of violence and early identification of violence risk factors.

Objective: Institutional violence in state hospitals is a public health problem that has been severely understudied. Given the personal (ie, staff and patients) and fiscal harms associated with institutional violence, more research into contributing factors for violence is needed. The overarching aim of this study then was to examine associations among psychiatric symptoms, criminal risk factors, and institutional violence., Methods: Participants were 200 male, female, and transgender forensic mental health inpatients adjudicated Not Guilty by Reason of Insanity and committed to the California Department of State Hospitals. Participants completed a psychiatric symptom measure, and measures of and associated with criminal risk. Institutional violence was recorded from file review and includes physical violence toward staff or patients for 6-months prior to and post patient participation in this study., Results: After adjusting for previous institutional violence, results indicated that psychiatric symptoms were not associated with follow-up institutional violence; however, criminal risk was associated with follow-up institutional violence. Unexpectedly, 2 aspects of criminal risk, antisocial cognitions and associates, were not associated with follow-up institutional violence after adjusting for previous institutional violence. Results also provided a tentative cutoff score on the Self-Appraisal Questionnaire for predicting follow-up institutional violence., Conclusions: These results have important implications for treating and managing patients at risk for institutional violence, including the need to assess criminogenic risk and leverage treatments that target these risk factors as a best practice approach.

WHAT IS KNOWN ON THE SUBJECT?: People admitted to psychiatric facilities have high rates of tobacco use and hospitalizations present an opportunity for patients to have conversations about tobacco use treatment. Clinicians may believe that people with mental illnesses are not interested in quitting or that they do not understand the importance of treatment. Positive attitudes towards tobacco treatment, viewing that participating in treatment is normal care, and feeling that one is quite able to participate in such treatment predicts intentions to participate in treatment, which, in turn, predicts actual participation. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Psychiatric patients who use tobacco use report poor prior involvement with tobacco treatment. Positive attitudes towards, encouraging opinions of other people about, and having a sense of control over taking part in tobacco treatment increases plans to engage in treatment. Having a sense of control in taking part in tobacco treatment is strongly associated with prior experiences with evidence-based treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Because psychiatric hospitalizations are an opportunity for addressing tobacco use and treatment, clinicians should be prepared to support willing patients, especially those with prior substance use histories. Support should include providing them with information regarding tobacco treatment options during their hospital stay and ways that they can continue to receive care after discharge. Clinicians should be promoters of pro-tobacco treatment attitudes and supporting patients' sense of control over participating in treatment during hospitalization., Abstract: Introduction Hospitalized tobacco users with mental illnesses (MI) may face several barriers to stopping smoking. However, motivational factors that affect the intention to engage in tobacco treatment have been shown to predict actual engagement. Aim To use the Theory of Planned Behavior to assess intentions to and prior experiences of engaging in evidence-based tobacco treatment among hospitalized individuals with MI. Method A cross-sectional survey was conducted among 115 patients in a state psychiatric hospital. Multivariate analyses were used to examine associations with the intentions and prior experiences of engaging in tobacco treatment. Results After controlling for demographic and smoking history, attitudes, subjective norms and perceived behavioural control towards engaging in tobacco treatment were significantly associated with intentions towards treatment engagement. Only higher scores on perceived behavioural control and lower education levels were associated with reported prior experiences of tobacco treatment. Discussion The low prior treatment engagement scores, but relatively higher intention to engage scores among participants suggests the need for deliberate support for evidence-based tobacco treatment during psychiatric hospitalizations. Implications for practice Clinician training in tobacco treatment can promote self-efficacy to engage patients while supporting patients' control so that tobacco treatment is an expected component of psychiatric care., (© 2017 John Wiley & Sons Ltd.)

Objective: This study estimated the effects of a waitlist policy on the monthly number and case mix of admissions to state psychiatric hospitals (SPHs) in North Carolina (NC)., Methods: Descriptive analyses compared pre/postwaitlist differences in the monthly number and case mix of nonforensic adult admissions (N=72,035) to NC's four SPHs by using data from the three years before and the three years after the waitlist announcement. Hospital-level fixed-effects regression models further evaluated the waitlist policy's impact on the number and case mix of admissions., Results: Regression results confirmed that the waitlist policy was associated with both fewer admissions and changes to the case mix of admissions, including a 4.2% decrease in the percentage of monthly admissions by patients with diagnoses of substance abuse disorders (p=.002) across all months postwaitlist (partially offset by an increase of patients with diagnoses of severe mental illness alone)., Conclusions: Waitlists led to reduced monthly admissions and altered case mix following implementation at NC SPHs.

Objectives: The goal of this study was to explore antipsychotic medication prescribing practices in a sample of 86,034 patients discharged from state psychiatric inpatient hospitals and to find the prevalence of patients discharged with no antipsychotic medications, on antipsychotic monotherapy, and on antipsychotic polypharmacy. For patients discharged on antipsychotic polypharmacy, the study explored the adjusted rates of antipsychotic polypharmacy, the reasons patients were discharged on antipsychotic polypharmacy, the proportion of antipsychotic polypharmacy by mental health disorder, and the characteristics associated with being discharged on antipsychotic polypharmacy., Methods: This cross-sectional study analyzed all discharges for adult patients (18 to 64 y of age) from state psychiatric inpatient hospitals between January 1 and December 31, 2011. The relationship among variables was explored using χ, t test, and analysis of variance. Logistic regression was used to determine predictors of antipsychotic polypharmacy., Results: The prevalence of antipsychotic polypharmacy was 12%. Of the discharged patients receiving at least 1 antipsychotic medication (adjusted rate), 18% were on antipsychotic polypharmacy. The strongest predictors of antipsychotic polypharmacy being prescribed were having a diagnosis of schizophrenia and a length of stay of 90 days or more. Patients were prescribed antipsychotic polypharmacy primarily to reduce their symptoms., Conclusions: Antipsychotic polypharmacy continues at a high enough rate to affect nearly 10,000 patients with a diagnosis of schizophrenia each year in state psychiatric inpatient hospitals. Further analysis of the clinical presentation of these patients may highlight particular aspects of the illness and its previous treatment that are contributing to practices outside the best-practice guideline. An increased understanding of trend data, patient characteristics, and national benchmarks provides an opportunity for decision-making that is sensitive to the patient's needs and cognizant of the hospital's accomplishments in adopting best practices.

This study investigated inequities in access, diagnosis, and treatment for African Americans and Hispanic Americans receiving treatment in northeast, public sector, inpatient mental health settings as part of a Department of Mental Health and Addiction Services Health Disparities Initiative. Data from 1,484 adults were obtained through a random extract of patients admitted to state inpatient facilities between 2002 and 2005. After controlling for demographic variables and symptom severity, logistic and linear regression showed that Hispanic Americans were significantly more likely to enter inpatient care through crisis/emergency sources and were significantly less likely to self-refer or come to inpatient care through other sources (e.g., family, outpatient). After admission, Hispanic Americans were more likely to be diagnosed with other psychotic disorders (e.g., schizoaffective disorder, delusional disorder), were less likely to receive an Axis II diagnosis at discharge, and had a shorter length of stay than non-Hispanic White Americans. African Americans were more likely than other groups to be diagnosed with schizophrenia, drug-related, and Cluster B diagnoses (discharge only), and they were less likely to be diagnosed with mood disorders and other nonpsychotic disorders. Although African Americans were more likely than other groups to come to inpatient units from numerous routes, including self-referral and referral from other sources (e.g., family, outpatient), they were more likely to terminate treatment against medical advice and displayed shorter length of stay despite receiving ratings of greater symptom severity at discharge. These findings highlight the need for policies, programs, and system interventions designed to eliminate disparities and improve the quality and cultural responsiveness of behavioral health services., ((c) 2015 APA, all rights reserved).)

The current study explored and described the experiences of individuals who either directed or participated in successfully reducing the use of restraint and seclusion (R/S) in two inpatient public mental health hospitals. A phenomenological methodology was used to capture the lived experiences of 21 study participants, including senior leaders, middle managers, and direct care staff, who were interviewed as key informants. Thirty-two themes were extracted and subsequently synthesized into five "meaning themes." The five meaning themes yielded six significant findings: (a) critical roles of leadership and staff in successful R/S reduction projects; (b) ability of leaders and staff to change their beliefs and behaviors; (c) ability of leaders and staff to build a shared vision that was critical to the reduction of R/S use in in-patient settings; (d) identification and resolution of key challenges staff and leaders experienced in reduction efforts; (e) use of a solid performance improvement lens to direct changes in practices; and (f) important lessons learned., (Copyright 2014, SLACK Incorporated.)

Objective: The purpose of this study was to assess the effectiveness of Washington State's PACT, a recovery-oriented assertive community treatment (ACT) initiative, in reducing state psychiatric hospital use., Methods: A quasi-experimental design and administrative data were used to compare 450 PACT consumers and 450 propensity score-matched consumers receiving usual care. Generalized estimating equations (GEE) assessed the effects of PACT on use of state and local hospitals, emergency departments, crisis stabilization units, and arrests. The marginal effects of PACT were estimated for high users and low users of state hospitals at baseline., Results: No difference between PACT participants and control participants was observed in the probability of having any state hospital use. A reduction in state hospital use of between 32 and 33 days per person per year was observed (p<.01). Reductions in state hospital costs were concentrated among PACT participants who had high state hospital use at baseline; cost reductions ranged from about $17,000 to $20,000 per person per year (p<.01). State hospital cost reductions were partially offset by increases in use of local services, with small but significant (p<.01) increases in local hospital use, use of emergency departments, and use of crisis stabilization services., Conclusions: PACT had its greatest effects for consumers who were high utilizers of state psychiatric hospitals at baseline. Contrary to studies and commentaries from the United Kingdom, ACT remains a viable intervention in areas where state hospitals are overused. Whether blending traditional ACT with recovery-oriented practices also promotes consumer recovery requires further study.

Objective: A previous study of recovery-oriented assertive community treatment (PACT) found large differences over three years in use of state psychiatric hospitals between PACT participants and consumers in a matched control group, especially for PACT participants with significant previous psychiatric hospitalization. This study extended these findings by examining the timing of PACT effects., Methods: Generalized estimating equation models of monthly cost data for state, local, and crisis hospital use estimated the time-varying effects of participation in one of ten PACT teams in Washington State. Data from PACT participants (N=450) and propensity score-matched consumers (N=450) were included. Additional analyses determined whether effects differed by prior state hospital use., Results: Differences in costs between PACT and control participants were largest immediately after PACT enrollment and tapered off. During the first quarter after enrollment, monthly per-person costs for state hospital use were $3,458 lower for PACT enrollees than for control participants. A composite measure of psychiatric hospital costs (state and local hospitals and local crisis stabilization units) declined by $3,539 monthly during the first quarter after PACT enrollment (p<.01). Differences were noted up to 27 months after enrollment, when the difference in the composite costs measure became insignificant compared with the prior quarter (months 25-27) (p>.05). Differences were larger for PACT enrollees with greater baseline state hospital use., Conclusions: The time-varying estimates may have implications for the length and intensity of ACT enrollment. However, the optimum time for receipt of ACT services needs to be considered in the context of outcomes other than hospitalization alone.

Objective: A previous study of a recovery-oriented assertive community treatment initiative (PACT) in Washington State found reductions in state psychiatric hospital use and related costs for PACT participants, especially in the first six months after enrollment and for consumers who were high users of the state psychiatric hospital before ACT enrollment. This study examined whether these outcomes varied by team fidelity to recovery-oriented ACT practices., Methods: Generalized estimating equations (GEE) were used to examine the relationship between scores on the Tool for Measurement of Assertive Community Treatment (TMACT), a recently developed tool for assessing fidelity to recovery-oriented ACT, and the use of state hospitals, local hospitals, emergency departments, local crisis stabilization units, and arrests for 631 PACT consumers. These relationships were also examined for PACT consumers with any state hospital use (N=450) and those considered high users of the state hospital (≥ 96 days in two years before PACT enrollment)., Results: TMACT scores were associated (p<.01) with a decrease in the amount of use but not the probability of using state psychiatric hospitals, local hospital psychiatric inpatient units, and local crisis stabilization units. The marginal effects of higher TMACT scores on the probability and use of emergency departments or arrests were not statistically significant., Conclusions: This study provides preliminary evidence for the predictive validity of the TMACT. Future research should examine the subscale structure of the TMACT as well as the association between TMACT fidelity and consumer well-being, quality of life, and other important person-centered outcomes.

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A prepost study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.

The present study is an effort to obtain preliminary data to assess the validity of the long-standing claim that the rate of seclusion and restraint is higher among deaf and hard of hearing individuals than among hearing individuals. This difference has been claimed repeatedly despite there being no research to support it. The sample was comprised of 22 deaf or hard of hearing individuals who had been committed to a large state hospital, all but three of whom had been discharged prior to data collection. The deaf and hard of hearing subjects were matched to subjects with no hearing loss on factors believed to be associated with behaviors that can result in seclusion or restraint. Archived clinical records of both groups of subjects were reviewed to determine the rates of seclusion and restraint for the two groups, as well as to assess the length of time each group was in seclusion or restraint. The results indicate a significantly higher frequency of seclusion and restraint for the deaf and hard of hearing group than for the hearing group. Of note is that the hearing individuals spent longer in seclusion and restraint than did the deaf and hard of hearing. The hypothesis of a higher rate of restrictive events among deaf and hard of hearing individuals is supported. The results of this study suggest that further research be undertaken to determine the generalizability of these results as well as possible sources of the differences between these two groups.

Recovery attitudes and concepts are often promoted to community mental health staff through educational and in-service trainings, but no study found has examined this in state hospitals. The current observational study aimed to examine the types of recovery-oriented trainings that occurred at two state hospitals over 1 year and subsequent changes in staff recovery attitudes. A total of 184 state hospital staff completed questionnaires assessing their personal optimism, consumer optimism, and agency recovery orientation at baseline and 1 year later. The types of recovery-oriented trainings staff received were categorized as general/inspirational or specific/practical training. Results found that the majority of staff at the two state hospitals received some recovery-oriented training, mostly general/inspirational training. Staff who received specific/practical training had a greater increase in agency recovery attitudes than staff who received only general/inspirational training or no training. However, the more trainings staff had, the higher their consumer optimism. These results suggest state hospitals are incorporating recovery-oriented staff trainings, but more specific trainings may be needed and all staff involved in different levels of care need to be included.

Objective: Little is known about the epidemiology of substance use disorders (SUD) among psychiatric inpatients in the Western Cape, South Africa. Therefore, this study was conducted to examine the prevalence of SUD among acute adult psychiatric inpatients at Stikland Hospital, one of three state acute psychiatric hospitals in the Western Cape., Method: A prospective descriptive prevalence survey was undertaken over a three-month period. During this period, data was collected on psychiatric patients (N=298) who were hospitalized in the acute psychiatric wards at Stikland. This included patient demography, psychiatric and substance use history. Urine was also collected and analyzed for substances commonly abused in the Western Cape., Results: A co-morbid SUD (abuse or dependence) was diagnosed in 51% of patients. In addition, a diagnosis of a substance-induced psychiatric disorder was made in 8% of these patients, 1% of who was diagnosed with a substance-induced mood disorder, while 7% was diagnosed with a substance induced psychotic disorder. Patients diagnosed with a co-morbid SUD were younger than those without a SUD and more likely to have been involuntary admissions. These patients also displayed more violence prior to admission that contributed to their admission and were more likely to have used cannabis or methamphetamine as their preferred drug of abuse. Only a small group of patients had documented evidence of any prior interventions for their SUD., Conclusion: SUD are prevalent among psychiatric inpatients and contribute to their morbidity. This has implications for staff training and service development.

Restoration to competence (RTC) of mentally disordered defendants has become increasingly important for state hospitals. In Indiana, most RTC admissions are sent to one primarily forensic state hospital, but many are admitted to other state hospitals. A state database of defendants admitted for RTC between 1988 and 2005 was analyzed for trends in annual admissions, length of stay (LOS), and success of restoration by hospital and by diagnostic category. Regression models were developed to identify factors associated with RTC success. Analysis of 1,475 RTC admissions showed increased annual admissions over the study period. While the forensic hospital restored a higher percentage of individuals than the other state hospitals, the percentage of RTC success decreased over time in all hospitals. Admission to the forensic hospital, female gender, and mood disorder diagnosis were associated with increased restoration success. Older age and psychotic disorder or mental retardation diagnoses were associated with decreased likelihood of restoration. Race was not significantly associated with RTC at six months, but white defendants were less likely to be restored within one year.

Objective and Method: Inpatients of "psychotherapeutic treatment units" at State Mental Hospitals in Bavaria are different from those treated in so-called psychosomatic clinics for rehabilitation, looking at additional criteria like psychiatric and somatic comorbidity or suicidal behaviour., Results and Conclusion: Treatment concepts and results are respectable and comparable to so-called psychosomatic clinic. In this paper we describe the "Psychotherapy Unit" at the Clinic for Psychiatry and Psychotherapy Bayreuth. Depressive episode is the most diagnosis, with 1 to 4 comorbid psychiatric diagnosis in 82 % of all patients and 28 % with somatic comorbidity.

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.

Objective: This study sought to determine the prevalence of pervasive developmental disorders (PDD) among children admitted to a state hospital day treatment service and to characterize the psychiatric disturbance of patients with PDD., Methods: A total of 146 consecutively admitted patients were evaluated for PDD. Patients who had PDD were compared with a sample of age- and sex-matched patients in day treatment who did not have PDD. Psychiatric symptoms, family history, and developmental and educational histories were examined., Results: Of the 146 patients, 20 (14 percent) met criteria for PDD. An additional five patients who had PDD were included, yielding a final sample of 25. Only two of an array of psychiatric symptoms were more prevalent among patients with PDD: engaging in unusual fantasy and talking to themselves, animals, or inanimate objects. Significantly more patients with PDD had a history of speech delay, language abnormalities, and inexplicable or lengthy episodes of crying or screaming. The groups did not differ significantly in IQ or global functioning. Seven patients with PDD (28 percent) met criteria for childhood-onset schizophrenia, and 19 (76 percent) had symptoms of a tic disorder., Conclusions: The study found that PDD is not rare and that children with PDD represent a significant subgroup of children with serious emotional disturbance referred for psychiatric treatment. The findings support the view that PDD may be easily missed because it may be mild and associated with psychiatric disturbances that are present among other severely ill youngsters.

Objective: This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients., Methods: Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support., Results: Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission., Conclusions: The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.

We report results of a study on suicides 1976-1998 of inpatient of the state Mental Hospital Bayreuth. Suicides were matched to a control group of psychiatric inpatients shortly admitted to the hospital after the suicide inpatient.

Background: Multiple studies have shown that individuals with severe mental illness are at increased risk for acquiring infection from human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Moreover, patients with chronic HCV infection are at risk for fulminant hepatitis from acquired infection with hepatitis A virus (HAV) or HBV, but there are limited data on the prevalence of HIV, HAV, and HBV in chronically hospitalized U.S. psychiatric patients without mental retardation who are HCV-seropositive. To address this issue, a comprehensive screening program was commenced at Oregon State Hospital (Salem, Ore.) beginning in 1999., Method: The computerized records of all non-geriatric adult inpatients at Oregon State Hospital on April 23, 2001, were reviewed to assess physician compliance with screening and the prevalence of infection with HIV, HAV, HBV, and HCV., Results: Among the 535 patient records reviewed, 94.8% of patients were screened for HCV, of whom 20.3% were seropositive. Among HCV-seropositive patients, only 1.9% were not screened for HAV and HBV, but 23.3% were not tested for HIV. In the HCV-seropositive group, 35.9% were HAV-positive, 49.5% HBV-positive, and 2.6% HIV-positive., Conclusion: Chronic psychiatric inpatients have high HCV prevalence rates. Hepatitis C-seropositive individuals may be at risk for complications unless vaccinated for HAV and HBV.

Objective: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital., Methods: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff., Results: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk., Conclusions: Use of a review team should be considered as a method for detecting and reporting medication errors.

The purpose of the present study is to compare the demographic and clinical characteristics of African Americans with and without an immediate history of homelessness upon entry into a state psychiatric hospital. Four variables made statistically significant contributions to the logit model predicting homelessness with the other variables controlled. They were never being married, lifetime comorbid substance abuse, severe paranoia, and high self-esteem. The four significant predictors from the logit model were used to assign patients to different risk groups. There was a significant dose-response relationship between the percentage of cases of homelessness and the number of these risk indicators.

Concomitant medications are frequently used in the treatment of resistant psychiatric conditions to augment the primary psychotropic agent or to ameliorate side effects. The present study evaluated the prescription of concomitant psychiatric medications for psychiatric inpatients that were prescribed either olanzapine at its first commercial availability or another first-line antipsychotic agent. Sixty-nine newly admitted patients (mainly with schizophrenia) who were prescribed either olanzapine (n = 35) or another first-line antipsychotic agent (n = 34) were assessed (for the prescription of other concomitant psychotropic drugs) before (2-4 weeks prior to study) and following 8 weeks of treatment (unless discharged sooner). The results indicate that significantly fewer olanzapine-treated subjects were prescribed anticholinergic agents as compared to those prescribed other first-line antipsychotic agents, and a similar trend was noted in the prescription of mood stabilizers as well. Olanzapine-treated subjects used less as needed (PRN) antipsychotic medication compared to pre-olanzapine treatment period. Olanzapine-treated subjects used more anxiolytic agents compared to the control group in the early stages of treatment, probably due to the greater baseline severity of illness. These data suggest that olanzapine use is associated with less use of anticholinergic and mood-stabilizing agents as compared to older antipsychotic agents. These results also suggest that there is less need for PRN antipsychotic medication following olanzapine treatment. More severely ill subjects may require more anxiolytics during olanzapine initiation. The need for less anticholinergic and mood-stabilizing agent use with olanzapine could lead to greater adherence to long-term treatment and perhaps decreased cost (i.e. use of blood and organ system monitoring with mood stabilizers). At the end of treatment, olanzapine-treated subjects had statistically significantly lesser concomitant medicine usage compared to control subjects.

Physical control (mechanical restraint and locked seclusion) of psychiatric patients has received increasing scrutiny, and better understanding of the timing of physical control would allow for more informed choices about its implementation. This study examined temporal regularities in the use of physical control at a general psychiatric hospital over a period of 8.6 years. As hypothesized, physical control was not randomly distributed through time but instead showed positive autocorrelation; yearly, weekly, and daily cycles; and higher frequency at patients' smoking, meal, and medication times. These results are discussed in the context of physical control research, theory, and policy., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: This study examined whether information obtained early in the hospitalization process can be used to assess a patient's need for extended care., Methods: A sample of 2,430 inpatients who were admitted to a state psychiatric facility during a one-year index period (January through December 1997) were randomly assigned to a primary sample or a replication sample. Data were collected on demographic characteristics and history of previous hospitalization. The Brief Psychiatric Rating Scale-Anchored Version (BPRS-A) was administered to patients within 48 hours of admission, and four new subscales derived from ratings of newly admitted patients were calculated. Univariate and multivariate analyses were conducted to identify factors associated with whether a patient was discharged to the community or transported to another hospital for extended care., Results: A discriminant analysis of the data correctly identified 70 percent of the patients who were referred for continued hospitalization and 80 percent of the patients who were discharged to the community. The main correlates of the need for extended inpatient services were, in descending order, scores on the BPRS-A resistance subscale, the number of previous referrals for extended hospitalizations, and scores on the BPRS-A positive symptoms and psychological discomfort scales., Conclusions: BPRS-A subscale scores should be considered to be at least as good as more traditional measures in predicting length of hospitalization.

This paper examines changes in use of state mental hospitals in Washington State from July 1, 1990, to July 1, 1997. It focuses on the phenomenon of ongoing use of state mental hospital by patients over a period of years. Two panels of state mental hospital users were identified: one preceded and one followed implementation of state mental hospital downsizing policies. Though the number of adults per year using the state mental hospital decreased following policy implementation, there was a significant increase in the overall rate of ongoing use. A logistic regression for ongoing use with multiple individual and regional predictor variables is described.

In the past, the term "chronic" referred to people who had serious mental illness and who typically received long-term care in a state mental hospital. Although this term recently has fallen out of favor, we resurrect the term here, not to revive a demeaning euphemism, but rather to redefine it as the result of a poor person-environment fit between the complex and challenging needs of those with serious psychiatric disorders and a community-based service system that often is ill-equipped to treat them. Previous research indicates that recurrent acute hospitalizations and an inability to establish or maintain tenure in the community may be due to a disconnection from community-based services and supports, social isolation, and demoralization. One promising approach to addressing these issues is that of peer support. To illustrate the potential utility of peer support in improving person-environment fit and decreasing the chronicity of the subsample of people who continue to have difficulty in establishing viable footholds in the community, we describe a peer support-based program, the Welcome Basket, developed, staffed, and managed entirely by mental health consumers. Preliminary analyses that evaluate Welcome Basket's effectiveness are included, and we discuss the implications of these data for future research and program development in this area.

This retrospective case note review describes the demographic, forensic and psychiatric backgrounds of 14 in-patient suicides in a maximum secure hospital. The majority were schizophrenic with chronic treatment-resistant illnesses, who had committed proportionally more violent offences, had a history of serious self-injury but no recognized clear depressive episodes. This profile is markedly different from that reported in general psychiatric in-patients, out-patients and suicides in prison, but is similar to that described in a maximum secure hospital in the United States and in long-stay patients in Canada. Many of the patients had continued to experience significantly subjective distress over many years. The clinical relevance of this series is discussed in the context of the assessment of suicidal intent in psychotic patients. We speculate that the decrease in in-patient suicides in the State Hospital may be due to a less restrictive ward milieu, increased staff/patient ratios, or the introduction of Clozapine.

Objective: Despite growing numbers of elderly persons with serious mental illness such as schizophrenia, little research has been conducted on the manifestation of serious mental illness in later life, and our understanding of the mental health care needs of this population is limited. This study examined length of stay and medication use among women age 50 and older admitted to an acute care state psychiatric facility., Methods: A computerized record search for all women discharged from a large urban state psychiatric facility over a one-year period was undertaken. Demographic and resource utilization data, including total length of stay and pharmacy utilization, were obtained from the hospital database., Results: The database search produced the records of 564 women, with a mean age of 37.5 years. Women constituted 60 percent of patients over age 50. The mean length of stay was 16.1 days for the entire group; for women under age 50 (N=492), mean length of stay was 15 days, and for women age 50 and older (N=72), it was 23.1 days (p=. 01). Among those age 50 and older, 58.3 percent had a diagnosis of schizophrenia or schizoaffective disorder, compared with only 38 percent of those under age 50., Conclusions: Our data suggest that women constitute the majority of patients over age 50 in a state psychiatric facility and that they have longer stays than younger women.

Background: The use of electroconvulsive therapy (ECT) in the state hospital setting currently represents a very small percentage of the total overall use of this modality in the treatment of the mentally ill., Method: Using records kept by a state hospital, we retrospectively identified all patients who had received ECT between the years 1986 and 1995. A review of the records at the state hospital from where patients were referred and the university hospital where ECT was administered was undertaken. Demographic and clinical characteristics, reasons for referral, symptom profile, ECT parameters, clinical outcomes, and restraint/ seclusion data were assessed., Results: Over 10 years, 21 patients were treated with ECT, representing 0.4% of all admissions to the state hospital. Of these subjects, 17 records could be retrieved. The majority were women (N = 12; 71%) and were diagnosed with a mood disorder. Ten subjects (59%) were over the age of 60 years, 4 of whom were 70 years or older. Most patients had a state hospital length of stay of 1 year or less. The mean number of ECT treatments was 12.2. There were no medical complications that led to premature termination of ECT. Eleven patients (65%) were discharged either directly from the university hospital or within 10 days of readmission to the state hospital. Six of 7 patients who had restraint and seclusion episodes prior to ECT were found to have no further episodes afterwards. The seventh experienced a dramatic decrease in number and total hours of episodes., Conclusion: For a substantial minority of patients in this state hospital setting, ECT appears to have been an effective and safe form of treatment, and its use should be considered early rather than late in the course of hospitalization.

Objective: We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany., Method: We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992., Results: The LKH patients were significantly older (74.8 +/- 8.7 y versus 70.3 +/- 8.3 y), more often living alone and/or without children. 31.9% of them were living in a nursing home compared to 6.5% of the PUK patients. Psychic disorders had not shown up before old age in 55.7% of all cases. 50.4% of the patients were in a psychiatric hospital for the first time. The majority of the patients (65.6%) had not been investigated by a psychiatrist before admission., Conclusions: More socially handicapped patients were treated in the LKH. For most cases, the hospital treatment had been the first psychiatric treatment at all.

Objective: We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany., Method: We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992., Results: Most patients of the LKH suffered from organic brain diseases/dementia (63.4%; PUK: 29.1%). In the PUK, depression was the most frequent diagnosis (57.6%; LKH: 21.1%). A part of about 25% of the patients showed neurological deficits. Specialised diagnostics were performed mostly in the PUK. Both institutions treated the wide majority of patients with CNS drugs. Antidementia drugs were given significantly more often in the LKH. About one third of the patients were released into changed living environments., Conclusions: Patients with further progressed dementias were treated mainly in the LKH. This has consequences for diagnostics, treatment duration and side effect rate.

Prior to managed care, extensive research documented the characteristics of assaultive inpatients in traditional state mental hospital settings as primarily older, male, psychotic patients with histories of violence toward others and of substance abuse. Recent early studies in rural and urban hospital settings have suggested that the characteristics of assaultive patients may be changing to include younger, more frequently female, patients with personality disorders and histories of personal victimization. This two-points-in-time study sought to assess the nature of assaultive patients in a suburban traditional state mental hospital after the implementation of managed care initiatives, and compared to the nature of the assaultive patients before and after the downsizing of this state mental health facility. Before census reduction, the assaultive patients were of the traditional type. After census reduction, the assaultive patients reflected more recent trends. The implications of the findings are discussed, and strategies for fostering facility safety in light of the newer violent patient are outlined.

The authors propose a new paradigm for designing and managing behavioral health care systems by using artificial neural networks to measure quality of care (Q), using length-of-stay (LOS) prediction and the variation in LOS prediction, and subsequently using the variation of Q to obtain a measure of uncertainty in treatment. The paper proposes that mental illness is fractal in nature (self-similar at all scales) and conforms to power laws like the Gutenberg-Richter (G-R) law, whereby there is a log-log relationship between frequency of episodes (i.e., admissions) and the severity of those episodes. The paper also hypothesizes that 28% is the average uncertainty (residual or excess entropy) in the treatment of mental illness. The authors use the G-R paradigm to calculate the severity of admission and, subsequently, the minimum number of beds for different behavioral health care facilities and propose the optimal partition of beds between community and state services, thereby "balancing" the delivery system. The data presented support the notion that mental illness manifests complexity and "self-organized criticality." The authors hypothesize that correcting deviations from the theoretical G-R curve for each level of care will allow optimum resource distribution, improve quality of care, and reduce costs.

Background: In spite of some inherent limitations, naturalistic data can provide information on populations that have greater heterogeneity than can controlled clinical trials and on functional outcomes that may be especially important in clinical practice. In the present retrospective naturalistic study, we evaluated key clinical outcomes among the first wave of risperidone-treated patients at a state psychiatric hospital., Method: Outcome data were extracted from the charts of 142 patients 2 years after initiation of treatment with risperidone. Their diagnoses included DSM-III-R schizophrenia (57%), schizoaffective disorder (22%), dementia and other organic conditions (7%), bipolar disorder (5%), and other psychiatric disorders (9%)., Results: During the 2-year period, 92 of 142 patients were discharged from the hospital: 61 (43%) were discharged on risperidone treatment and 31 (22%) were discharged on treatment with other drugs. At the time of the study, 50 of 142 patients were still in the hospital: of these, 18 (13%) were still receiving risperidone. The modal maximum daily dose of risperidone was 4.1 mg in patients discharged on risperidone treatment and 7.5 mg in patients still in the hospital. All groups were granted more ward privileges after starting risperidone, the most being granted to patients discharged from the hospital on risperidone treatment (p<.05 versus patients discharged on treatment with other drugs) and those still receiving risperidone in the hospital. Significantly fewer patients discharged on risperidone treatment than on treatment with other drugs were readmitted to the hospital within 2 years after discharge (p<.01)., Conclusion: Improved privilege levels and a reduced readmission rate indicate that risperidone was an effective antipsychotic agent among a heterogeneous patient population in a state hospital. These factors may be especially important to justify use of this agent in the current fiscal climate.

This article explores the increased role of state-operated public psychiatric hospitals in treating forensic patients. Patients with a forensic legal status have a mental illness and are involved with the criminal justice system. Using data from Missouri's forensic system, the article compares the characteristics of voluntary hospital patients with those of the largest hospitalized group of forensic patients--those found not guilty by reason of insanity (NGRI). Overall, NGRI patients tended to be higher functioning, less likely to have committed assaultive acts, and more likely to have substance abuse and personality disorder diagnoses. The article explores the treatment needs of forensic patients who reside in public psychiatric hospitals and discusses the effect of the strong presence of forensic patients in public psychiatric hospitals on social work practice, including clinical work with forensic patients, social work administration, and social work advocacy.

The author describes outcomes of interventions that were aimed at decreasing high use of state hospitals. Research focused on changes in state hospital case mix and dynamics of use by individuals identified as "high utilizers" before and after the Washington State Mental Health Division (MHD) implemented a series of interventions designed to reduce use. A set of recommendations are offered for policymakers who plan interventions that shift the locus of care for severely and persistently mentally ill adults.

Objective: The state psychiatric hospital is experiencing an increase in medically sick and aging patients who die of natural causes while hospitalized. This study explored the "medicalization" of the state hospital by examining the prevalence of medical illness and its relationship with psychiatric illness and age among state hospital psychiatric inpatients who died of natural causes--deaths that were not accidents, homicides, or suicides., Methods: A total of 179 inpatients who died of natural causes at Western State Hospital in Washington State between 1989 and 1994 were studied retrospectively through case file review. Their demographic and institutional characteristics and psychiatric diagnoses were compared with those of others treated at the hospital (N=9,258). The medical diagnoses of patients who died were analyzed by age and psychiatric condition., Results: The patients who died were much older than the other patients treated during the study period. Two-thirds of those who died had organic mental disorders, mostly dementia, whereas only a fifth of the other patients had these disorders. The patients who died had a mean of eight physical illnesses, with a range from none to 21. Circulatory and respiratory conditions were most prevalent, affecting half to two-thirds of patients; these conditions had high rates of comorbidity with organic mental disorders., Conclusions: The characteristics of the state hospital population and the services provided are shifting in response to mental health reform and new policies on patient self-determination. Increased emphasis on medical care added to traditional psychiatric services will require increased financial and personnel resources.

Objectives: This paper explores the relationship of state hospital and general hospital psychiatric caseloads in a statewide system of care., Methods: Probabilistic population estimation was applied to general hospital and state hospital data sets., Results: General hospitals provide inpatient psychiatric services to more people than do state hospitals, and a significant number are served in both sectors. There were notable differences in use patterns related to patient gender and age., Conclusions: These results demonstrate that probabilistic methodologies can significantly enhance the value of existing databases for epidemiological research.

This pilot study investigated the importance of social, clinical, and discharge factors in predicting extended length of stay (LOS) in a state geropsychiatric hospital. The authors reviewed medical records of all first time admissions during a 22 month period. A total of 272 patients age 60 and older were admitted for the first time during this period. Nine variables comprised of medical, demographic, social, and discharge information were examined in retrospective analysis to assess their relationship to LOS. The mean and standard deviation of days spent in hospital was 392.3 +/- 752.81. The median number of days of hospitalization was 72.0. Single marital status, type of living arrangement, polypharmacy, and limited functional status were predictive of LOS. Our findings underscore the challenge within geropsychiatry of treating patients with coexisting medical conditions who also have significant behavioral, mood, and/or cognitive disturbances.

Of 195 patients admitted to a state hospital over a four-month period, 74 were multiple recidivists. Nearly half of the 195 patients could be assigned to one of six profile subgroups of recidivists described in a previous study. Because of the high rate of medication noncompliance in this state hospital sample (65 percent), noncompliance alone was not an adequate predictor of multiple recidivism. The study found that membership in a profile subgroup coupled with factors related to gender, medication noncompliance, homelessness, and arrest history may be a more useful way of predicting multiple recidivism in samples of newly admitted patients.

The diversion of people with severe mental illness into the private sector is examined. The purpose of the diversion system is to reduce the number of admissions to the state hospitals by diverting patients into the private hospitals, which may offer more diverse treatment to these patients. Insurance is highlighted as an important factor in diverting patients from state hospitals. When the diversion system fails and the patient is transferred from the private sector to the state hospitals, continuity of care is disrupted. The failure of the diversion is more costly not only to the patient but to the federal and state governments as well. Policy issues such as cost to the mental health system and continuity of care are discussed.

Objective: The study examined factors predicting early readmission (within 30 days of discharge) to a state hospital., Methods: A total of 189 patients with acute symptoms who were admitted to a state hospital were evaluated at discharge using the Brief Psychiatric Rating Scale (BPRS) and the Nurses Observation Scale for Inpatient Evaluation (NOSIE). Patients who were readmitted within 30 days were compared with those who were not on BPRS and NOSIE ratings and on other variables, including length of stay, number of previous admissions, demographic characteristics, and diagnosis., Results: Scores on the thought disorder factor and self-neglect question on the BPRS and the number of previous admissions were significantly higher among patients who where readmitted within 30 days of discharge. The variables correctly predicted readmission for 86 percent of cases in the study., Conclusions: The characteristics of high scores at discharge on the BPRS thought disorder factor and the BPRS item on self-neglect, along with a high number of previous admission, may be helpful in identifying patients at risk for readmission to inpatient psychiatric settings.

The authors describe a sample of homeless mentally ill patients receiving extended psychiatric care on an intensive placement unit. Summaries of 246 discharges were reviewed to examine demographic and clinical factors associated with extended psychiatric care and postdischarge placement. It was found that homeless patients requiring extended care were often medically ill and substance abusing. Residential placements were accepted by most patients on discharge. It was determined that homeless psychiatric patients benefited from extended care on an inpatient unit designed to alleviate anxieties regarding living arrangements and psychiatric treatment systems historically rejected by this population.