Containing mental health treatment costs through program design: a Massachusetts study.

A single site pre-post study of seriously mentally ill patients treated in a public mental health system shows that annual treatment costs can be substantially reduced with the use of day hospital treatment. Two cohorts of psychiatric patients--282 consecutive admissions to a traditional public inpatient unit in 1980, and 340 consecutive admissions to a combination of inpatient and day hospital care in 1984--were followed 12 months after admission. The substitution of the day hospital is made possible because the facility provided a dormitory residence for those who could not go home at night. Cost savings per hospital episode are about 31 per cent when the additional costs of day hospital and residence are considered. Cost shifting from inpatient to residential sites is noted, but overall mean annual costs, when all other treatment (including additional admissions), residential and family costs were included, are reduced. Readmission rates did not rise. The generalizability of the findings is limited to public mental health centers and state hospitals.

The value of hospital-based treatment for the homeless mentally ill.

The access of the homeless mentally ill to the benefits of psychiatric hospitalization has been excessively limited by deinstitutionalization, the devaluation of the benefits of inpatient evaluation and treatment, a shortage of public-sector psychiatric beds, and a tendency to regard the homeless mentally ill as untreatable. A pilot program was devised to increase the access of the homeless mentally ill to short-term hospital-based treatment within a public mental health system in which beds are in short supply. The program's usefulness demonstrates the value of hospital-based treatment for this population and suggests that hospital-based treatment is currently underutilized.

A biopsychosocial approach to treating patients with affective disorders.

The authors describe the development of an affective disorders consultation service that implemented a biopsychosocial model of subspecialty consultation within a university-affiliated community mental health center. They retrospectively analyzed the first 2 years of consultations, assessing the process of consultation and examining patterns of consultee inquiries and consultation recommendations. Consultants recommended combined psychopharmacologic and psychodynamic therapies for most patients and found psychodynamic psychotherapy strikingly overlooked by consultees, all of whom were psychiatrists or other mental health professionals. This evaluation documents the psychiatric consultees' deemphasis of the biopsychosocial perspective in clinical practice.

The Quarterway House: a two-year cost study of an experimental residential program.

A comprehensive cost comparison was made of resource utilization by seriously disabled chronic psychiatric patients randomly assigned to inpatient care and to an experimental residential program that provided an intermediate level of 24-hour care. At the end of the two-year study period, no significant changes in patients' clinical condition were observed, but costs for the experimental group averaged about $14,500 less (in 1981 dollars) than for the controls. The cost model included all treatment costs and nontreatment costs such as medical care, community services, case management, law enforcement and fire safety, maintenance outside the mental health system, and collateral costs. The study findings suggest that a program such as this one may be a viable alternative to back-ward long-term care for seriously disabled chronic patients.

Mental health cost models. Refinements and applications.

This paper describes a 2-year study whose goal was to refine Burton Weisbrod's cost model for public programs for the chronically mentally ill. The authors made comprehensive cost assessments of all the resources, including treatment programs, used by a small sample of severely disturbed chronically ill patients. Refinement of the model included a method to assess capital costs of public facilities. The use of disaggregated patient information permitted analysis of cost differences between patients when adjusted for case mix. Patient costs over the study period ranged from $24,000 to $99,000. Patient characteristics and change in clinical status account for 30% of the variance.

Four-year assessment of a day hospital-inn program as an alternative to inpatient hospitalization.

The authors report on a new system of care in which all patients who require psychiatric hospitalization are admitted to a day hospital with an inn and an intensive care unit. Data on use of services, length of stay, recidivism, security, medical emergencies, staff accidents, and seclusion and restraint over a 4-year period suggest that the new delivery system provides care which is at least as effective as the previous system of care. Evidence is presented that the new system offers certain advantages, including less seclusion and restraint, fewer episodes of escape, and substantial cost savings.

From inpatient to inn status. A new residential model.

This article presents a new residential model that has been developed at the Massachusetts Mental Health Center. The "dormitory-inn" provides an alternative to 24-hour inpatient hospitalization for patients who traditionally would have been admitted and retained on inpatient services. Issues covered include hours and location, referrals, requirements for staff, medical and nursing coverage, and a review of the efficacy of the program.

Toward a biochemical classification of depressive disorders--VIII. Platelet monoamine oxidase activity in subtypes of depressions.

Platelet monoamine oxidase (MAO) activity was examined in 77 depressed patients (40 males and 37 females) and 28 controls (14 males and 14 females). Patients were compared across increasingly specific diagnostic groupings in a four-step data analytic procedure. In step 1, MAO activity in the total sample of depressed patients was compared with that of control subjects. In step 2, Unipolar depressed patients were compared with Bipolar (Bipolar I and Bipolar II) depressed patients. In step 3, Unipolar depressed patients with and without schizotypal features were compared. In step 4, both the nonschizotypal Unipolar patients and compared. In step 4, both the nonschizotypal Unipolar patients and nonschizotypal Bipolar patients were separated into those who met RDC criteria for a definite Endogenous depression and those who did not; and platelet MAO activity was compared in the resulting four groups. Results indicated significantly higher platelet MAO activity in nonschizotypal Unipolar Endogenous depressed patients than in nonschizotypal Bipolar Endogenous depressed patients or nonschizotypal Unipolar Other patients. In addition, the presence of a definite Endogenous depressive syndrome was associated with greater overall symptom severity in both Unipolar and Bipolar depressed patients. Findings are discussed with respect to the conflicting results reported in previous studies of MAO activity in patients with depressive disorders.

Toward a biochemical classification of depressive disorders, VI: Platelet MAO activity and clinical symptoms in depressed patients.

The authors compared platelet monoamine oxidase (MAO) activity with clinical signs and symptoms in 32 patients with unipolar depressions. There was a statistically significant positive correlation between platelet MAO activity and scores on the Hamilton Rating Scale for Depression and between platelet MAO activity and specific clinical signs and symptoms in the spheres of depression, psychic anxiety, and somatic complaints. The clinical items found to be related to platelet MAO activity correspond to symptoms reported by other investigators to be associated with favorable responses to treatment with MAO inhibitors.

Overview: deinstitutionalization of psychiatric patients, a critical review of outcome studies.

The authors performed a critical review of experimental studies on the outcomes for psychiatric patients of 1) alternatives to hospital admission, 2) modifications of conventional hospitalization, and 3) alternatives to continued long-term hospitalization. The internal validity of many of the studies was compromised by shortcomings in design and performance and generalizability limited by selection of patient populations. With these qualifications experimental alternatives to hospital care of patients have led to psychiatric outcomes not different from and occasionally superior to those of patients in control groups. This conclusion is best supported for alternatives to admission and for modifications of conventional hospitalization. The available studies do not permit firm conclusions regarding alternatives to continued long-term hospitalization of chronically ill patients or for a critical analysis of the optimal management of specific subpopulations of psychiatric patients. Satisfactory deinstitutionalization appears to depend on the availability of appropriate programs for care in the community.

A follow-up of deinstitutionalized chronic patients four years after discharge.

Twenty-seven chronically ill mental patients were followed up four years after their discharge from a state hospital to the Massachusetts Mental Health Center. In interviews with the patients and their caregivers, data were gathered on the patients' current places of residence, mental status, time spent in the hospital since discharge, levels of functioning, and quality of life. The authors found that patients tended to move from hospital to community, with rehospitalization dropping dramatically once patients were placed in the community; that the group of patients living in the community had a better average mental status; that all but two patients preferred their current living situations to life at the state hospital; and that the best predictor of community residence was age at first admission (over 20). Two policy issues are discussed: the relationship (or lack of one) between restrictiveness and type of residence, and the importance to the findings of changes in psychiatric practice over the lifetime of the sample.

Alternative to the back ward: the quarterway house.

The Quarterway House was founded in December 1978 to deinstitutionalize and provide rehabilitation services to a small group of long-term, seriously ill inpatients of the Massachusetts Mental Health Center. The purposes of the residential program are to provide a less institutional therapeutic environment and to develop a psychosocial treatment program that might enable some patients to move toward more independent settings in the community. In a randomized experimental study, with center inpatients as the control group, the effectiveness of the program was assessed by multiple outcome measures before the program began and at one year. Although neither group moved rapidly to more independent community living, Quarterway House patients showed improvement in general functioning and socialization-survival skills and decreased medication and seclusion. They did not show a decline in psychotic symptoms, obstreperousness, or antisocial behavior. Over-all, the findings suggest the program may prove useful for the long-term rehabilitation of severely ill patients.

A surfeit of surveys: escalating data demands on community mental health centers.

In a recent six-month period, a state-operated community mental health center was required to gather data for nine major surveys, reviews, and budget requests. Such surveys cover much the same ground, yet without any attempt to standardize formats so that the data a center compiles for one survey can be used in the next. The surveys frequently are not designed for the programs required to complete them; they are a drain on increasingly scarce staff time and deplete staff morale. A two-part solution to the problem would involve coordiantion and control of the demands for data, perhaps through the development of a model mental health data set and format by the National Institute of Mental Health, and the development of locally based, smaller-scale information systems. The latter step would generate more complete and reliable data for local clinicians and administrators and yield a limited amount of basic information to be used by outside agencies.

Toward a biochemical classification of depressive disorders. I. Differences in urinary excretion of MHPG and other catecholamine metabolites in clinically defined subtypes of depressions.

The urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) and other catecholamine metabolites was measured in a series of 63 patients with various clinically defined subtypes of depressive disorders. MHPG excretion was significantly lower in patients with bipolar manic-depressive depressions and schizo-affective depressions than in patients with unipolar nonendogenous depressions. Patients with schizophrenia-related depressions also excreted reduced levels of MHPG when compared with patients with unipolar nonendogenous depressions. Moreover, levels of urinary epinephrine and metanephrine were significantly lower in patients with schizophrenia-related depressions. These data, coupled with our recent finding that patients with schizophrenia-related depressions had significantly higher levels of platelet monoamine oxidase activity than control subjects of patients with unipolar endogenous depressions, suggest that we can discriminate three biochemically discrete subgroups of depressive disorders corresponding to the following clinically defined subtypes: (1) the bipolar manic-depressive depressions plus the schizo-affective depressions; (2) the unipolar nonendogenous depressions; and (3) the schizophrenia-related depressions.

Toward a biochemical classification of depressive disorders. II. Application of multivariate discriminant function analysis to data on urinary catecholamines and metabolites.

The previous article in this series reported on the differences in urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) in patients with various clinically defined subtypes of depressive disorders. We now report that further biochemical discrimination among depressive subtypes is provided by the following equation, derived empirically by applying multivariate discriminant function analysis to data on urinary catecholamine metabolits: Depression-type (D-type) score = C1(MHPG) + C2(VMA) + C3(NE) +C4(NMN + MN)/VMA + C0. In the original derivation of this equation, low scores were related to bipolar manic-depressive depressions, and high scores were related to unipolar nonendogenous (chronic characterological) depressions. Findings from a series of depressed patients whose biochemical data had not been used to derive this equation confirmed these differences in D-type scores among subtypes of depressions. The findings presented in this report further suggest that we can discriminate three biochemically discrete subgroups of depressive disorders.