Teaching managed care : philosophy and technique.

The authors describe a case-oriented seminar on managed care designed to teach psychiatric residents and medical students the principles of cost containment and delivery of quality care. The participants engage in role-play (reviewer, provider, appeal arbitrator) to elucidate the process. The response of the participants indicates that this seminar is a useful teaching model. Salient points regarding the content and process of the seminar are discussed in some detail.

GHB: a home brew.

Gamma-hydroxybutyric acid is an allegedly benign illicit substance that is gaining increasing recognition and attention among substance abusers and athletes. Alongside foreign-made brands, the compound is also easily available, at low cost because of the facility with which it can be produced in one's kitchen. Named by some "Nature's Quaalude" or sold as a health product, it is often used with a false sense of security as it may cause serious and disabling complications, as illustrated by this clinical vignette.

Retrospective study of 2,200 involuntary psychiatric admissions and readmissions.

OBJECTIVE: The authors describe demographic data, the distribution of diagnoses, and comorbid psychoactive substance use in a large sample of patients involuntarily admitted to a psychiatric hospital from multiple crisis centers and explore the relative roles these variables may play in service utilization and admission rates. METHOD: Data on demographic characteristics and comorbid psychoactive substance use in 2,200 consecutive involuntary hospital admissions of 1,755 psychiatric patients were gathered. Pertinent demographic and comorbidity data at first admission for the 1,755 patients, 314 of whom were admitted more than once, were analyzed; then the data for the 1,441 single-admission patients and the data at first admission for the 314 patients who had multiple admissions were compared. Finally, the diagnostic distribution and comorbid psychoactive substance use in all 2,200 admissions were investigated, with attention to a subgroup of 88 high-risk patients (those with three or more admissions) who represented a total of 307 admissions. RESULTS: Specific demographic characteristics were represented in the patient group at a high level of statistical significance. The diagnosis of schizophrenia was significantly overrepresented. Schizophrenia and psychosis not elsewhere classified clustered in the subgroup with a high risk of readmission. CONCLUSIONS: The results suggest a specific profile for the patient with heightened risk of hospital admission: a young, unmarried, African American male who has schizophrenia without comorbid substance abuse. An effect size data analysis identified marital status and a diagnosis of schizophrenia as the variables associated with the greatest likelihood of admission. Unexpectedly, the impact of comorbid psychoactive substance use was relatively modest and showed a uniform distribution among diagnostic groups.

Gender differences among civilly committed schizophrenia subjects.

The authors describe a sample of 815 acutely ill schizophrenia patients hospitalized under a petition for involuntary inpatient treatment and illustrate how this group of patients can be considered as more representative of involuntary commitment status than more traditional "involuntary" patients drawn from State hospitals' wards. Available demographics of the general population from which the sample was drawn are also presented for comparison. The authors then report the gender distribution of several variables--age, marital status, psychoactive substance use, comorbidity, length of stay, and frequency of readmissions--among the study sample and discuss the relevance of these findings.

Providers and reviewers teach informed managed care.

Two utilization review case studies are summarized, with discussion of both the provider's and the reviewer's perspective. This interface between managed care organizations and behavioral health care professionals offers some instructive guidelines on how to best approach the utilization review process.

Comorbid substance abuse and recovery from acute psychiatric relapse.

OBJECTIVE: The study investigated whether chronic mentally ill patients whose psychiatric relapse was complicated by active substance abuse recovered from relapse at a different rate than similar patients with no comorbid substance abuse. METHODS: A total of 401 patients involuntarily hospitalized on a short-term psychiatric treatment unit received a urine toxicology screen on admission; the severity of their psychiatric symptoms was rated on the fifth day of hospitalization using the Brief Psychiatric Rating Scale (BPRS). Differences in scores between patients who had positive screens and those who had negative screens were evaluated for various diagnostic groups. RESULTS: Patients who had a positive screen and a primary discharge diagnosis of psychoactive substance abuse had a BPRS total score indicating less psychopathology than similarly diagnosed patients with negative screens. Patients who had positive screens and a diagnosis of personality disorder had some BPRS subscale scores indicating greater psychopathology than their counterparts with negative screens. No other significant differences in recovery rates between the two groups were found, although comparisons indicated trends toward faster recovery in some areas of functioning by schizophrenic patients with positive screens and affective disorder patients with negative screens. CONCLUSIONS: Results suggest that use of a urine toxicology screen and the BPRS early in treatment may aid in assessing the acute course of several psychiatric disorders and the effect of comorbidity.

Reported prevalence of drug abuse comorbidity in a city-wide emergency rooms system.

Frequency and results of urine toxicology screens in a state-guided system of emergency rooms in a large city were compared with frequency and results of the same tests in the same population at a university-run intensive treatment psychiatric unit. Differences both in prevalence and in results were noted, with the emergency rooms testing significantly less patients than the intensive treatment unit and documenting a significantly lower rate of active substance abuse comorbidity to psychiatric disorders. Possible explanations for these differences are discussed, including clinical, attitudinal, and cost containment factors. These findings have a definite impact on treatment decision making, diagnostic precision, and validity of epidemiologic reports.

Factors related to emergency commitment of chronic mentally ill patients who are substance abusers.

A total of 247 chronic mentally ill patients committed for emergency involuntary hospitalization in a public intensive treatment unit were grouped on the basis of positive or negative urine toxicology screens for psychoactive substances at admission. Patients whose screens were positive for substance abuse were more likely to live alone or to be homeless, to be committed for making threats, and to have a diagnosis of organic mental disorder or substance abuse disorder. Patients who screened negative were more likely to live in a supervised setting, to be committed for actions such as assaults and suicidal behavior, and to have a diagnosis of schizophrenia or other psychotic disorder.

A retrospective study on the perceived need for and actual use of psychiatric consultations in older medical patients.

OBJECTIVE: The authors examined the (under) utilization of the psychiatric consultation service for patients aged sixty to seventy-five who were hospitalized for medical reasons, and explored whether one could retrospectively document and identify a greater need for psychological support than the one reflected in the number of actual consultations requested. Three questions were addressed: 1) the psychiatric consultation rate; 2) the frequency of unrecognized medical, psychiatric, and psychosocial complicating factors; and 3) whether the distribution of these factors differed by gender. METHOD: Records of 203 consecutively-admitted elderly patients hospitalized on medical wards were reviewed by two experienced general hospital psychiatrists for any indication of medical, psychiatric, and psychosocial risk factors. The frequency of actual psychiatric consultations was also recorded. RESULTS: Three or more risk factors were noted in the records of 36 percent of all patients. Consultation was sought for only 3 percent. Gender differences in type and distribution of risk factors were identified. CONCLUSIONS: Indicators and profiles that define probable need for psychiatric consultation were identified and briefly discussed. More well-designed, prospective studies testing these indicators and profiles are needed.