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Objective: As the number of older adults in the United States continues to grow, the population of older adults with severe mental illness in institutional settings (OASIS) is expected to place a significant demand on healthcare resources. This study presents an update to research regarding the clinical characteristics of OASIS inpatients with histories of extensive hospitalization through the use of a newly developed psychiatric measure: the Clinician-Rated Dimension of Psychosis Symptom Severity., Methods: We investigated an OASIS sample (N = 55) with an average of nearly 30 continuous years of hospitalization at a forensic state psychiatric hospital., Results: The average OASIS patient exhibited the most prominent psychiatric symptoms via delusions and negative symptoms, received psychotropic medications at substantially higher doses than recommended therapeutic levels, rarely committed acts of institutional violence (IV), and performed more than two standard deviations below the normative mean on cognitive testing. More severe hallucination symptoms were associated with higher psychotropic medication dosage, and more severe depressive symptoms were associated with more IV incidents. OASIS inpatients performed moderately worse than general psychiatric inpatients in the areas of overall cognition, immediate memory, and delayed memory; older age was associated with poorer language and attention. No psychiatric or cognitive factors predicted IV incidents., Conclusion: These results highlight the continued importance of understanding the psychiatric, forensic, and cognitive factors associated with aging in an institutional setting and how these factors among OASIS inpatients may vary from general psychiatric inpatients., (Copyright © 2017 American Association for Geriatric Psychiatry. All rights reserved.)

The current study examined the association between number of hours attended of the Illness Management and Recovery (IMR) program and psychiatric readmission rates after discharge from a state psychiatric hospital. The study used archival data, N = 1186, from a large northeastern state psychiatric hospital in the United States. A Cox's regression survival analyses was conducted, adjusting for extreme outliers and controlling for sociodemographic covariates, to examine the association between different amounts of IMR and the risk for returning to the hospital. After controlling for the client characteristics of age, sex, marital status, psychiatric diagnosis, and Global Assessment of Functioning score at discharge, as well as controlling for mean daily dose of generic hospital programming and the number of days of hospitalization, it was found that, for each hour of IMR, there was an associated 1.1% reduction in the risk for returning to the hospital. This suggests that participation in IMR while in inpatient settings may assist individuals in reducing their risk for returning to the hospital.

Introduction: Results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) indicate that, with the exception of olanzapine, no substantial overall differences were identified between second generation antipsychotics (SGAs) and the first generation antipsychotic (FGA) perphenazine., Methods: This study evaluated the effect of CATIE on antipsychotic prescribing. A retrospective review of 1807 adults with schizophrenia was conducted and relative quarterly percentages of FGA versus SGA prescriptions were calculated., Results: Time series analysis did not identify significant differences in rates of FGA prescriptions., Conclusions: Critiques of the methods used in CATIE may have mitigated its potential impact on antipsychotic prescribing despite cost-effectiveness of perphenazine treatment., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: Given financial difficulties precipitated by the flagging national economy, state policy makers are interested in the impact of Medicaid cutbacks on individuals with schizophrenia. Starting in 2003, the Oregon legislature eliminated all Medicaid coverage for large numbers of people, including many with schizophrenia. The objective of this project was to examine state psychiatric hospital utilization among persons with schizophrenia who maintained or lost Medicaid coverage., Methods: This longitudinal cohort study examined Oregon schizophrenia patients who had used Medicaid mental health services before the state's massive Medicaid reductions. Data were obtained from the state mental health, Medicaid, and vital statistics agencies. The outcome measures were involuntary psychiatric admissions to general hospitals and to state psychiatric hospitals, respectively. There were three cohorts, which comprised those who lost Medicaid coverage in calendar year 2003 (N=435), those who lost Medicaid coverage in 2004 (N=187), and those who maintained Medicaid coverage throughout study years 2002-2004 (N=3,427)., Results: Cohort members were on average 43 years old, and the sample was 42% female and 88% white. Analyses controlling for age, gender, race-ethnicity, Medicaid eligibility, and Medicare coverage showed that persons who maintained Medicaid coverage had little change in state psychiatric hospitalization, whereas utilization increased markedly over time for those who lost Medicaid coverage (p<.003). There were few differences in utilization of general hospital psychiatric units. Loss of Medicaid coverage generally preceded hospitalization., Conclusions: State policies designed to decrease Medicaid enrollment may have led to increased use of state psychiatric hospitals by former Medicaid enrollees with schizophrenia.

Background: The purpose of this article is to review the utilization and dosing of ziprasidone in a state hospital system and to compare the dosing to dosing recommendations contained in product labeling that suggest a starting dose of 40 mg/day and a target dose range of 40 to 160 mg/day for schizophrenia., Method: Dosing of ziprasidone was examined from the time when it was first marketed in 2001 up to and including calendar year 2006 using a database that contains patient information and drug prescription information for every inpatient within the adult civil facilities of the New York State psychiatric hospital system operated by the New York State Office of Mental Health. Supporting evidence for a therapeutic dose response for ziprasidone was examined by conducting a PubMed search for the period January 1, 1990, to June 1, 2008, identifying English-language articles related to ziprasidone dose in schizophrenia using the search terms ziprasidone, dose, and schizophrenia., Results: Although the highest efficacious dose of ziprasidone recommended in the manufacturer's product label is 160 mg/day, the mean dose of ziprasidone prescribed among patients hospitalized in New York State in calendar year 2006 and receiving antipsychotic medication (N = 7154) was 179 mg/day (N = 709), with 51.6% receiving doses in excess of 160 mg/day (N = 366). Patients discharged on treatment with ziprasidone (N = 189) received a mean dose of 206 mg/day. Patients with schizophrenia with a history of prior state hospital admission were more likely to receive doses greater than 160 mg/day. Clinicians in hospitals with the highest prescribing rates for ziprasidone were more likely to prescribe ziprasidone in excess of 160 mg/day. The initial dose on the first day for new starts on treatment with ziprasidone was 91 mg/day (N = 112). Published anecdotal reports describe the use of ziprasidone in excess of 160 mg/day and up to 640 mg/day among patients not responding to lower doses, but, currently, there are no published reports from double-blind randomized clinical trials establishing the utility of this high-dose treatment strategy., Conclusions: Dosing of ziprasidone in a large state hospital system is higher than what has been established in the registration program for schizophrenia. Although there is anecdotal evidence describing the use of ziprasidone in excess of 160 mg/day, controlled clinical trials are needed to determine if these higher doses are more effective., (©Copyright 2009 Physicians Postgraduate Press, Inc.)

This retrospective survey aims at describing patients subjected to prefrontal lobotomies and the general treatment conditions at Umedalen State Mental Hospital during the period 1947-1958. Data collected from psychiatric and surgical medical records was analysed using quantitative and qualitative content analysis. A total of 771 patients subjected to lobotomy during the years 1947-1958 were identified. From these, a sample of 105 patients was selected for the purpose of obtaining detailed data on socio-economic status, diagnosis, symptomatology, other psychiatric treatments applied before the pre-frontal lobotomy operation, time spent in hospital before operation, praxis of consent and mortality. The diagnosis of schizophrenia was found in 84% of the 771 lobotomized patients. The post-operative mortality was 7.4% (57 deaths), with the highest rate in 1949 (17%). The mean age of the patient at the time of operation was 44.8 years for females and 39.5 years for male patients. The average length of pre-operative time in hospital for females was 10.7 years and for males 3.5 years. It remains unclear why this mental hospital conducted the lobotomy operation to such a comparatively great extent. Factors such as overcrowding of wards and its status as a modern mental hospital may have contributed.

The lifetime outcome for individuals diagnosed with affective disorders is generally more favorable than for those diagnosed with a schizophrenic disorder. We determined if a similar differential outcome could be detected among 139 patients hospitalized on the admissions unit of a state psychiatric facility between 1998 and 2001, and diagnosed with a Schizophrenic, Schizoaffective or Affective Disorder. The placement of each patient on discharge was categorized as an outpatient environment, a minimum-security treatment unit, a locked ward, or a highly secure forensic facility. Patients with an affective disorder were significantly less likely than the other two groups to have a co-occurring diagnosis of substance abuse, and they performed better on the neuropsychological assessments. However, the groups did not differ in their discharge placements, or in their length of stay. These findings suggest that resolution of more acute symptomatology may be unrelated to factors associated with long-term outcome for individuals suffering from severe and persistent mental illness.

Objectives: The study was aimed at evaluating facets of psychiatric inpatient care of patients with schizophrenia in a German and a Japanese hospital., Methods: Based upon a sample of 865 inpatients of the Psychiatric State Hospital Regensburg (BKR) and 50 inpatients of the Tokyo Women's Medical University (TWMU) admitted in 1997, data of a psychiatric basic documentation system (BADO) were analysed with regard to essential process and outcome indicators., Results: Despite dissimilarities between both patient groups with respect to schizophrenic subtype, duration of illness as well as severity of illness and psychosocial functioning, the differences regarding therapeutic treatment and outcome were marked. In 1997, the rate of atypical neuroleptics was 18% at the BKR and 12% at the TWMU. Inpatients of the TWMU were given benzodiazepines and anticholinergic drugs significantly more frequently. Male patients of the TWMU showed more severe side-effects. Psychotherapy and sociotherapy were less frequently applied at the TWMU. Although the patient groups did not differ with regard to suicidal behaviour and overt aggressions during hospitalisation, we found a higher rate of mechanical restraints at the TWMU. In 1997, the average length of stay was significantly higher at the TWMU (153 days) than at the BKR (52 days), but inpatients of the TWMU improved only slightly better with regard to global psychosocial functioning (GAF) and severity of illness (CGI)., Conclusions: The revealed differences in treatment are likely due to differences in service provision and national practices in Germany and Japan and provide clues for quality improvements. The BADO is a useful tool for continuous quality management and an ongoing international exchange concerning psychiatric inpatient care.

Three hundred thirty-three elderly schizophrenic inpatients were rated on the Positive and Negative Syndrome Scale (PANSS), and those remaining in the hospital after 1 year (N = 267) were rated and followed for an additional year. Based on previous studies showing that aggressive episodes and hostile behavior predicted inability to discharge schizophrenics, we hypothesized that low discharge rates would be correlated with high baseline ratings on the activation factor of the PANSS (PANSS-AF), obtained by summing six items (hostility, poor impulse control, excitement, uncooperativeness, poor rapport, and tension). Baseline PANSS-AF scores were found to be inversely correlated with discharge rates, independent of ratings on other symptom dimensions. PANSS-AF scores were a better predictor of outcome than any individual PANSS item (e.g., hostility), and individual item scores did not add significantly to prediction of discharge. Attention to and development of treatments for activation symptoms, highly prevalent in schizophrenia but not included in our present diagnostic systems, may increase the chances of elderly inpatients with schizophrenia of moving to community settings.

Differences between public mental health delivery systems do not permit generalizing most research findings from one service system to another. Under certain circumstances, generalizing psychopharmacological research findings may be feasible when patients served at these health care systems share a similar illness severity profile. This study compared the illness severity of schizophrenia patients served at the Veterans Healthcare Administration (VA) with that for Non-VA Medicaid patients served at state facilities. Findings demonstrate remarkable clinical comparability and suggest the potential for generalizing psychopharmacological research findings from one health care delivery system to the other, after adjustments for relevant background characteristics.

Background: This retrospective study attempted to replicate the observation that African Americans are more prone to receive excessive doses of antipsychotics, even after variables that have not been well explored in previous studies (smoking and antipsychotic potency) are controlled for., Method: The populations of 2 neighboring U.S. state hospitals, which were screened for patients who smoked, were included. The total sample comprised 316 patients from the first hospital (surveyed in 1990) and 447 patients from the second hospital (surveyed in 1992) who were taking antipsychotics and were either African American or white. An excessive antipsychotic dose (greater than 1000 mg of chlorpromazine equivalents per day) was the dependent variable in logistic regressions in all patients and in those patients with or without (DSM-III-R) schizophrenia., Results: In the total sample from both hospitals, excessive dosing was associated with schizophrenia, age under 56 years, long hospitalization duration, high-potency antipsychotics, second hospital, and depot antipsychotics. The odds of being prescribed excessive doses of typical antipsychotics were 1.8 times higher for African American than for white schizophrenic patients. African American race in schizophrenic patients appeared to be associated with the prescription of high-potency antipsychotics and with excessive dosing of this type of antipsychotic. Excessive dosing did not appear to be associated with race in nonschizophrenic patients nor in schizophrenic patients taking low-potency antipsychotics., Conclusion: Pharmacogenetic differences are not likely to explain this racial difference in prescription of excessive dosing of high-potency antipsychotics, which suggests that clinician attitudes may be a possible explanation. In future studies, pharmacogenetic tests and control for confounding factors, such as smoking, will help to establish whether racial differences in dosing are influenced by different metabolic capacities or physician biases.

Objective: This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period., Methods: This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use., Results: There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication., Conclusions: In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders., (Copyright 2002 John Wiley & Sons, Ltd.)

This study compared the discharge rates and drug costs of 789 patients with schizophrenia or schizoaffective disorder who began pharmacotherapy with olanzapine or risperidone between July 1997 and June 1998. Discharge rates 30 days after the start of treatment were 45 percent for the patients treated with risperidone and 32 percent for those treated with olanzapine (p=.001). Daily drug costs during the same period were $6.42 for risperidone and $12.29 for olanzapine (p<.001). For risperidone, lower dosages were associated with higher hospital discharge rates, whereas no significant association was observed for olanzapine. These data suggest that among inpatients with schizophrenia or schizoaffective disorder, use of risperidone results in a higher discharge rate and a lower drug cost than use of olanzapine.

Objective: To report and discuss differences between schizophrenic patients in the community and those in maximum security care., Method: Comparison of 193 community schizophrenic patients with 169 in high security care. Data included case notes, interviews and cognitive tests., Results: Compared to high security patients, community patients tended to be female and married. They had higher school achievement, higher premorbid IQ and better occupational levels, were less likely to have a family history of alcohol abuse, to have had police contact and to have attempted suicide. They had more frequent shorter psychiatric admissions and fewer current and lifetime schizophrenic symptoms. Logistic regression models discriminated the groups with considerable accuracy., Conclusion: Patients needing high security care may be recognizable when schizophrenia is first diagnosed. Progression to the State Hospital seems to result from schizophrenia together with other factors such as deprivation rather than from a worse schizophrenic process per se.

Objective: We wished to study long-term psychiatric hospital utilization in a large sample of patients with schizophrenia and/or schizoaffective disorders who were treated with clozapine for up to 4.5 years, and to determine whether or not the reduction in hospital utilization we previously observed in smaller groups for up to 2.5 years was sustained with larger groups and in the longer term., Method: Patients in Texas state hospitals who had schizophrenia and/or schizoaffective disorder took either clozapine or traditional antipsychotics for 1.5 to 4.5 years. The number of patients in the clozapine group ranged from 383 (1.5 years of treatment) to 29 (4.5 years). The group of patients who took traditional antipsychotics was made up of all patients (N = 233) with similar diagnoses, symptom severity, and duration of illness present in Texas state hospitals on an index day., Results: The clozapine group showed a rapid and continuing decrease in hospital bed-days compared with controls who took traditional antipsychotics. The number of clozapine-treated patients who required little or no hospitalization during successive 6-month periods became significant (p < .0001) within 1.5 years, and continued to increase. Conversely, the number of patients taking clozapine who required virtually continuous state hospitalization decreased markedly compared with those taking traditional antipsychotics., Conclusion: Potential hospital cost savings are substantial, even though overall group results are diluted by clozapine nonresponders. Most treatment costs for clozapine nonresponders were related to hospital care; most or all of such costs would have been present in any event had these patients remained on traditional antipsychotic therapy. We believe a trial of clozapine therapy provides a low-cost opportunity for a highly effective and highly cost-saving outcome in those patients who will favorably respond to this therapy. We discuss clinical, social, and economic advantages of modern pharmaceutical treatments over traditional drugs.

This cross-sectional survey attempts to establish the prevalence of polydipsia and water intoxication at a state hospital (N = 360) using staff diagnosis, specific gravity of the urine (SPGU), weight changes, and chart review. There were 150 [42%, 95% confidence interval (CI) 37-47%] patients diagnosed as polydipsic by the staff or by SPGU. At least 93 (26%, CI 21-30%) had primary polydipsia not explained by other causes. Chart review identified 17 (5%, CI 3-7%) patients with a history of water intoxication. Using a case-control study design, schizophrenia, extended duration of hospitalization, and heavy smoking were associated with primary polydipsia in a logistic regression analysis (respective odds ratios were 1.6, 1.8, and 3.6). All patients with a history of water intoxication were Caucasian (versus 83% in those without a history) and had significantly more extended hospitalizations (94 vs. 49%). Future case-control studies should combine longitudinal identification of true cases and controls and exhaustive collections of clinical information in a standardized way.

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: 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.

Medical records of 90 consecutive patients who started clozapine were reviewed to see how this drug is being used with other psychotropic medications and to evaluate what impact it has had on the drug regimens of these patients. Data from up to 6 months before to 12 months after clozapine's initiation was included. The percent of patients receiving medications for antipsychotic side effects decreased from 86% 6 months prior to clozapine to 13% 12 months after. The use of benzodiazepines decreased from 43% to 23% during this time period as did lithium use from 57% to 17%. While 28% of the patients were receiving carbamazepine prior to starting clozapine, no patients remained on this drug concurrently with clozapine. The average number of psychiatric medications per patient decreased from 3.39 +/- 1.37 6 months prior to clozapine to 1.61 +/- .83 at month 12. Concern for drug interactions along with clozapine's reduced incidence of extrapyramidal side effects and increased efficacy contributed to the reduction in medication use observed.

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.

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.