Prediction of treatment outcomes: lifetime depression versus the continuum of care.

We sought to determine the impact of a lifetime diagnosis of major depression on addiction treatment outcome. Structured interviews were conducted upon admission, and consecutive structured interviews were conducted prospectively for treatment outcome at 6 and 12 month follow-up periods. A multisite evaluation study of patients undergoing addiction treatment for alcohol and drug dependence was conducted in private outpatient facilities. Two thousand twenty-nine subjects from 33 independent programs were enrolled in a national registry for addiction treatment outcomes. The patients received abstinence-based addiction treatment with referral to a 12-step recovery program, often Alcoholics Anonymous, and continuing care in the treatment programs. The outcome areas measured were treatment completion, posttreatment substance use, exposure to psychosocial relapse risk factors, involvement with continuing care (formal aftercare and peer support groups), and posttreatment vocational functioning, health care utilization, and legal involvement. The prevalence rate of depressive symptoms over at least a 2-week period (major depression) in our sample was 28%. Multivariate analysis with stepwise multiple regression indicated that the most powerful predictors (relatively) of posttreatment alcohol/drug use were peer support group attendance and program continuing care involvement. Lifetime depression by itself and in interaction with each of these factors accounted for less than 2% of the variance in outcome. Logistic regression yielded similar results in the prediction of abstinence versus relapse. Posttreatment more than pretreatment factors appear to be more decisive in predicting risk for relapse.

Lifetime diagnosis of major depression as a multivariate predictor of treatment outcome for inpatients with substance use disorders from abstinence-based programs.

A multisite, longitudinal study of patients undergoing inpatient alcohol and drug dependence treatment was conducted in private inpatient facilities, consisting of 4339 subjects from 38 independent programs enrolled in a national addiction treatment outcomes registry. Structured interviews were conducted upon admission, including documentation of current alcohol/drug disorder (DSM-III-R) and lifetime diagnosis of major depressive syndrome; structured interviews were conducted prospectively at 6- and 12-month follow-up periods. The prevalence rate of lifetime diagnosis of major depression in the sample was 39%. Comorbidity varied according to gender and substance of choice. Lifetime depressive symptoms did not correlate with differential length-of-stay, treatment completion, or follow-up consent and, at best, were very weakly associated with follow-up contact. Patients diagnosed with lifetime depression showed the same frequency of participation in posttreatment continuing care: they also showed statistically significant reductions in job absenteeism, inpatient hospitalizations, and arrest rates pre- vs. posttreatment comparable to those of patients without lifetime depression diagnosis. Lifetime major depressive syndrome was not a predictor of outcome in response to abstinence-based treatment. Involvement in posttreatment continuing care accounted for far greater outcome variance. Posttreatment vs. pretreatment factors may be more decisive in influencing risk for relapse.

Case management in psychiatry: an analysis of tasks.

OBJECTIVE: The authors analyze the concept of case management from the perspective of the task areas of psychiatry and demonstrate the importance of case management in the organization of psychiatric services. METHOD: The relevant literature was reviewed, and a functional analysis of current practices is provided. RESULTS: Case management is an ambiguous concept without a clear base in a professional discipline, and thus there is ongoing uncertainty about its mission, practice, and training, as well as authority and accountability issues. The activities of the case manager in both the private and the public sectors entail work in the task areas of medical care, rehabilitation, social control, growth and development, and social welfare. In all of these areas, the case manager may function in boundary management and in system enhancement and development as well as provide clinical services. CONCLUSIONS: Case management has considerable potential as a means of organizing and delivering mental health services in a cost-effective manner as long as its purpose, practice, and organizational structures are consistent. Psychiatrists should be involved in the organization of case management services.

Issues and approaches in evaluating managed mental health care.

Data on the ways in which alternative forms of managed care affect the costs, quality, and outcomes of mental health are needed to inform health policy and clinical care decisions. Such evaluations, however, are difficult to implement for conceptual and practical reasons. The definition of managed mental health care is reviewed, alternative forms are described, and the activities and procedures that constitute managed care are identified. Examples from existing studies are used to describe the common roadblocks to implementing evaluations and to suggest methods for dealing with these barriers.

Emergency physicians' ratings of alcoholism treaters.

The purpose of this study is to identify treaters whom emergency physicians perceive to offer effective treatment of alcoholism. A random sample of 2,500 emergency physicians received a questionnaire comparing attitudes toward Alcoholics Anonymous (AA) and professional alcoholism treaters. Physician agreement on the efficacy of alcoholism treaters was greatest for AA (87%), moderate for mental health professionals (including psychiatrists and psychologists, 55%) and least for physicians and surgeons (excluding psychiatrists, 23%; chi-square = 1,024, p = .000000005, df = 2). Physician education about other alcoholism treaters may be necessary if all types of treatment are to be considered for the emergency room patient.

Reporting alcohol-impaired drivers: results from a national survey of emergency physicians.

STUDY OBJECTIVE: The purpose of this exploratory study was to learn of physicians' opinions on mandatory reporting of alcohol-impaired drivers they encounter in the course of their clinical work to the police or authorities from the Division of Motor Vehicles. DESIGN AND PARTICIPANTS: Two thousand four hundred sixty-four physicians randomly selected from the American College of Emergency Physicians were sent an anonymous, one-time only, self-administered questionnaire seeking demographic information and assessing attitudes toward mandatory reporting and alcohol treatment. MEASUREMENTS AND MAIN RESULTS: One thousand fifty-five physicians returned the survey. Seventy-eight percent of respondents agreed with mandatory reporting. More than half expressed strong agreement. Through canonical discriminant analysis we are able to identify the complex factors influencing attitude toward mandatory reporting. CONCLUSION: Although our preliminary results must be interpreted with caution, it appears that with the appropriate legal safeguards, physicians are supportive of mandatory reporting of the alcohol-impaired driver encountered in the course of clinical work.

Single and repeated admissions to a mental health center: demographic, clinical and use of service characteristics.

Eight hundred and forty one patients with 1,135 consecutive admissions to a university-affiliated mental health center were studied to examine patterns of treatment program use. Twenty two percent of patients had repeat admissions accounting for 42% of hospital episodes. Single admission and repeater groups are compared, and differences among repeater subgroups with progressively greater numbers of admissions per patient are described. Only 10 patients with the highest number of admissions during the study period also were very high utilizers of all services (inpatient, crisis, day hospital, regional chronic state hospital). These patients' characteristics are discussed with implications for future study.

Regional variation in patterns of inpatient psychiatric care.

Regional variation in both average length of stay and number of beds per 100,000 population is described for inpatient psychiatric care in the United States during 1983. The greatest differences were between the Northeast and Mid-Atlantic regions, on the one hand, and the Pacific and Southwest regions, on the other. Medical centers of the U.S. Department of Veterans Affairs (VA), whose policies are largely centrally determined, followed the same regional trends. Regional average length of stay, particularly in public sector mental health care organizations, was higher in regions with more occupied beds per 100,000 population.

The impact of DRG-based budgeting on inpatient psychiatric care in Veterans Administration medical centers.

In 1985 the Veterans Administration (VA) implemented a prospective budgeting system for acute inpatient care based on diagnosis-related groups (DRGs). To assess the impact of this system on psychiatric care, this study reviewed data on all VA discharges for psychiatric or substance abuse disorders that occurred during the four years before and the four years after this system was implemented. During the four years following the implementation of DRG-based budgeting the number of annual discharges increased by 28.7% and the number of unique patients discharged increased by 15.5%. Average lengths of stay declined by 36.9% and total annual bed days of care per unique patient declined by 29.7%. These changes occurred in association with an 11.5% reduction in the total number of beds occupied by psychiatric patients, an 8.9% reduction in direct per diem expenditures for psychiatric care nationally, and a 32.7% decline in direct expenditures per episode, after adjustment is made for inflation. In spite of a continuing decline in the value of the available resources, largely due to the effect of inflation, prospective budgeting appears to have had a major impact on the pattern of inpatient psychiatric care in this large health care system.

Mentally ill chemical abusers discharged from VA inpatient treatment: 1976-1988.

Discharge abstracts were analyzed for all patients discharged from Department of Veterans Affairs (VA) medical centers with a primary non-substance abuse psychiatric diagnosis over a twelve year period (1976 to 1988). Patients were identified as Mentally Ill Chemical Abusers (MICAs) if they had a primary mental illness diagnosis and either a secondary substance abuse diagnosis or an admission for substance abuse treatment during the same fiscal year. The percentage of MICAs doubled, from 22.6% to 43.6%, during these twelve years. In 1988, MICAs were younger and more likely to be minorities than other VA psychiatric patients, and they spent only half as many days in the hospital per year.

Economics of practice and inpatient care.

The nature and structure of inpatient psychiatric services are rapidly evolving. This article identifies and explores how these changes are being influenced by four interrelated areas: rapid growth in general and private hospital psychiatric practice; increased connections of public, private, and voluntary sectors of care; the emergence and quick acceptance of capitated and managed care programs; and dramatic change and growth in the insurance industry. These four interrelated areas further the development of a two-tier system in psychiatry: one for those with insurance, and one of the poor and the severely disabled. The changes in these four areas have also led to greater demand for increased economic competition among services, and new alliances and innovations in the delivery of treatment. This article discusses how the four areas have combined to support a two-tier system and how they are likely to affect the future evolution of general and private hospital inpatient psychiatric practice.

Initial assessment data from a 43-site program for homeless chronic mentally ill veterans.

In May 1987 the Veterans Administration established the Homeless Chronically Mentally Ill Veterans Program at 43 sites to provide outreach, health care, and residential rehabilitation services. Intake assessment data on 10,529 homeless veterans screened as potential candidates for clinical services during the program's first 11 months are presented. With a median age of 40, the homeless veterans were considerably younger than veterans in the general U.S. population. More had served in the Vietnam era than in other military eras. Almost three-fifths were white, and a third were black; more than 40 percent were receiving some form of public support. Almost half manifested one or more severe psychiatric symptoms at screening, and almost two-thirds had previously been hospitalized for either a psychiatric or a substance abuse problem.

Medical practice in organized settings. Redefining medical autonomy.

Physicians are perplexed by the ongoing erosion of their individual professional autonomy. While the economic forces underlying such change have received much attention, the evolution of new organizational forms that modify and often diminish medical autonomy is less well understood. The practice of medicine is becoming more organized and more hierarchical. We emphasize the importance of organized medical groups, including the medical staff organization, as structures for appropriate peer monitoring, and for counterbalancing the burgeoning influence of governance and administrative constraints on practice. There is an ongoing tension within organizations between management, governance, and physicians. Over time one or another of these groups achieves some measure of dominance, but good management requires a balance of power. The role of the medical staff, which is poorly represented in some health care institutions and under threat in others, is considered. In general, we find that medical work is becoming more hierarchical, and that physician "leaders" do not substitute for collegial processes.

The emergency department surveillance of alcohol intoxication after motor vehicle accidents.

To assess the surveillance of alcohol intoxication by surgical house staff, we examined the charts of 346 motor vehicle accident patients who presented to the trauma center of an urban teaching hospital emergency department. Half of the charts were reviewed before and half were reviewed after June 1986, when Connecticut enacted PA86-345, a law changing court rules of evidence so that the analysis by a hospital of a patient's blood could be used to establish probable cause for driving while under the influence of an intoxicant. We predicted and found no change in house-staff practice after passage of the law, since information about intoxication was obtained for immediate treatment. The rate of testing remained constant at 25%, with the median alcohol concentration at 200 mg/dL. Not one patient was referred for alcohol abuse evaluation or treatment. We recommend more vigorous attempts to evaluate, diagnose, and refer patients who abuse alcohol since they threaten the public health.

Conceptual and methodological issues in the comparison of inpatient psychiatric facilities.

The authors compared the length of stay of acute admission patients at a mental health center and a nearby state hospital. The two facilities had significantly different length of stay distributions; the mean was not an adequate index to describe these patterns. Despite careful matching, patients at the state hospital were more disabled. Different patient characteristics were associated with length of stay at the two facilities, and these were also characteristics on which the patient populations differed at admission. The authors conclude that comparisons of hospitals, for example, on mean or median length of stay can be misleading unless the different functions, policies, and constraints of the facilities are taken into account.