Psychiatric Services Current Issue

Use of Longer Periods of Temporary Detention to Reduce Mental Health Civil Commitments

Tue, 15 May 2012 00:00:00 GMT

Objective:

This study examined whether lengthening the holding period for an individual experiencing a mental health crisis under a temporary detention order (TDO) can reduce the number and length of post- TDO involuntary hospital commitments.

Methods:

Data from the Virginia Court System were matched to the Commonwealth of Virginia Medicaid claims database for July 1, 2008, through March 30, 2009. The final data set included 500 Medicaid recipients who had a mental health diagnosis and at least one TDO during the study period. Covariates included sex, race, age, primary diagnosis, and Community Service Board serving the individual. Logistic and multivariate regression models were used.

Results:

Longer TDO periods were correlated with an increased probability of a dismissal of the commitment petition rather than hospitalization after a TDO. Among individuals who were hospitalized, longer TDO periods were correlated with an increased likelihood of voluntary hospitalization, rather than involuntary commitment, and shorter hospitalizations, although the net care time (TDO period plus post-TDO hospitalization) increased for individuals whose TDO length was greater than 24 hours.

Conclusions:

Longer TDO periods were correlated with shorter hospital stays and fewer involuntary commitments. These findings support previous work showing that short TDO periods provide insufficient time to stabilize and evaluate individuals. More research is needed to establish a causal link between TDO length and health outcomes. (Psychiatric Services in Advance, May 15, 2012; doi: 10.1176/appi.ps.201100359)

An Examination of Costs, Charges, and Payments for Inpatient Psychiatric Treatment in Community Hospitals

Tue, 15 May 2012 00:00:00 GMT

Objective:

Hospitalization is a critical component of treatment for individuals with serious and persistent mental illness. Despite its resource intensity, the costs of inpatient psychiatric hospitalizations in the United States are not well understood. The objective of this research was to provide cost estimates for inpatient psychiatric care.

Methods:

Using Premier's Perspective Comparative Database, supplemented with the MarketScan database, this study estimated the average charges, cost to provide care, and amount of reimbursement for inpatient psychiatric care in 418 community-based hospitals in 2006 (N=261,996 hospitalizations).

Results:

Charges were 2.5 times higher than the hospitals' reported costs to deliver care. Reimbursed amounts indicated by MarketScan were similar to the reported costs to deliver care. The average cost to deliver care was highest for Medicare and lowest for the uninsured: schizophrenia treatment, $8,509 for 11.1 days and $5,707 for 7.4 days, respectively; bipolar disorder treatment, $7,593 for 9.4 days and $4,356 for 5.5 days; depression treatment, $6,990 for 8.4 days and $3,616 for 4.4 days; drug use disorder treatment, $4,591 for 5.2 days and $3,422 for 3.7 days; and alcohol use disorder treatment, $5,908 for 6.2 days and $4,147 for 3.8 days.

Conclusions:

Consistent with past research, the results suggest that previous attempts to control pricing may have led to unintended consequences, including a large gap between charges and reimbursed amounts, potential cost shifting between payers, and potentially extended lengths of stay to offset reduced per diems. The lack of transparency in pricing makes it challenging to estimate the cost to society for a day of psychiatric hospitalization. (Psychiatric Services in Advance, May 15, 2012; doi: 10.1176/appi.ps.201100402)

The Role of Culture in Substance Abuse Treatment Programs for American Indian and Alaska Native Communities

Tue, 15 May 2012 00:00:00 GMT

Objective:

Culture figures prominently in discussions regarding the etiology of alcohol and substance abuse in American Indian and Alaska Native (AI/AN) communities, and a substantial body of literature suggests that it is critical to developing meaningful treatment interventions. However, no study has characterized how programs integrate culture into their services. Furthermore, reports regarding the associated challenges are limited.

Methods:

Twenty key informant interviews with administrators and 15 focus groups with clinicians were conducted in 18 alcohol and substance abuse treatment programs serving AI/AN communities. Transcripts were coded to identify relevant themes.

Results:

Substance abuse treatment programs for AI/AN communities are integrating culture into their services in two discrete ways: by implementing specific cultural practices and by adapting Western treatment models. More important, however, are the fundamental principles that shape these programs and their interactions with the people and communities they serve. These foundational beliefs and values, defined in this study as the core cultural constructs that validate and incorporate AI/AN experience and world view, include an emphasis on community and family, meaningful relationships with and respect for clients, a homelike atmosphere within the program setting, and an “open door” policy for clients. The primary challenges for integrating these cultural practices include AI/AN communities' cultural diversity and limited socioeconomic resources to design and implement these practices.

Conclusions:

The prominence of foundational beliefs and values is striking and suggests a broader definition of culture when designing services. This definition of foundational beliefs and values should help other diverse communities culturally adapt their substance abuse interventions in more meaningful ways. (Psychiatric Services in Advance, May 15, 2012; doi: 10.1176/appi.ps.201100399)

Screening, Diagnosis, and Treatment of Dyslipidemia Among Persons With Persistent Mental Illness: A Literature Review

Tue, 15 May 2012 00:00:00 GMT

Objective:

Cardiovascular disease is the most frequent cause of death of persons with severe and persistent mental illness, and there is evidence of a widening mortality gap with the general population. Modifiable risk factors for cardiovascular disease, including dyslipidemia, are frequently underrecognized and undertreated. This review provides practitioners with an update on screening, diagnosis, and referral or treatment of dyslipidemia in this population.

Methods:

A literature search in PubMed from 1990 to 2012 that used various combinations of the terms cholesterol, screening, diagnosis, treatment, and severe mental illnesses identified 74 clinically relevant articles for review, and reference lists guided further exploration of sources. Additional material was selected with a focus on emerging guidelines to create clinically relevant recommendations for practitioners.

Results:

Multiple barriers can prevent clinicians from obtaining samples from fasting patients, which can be detrimental to successful screening. Dyslipidemia can be successfully screened for with nonfasting total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides, with follow-up measurement of fasting low-density lipoprotein (LDL) cholesterol if total cholesterol is greater than 200 mg/dl or triglycerides are above 500 mg/dl. Compelling evidence supports pharmacologic treatment of dyslipidemia to reduce cardiovascular events among high-risk patients.

Conclusions:

When obtaining samples from fasting patients is not feasible, use of samples from nonfasting patients can radically improve management of dyslipidemia among persons with severe and persistent mental illness. Common medications used to treat dyslipidemia are inexpensive, safe, and effective and could be more liberally employed to address comorbidities in this population. (Psychiatric Services in Advance, May 15, 2012; doi: 10.1176/appi.ps.201100475)