Glucocorticoids inhibit activation-dependent expression of costimulatory molecule B7-1 in human monocytes

OBJECTIVE: The relationship between hospital utilization and psychometric, demographic, and diagnostic data was examined among veterans with psychiatric problems. METHODS: Data were obtained from the records of 500 psychiatric inpatients admitted to a Veterans Affairs medical center between 1984 and 1987 and followed for four years. All patients completed the Minnesota Multiphasic Personality Inventory, the California Personality Inventory, the Millon Clinical Multiaxial Inventory, and the Psychological Inventory of Personality and Symptoms. Stepwise linear regression analysis was used to predict the number and length of inpatient stays, and Cox and logistic regression analyses predicted rehospitalization. RESULTS: Higher rates of psychiatric hospital utilization were found among patients who were unmarried, who had disabilities connected with their military service, who had lower levels of adaptive functioning, and who were diagnosed as having posttraumatic stress disorder, drug or alcohol use disorder, or passive-aggressive or antisocial personality disorder. Higher utilization was also found among those whom psychometric data characterized as less responsible and more compulsive. The data also predicted the length of subsequent medical hospitalization and identified patients who stayed out of the hospital longer and who were not rehospitalized. CONCLUSIONS: Hospital utilization was found to be a function of psychiatric diagnosis, marital status, and various personality factors. Factors relating to social disadvantage also played a role. Axis I diagnoses, particularly substance use disorders, were as important as, if not more important than, axis II diagnoses in predicting utilization.     

Determinants of suicidal ideation: the role of substance use disorders

BACKGROUND: This study tested the hypothesis that the amount of psychoactive substance consumed (frequency and/or quantity), life problems resulting from this use, and a DSM-IV diagnosis of substance abuse/dependence are independent risk factors associated with increased suicidal ideation in a population of psychiatric inpatients with major depressive disorder. METHOD: 891 hospitalized patients with a primary diagnosis of nonpsychotic major depressive disorder (MDD) received a standardized, psychiatrist-administered assessment battery. To examine the relationship between admission suicidality and demographic, psychiatric history, and admission variables, chi-square analyses were used for categorical data and one-way ANOVAs were used for continuous indices. Stepwise hierarchical multiple regression analyses were performed to determine the set of variables that was independently related to admission suicidality level. RESULTS: There was general agreement between our findings and previous literature in regard to the association between severity of Axis I diagnosis, depressed mood, hopelessness, male gender, unemployment, involuntary treatment, and alcohol/drug problems and higher suicidal ideation. In our sample of hospitalized patients with unipolar major depressive disorder, higher current drug and/or alcohol dependency and high current use of alcohol or other substances of abuse were independently associated with higher levels of suicidal ideation. CONCLUSION: This association with higher suicidal ideation lends support to the importance of treating patients for both alcohol/drug problems and depression in an effort to decrease their risk for future suicide. We hope that our findings will improve the care that patients with dual diagnoses receive.     

Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients

OBJECTIVE: Relationships among different dimensions of patient satisfaction and selected demographic, clinical, and outcome variables were explored in a sample of severely ill people receiving inpatient psychiatric services. METHOD: The sample consisted of 81 patients admitted to and discharged from an inpatient psychiatric unit at a midwestern Veterans Affairs medical center. Stepwise multiple regression was used to examine the relationship between patient satisfaction and self-reported changes in quality of life, symptomatology, and level of functioning as measured by the Treatment Outcome Profile. Other variables such as diagnosis, length of stay, employment, living situation, and prior psychiatric and substance abuse treatment were also considered. A subsample of the most satisfied and dissatisfied patients was chosen to further explore variables contributing to satisfaction with services. RESULTS: Patient satisfaction was related to initial level of functioning, certain diagnoses, and treatment gains. Clinicians were highly accurate in identifying patients who were satisfied, based on blind chart reviews. CONCLUSIONS: This study underscores the significant relationships between patient satisfaction, psychiatric diagnosis, and other outcome measures, and argues for the validity and utility of patient satisfaction measures in assessing the efficacy of inpatient care.     

Prediction of outcome in neurotic disorder: a 5-year prospective study

BACKGROUND: There have been no previous studies of the outcome of different neurotic disorders in which a prospective group with original randomization to treatment have been followed up over a long period. Such studies are important in identifying the factors associated with good and poor outcome. METHODS: A 5-year follow-up assessment was made of a cohort of 210 psychiatric out-patients seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74) or dysthymic disorder (65) and randomized to drug treatment, cognitive and behaviour therapy, and self-help. A total of 182 of the patients (87%) were assessed after 5 years by examination of hospital and GP records using a standardized procedure and outcome determined with a four-point outcome scale. RESULTS: One hundred and seven (60%) of the patients had a favourable outcome but the remainder continued to be handicapped either intermittently or continuously throughout the 5-year period. Analysis of the value of initial data in predicting outcome using polychotomous step-wise logistic regression revealed that five variables were significant predictors of poor prognosis: older age; recurrent episodes; the presence of personality disorder at entry; general neurotic syndrome at entry; and symptom severity after 10 weeks. The initial DSM diagnosis and original treatment given, together with ten other variables, were of no predictive value. CONCLUSIONS: The long-term outcome of neurotic disorder is better predicted by age, personality and recency of onset than by other clinical variables with the exception of initial response to treatment.     

Gallstones and isoflurane hepatitis

OBJECTIVES: To assess the level of satisfaction of physicians in provincial psychiatric hospitals with Review Boards (RBs) regarding Civil Commitment Certificates (CCCs), Certificates of Incompetence (COIs), and Treatment Orders (TOs). METHOD: A total of 200 survey questionnaires were distributed to physicians in provincial psychiatric hospitals. Ninety surveys (completed by 25 females, 45 males, and 20 unknown gender) were returned, representing a 45% return rate. Because of their assignments (for example, outpatient department), not all physicians were involved with RBs, and the return rate is likely to have been influenced by this factor. RESULTS: Physician satisfaction rates of 58.2% for CCCs, 66.7% for COIs, and 70.0% for TOs were obtained. Stepwise multiple regression analysis showed that the level of physician satisfaction with RBs for CCCs was predicted best (44.7% of variance) by physician level of comfort with certification and years of institutional affiliation. Qualitative physician responses revealed 3 major themes: patient-related issues, physician-related issues, and RB structure- and process-related issues. CONCLUSIONS: Strategies that increase physician comfort level with RBs and changes in the medicolegal structure and process are discussed. A similar survey of patients and RB members is recommended.     

Combined MMPI and demographic data in predicting length of neuropsychiatric hospital stay.

Data available on 316 psychiatric patients, soon after admission to a hospital, were used in a multiple regression formula and in less formal statistical techniques to predict length of stay. Demographic and MMPI predictors made possible early identification of long stay patients at greater than base rate frequency. The asymptote of prediction was reached when 6 of 24 variables had been included, suggesting that further search in the area would be redundant. Prediction with the 5 prediction schema was stable on a cross-validation sample of 352. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Management of intractable intracranial hypertension in severely head-injured patients: second-tier therapy

This study examined pretreatment factors associated with attrition from a clinical trial for panic disorder. The study group consisted of 162 patients who began 11-visit treatments. Six domains (demography, panic disorder severity, psychiatric comorbidity, illness/treatment attributions, coping styles, and personality styles) with 52 variables were used to predict attrition. One hundred twenty-two patients completed and 40 dropped out from treatment. Final multivariate regression analyses showed that the following two variables were independently associated with attrition: lower household income and negative treatment attitudes; attributing the panic disorder to life stressors and greater age were independently associated with attrition at the trend level. Preliminary analyses suggested, in addition, associations between attrition and lower education, shorter length of prior treatment, higher anxiety sensitivity, lower agoraphobic avoidance, and a coping style of seeking social support that were not confirmed by best predictor analysis. Psychiatric comorbidity and personality styles were unrelated to attrition. The implications of these findings for future research and clinical practice are discussed.     

Medical-technical basis for creation of functional eye prosthesis - technical means for compensation of poor vision and blindness

Thirty-six hospitalized patients who were considered by emergency room physicians to have ingested medically serious tricyclic overdoses were studied. The purpose of the project was to determine if psychiatric diagnosis and associated psychiatric factors correlated with the severity of the overdose as defined by plasma drug levels. Medically serious overdoses were ingested by patients with alcoholism, primary affective disorder, undiagnosed psychiatric illness, and Briquet's syndrome. Prior psychiatric treatment, prior admissions, prior overdoses, or precipitating events did not correlate with the medical severity of the ingestion. Attempting to predict the individual medical severity of the overdose from psychiatric factors resulted in a dangerous underestimation of the risk of patients with Briquet's syndrome and an overprediction in the case of primary affective disorder.     

Use of demographic and clinical characteristics in predicting length of psychiatric hospital stay: A final evaluation.

The literature on patient demographic and clinical characteristics as predictors of length of psychiatric hospital stay suggests that investigators have been unsuccessful in producing a prediction model using this information to account for any substantial criterion variance. The present study maximized predictions of length of hospital stay by using a more powerful statistical procedure and an expanded number of predictor variables. Data were obtained on 877 patients who were discharged from psychiatric hospitals in 1980. Results show that despite these improvements, the resulting proportion of variance was moderate at best. It is concluded that increases in similar information are unlikely to improve predictions. The use of untapped variables (e.g., management philosophies and politically based information) is discussed. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postoperative brain infarction in a patient with the previous asymptomatic brain infarction

OBJECTIVE: Racial differences in variables that predict return to the psychiatric emergency room were examined. METHODS: A random sample of 319 clients was obtained from the logs of a psychiatric emergency room of a state-operated, acute care psychiatric hospital. The dependent variable was a return visit to the psychiatric emergency room within 18 months of the index visit. Separate logistic regression equations were calculated for African Americans (N = 163) and Caucasians (N = 156) to estimate the moderating effects of race. RESULTS: Four variables predicted return to the emergency room for both African Americans and Caucasians: previous visits to the psychiatric emergency room, previous psychiatric hospitalizations, current receipt of outpatient treatment, and nonreceipt of aftercare following the index visit to the emergency room. Three unique predictors were found for African Americans: never having been married, not living in stable housing, and not being admitted at the index visit. CONCLUSIONS: Generally, repeat visitors from both racial groups tended to be chronic users of psychiatric services who may be using the psychiatric emergency room for routine psychiatric care. However, race was also an important moderator variable; several risk factors predicted a return visit only for African Americans.     

Patients admitted to psychiatric hospital: Presenting problems and resolution at discharge.

Examined a cohort of admissions (N?=?280) to a 150-bed public psychiatric hospital to investigate homogeneity in patient problems and patient subtypes. The interrelationships of presenting problems, treatment provided, length of stay, resolution of presenting problems, and several other variables were also studied. Results indicated that many problems experienced by patients were not psychiatric symptoms. Most presenting problems were addressed but few resolved. The primary form of treatment was psychotropic medication. Many patients were discharged before treatment effectiveness was determined. Little association was found between diagnosis, patients' problems or patient subgroup, and psychotropic drugs prescribed. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Application of functional independence measure-function related groups and resource utilization groups-version III systems across post acute settings

OBJECTIVES: The present study evaluated alternative patient classification systems for skilled nursing facility and rehabilitation facility patients. METHODS: Medicare patients were selected from a random sample of 27 rehabilitation facilities and 65 skilled nursing facilities participating in a national longitudinal study of subacute care. Detailed casemix and resource use data was obtained on 513 patients with hip fracture and 483 stroke patients. The Functional Independence Measure-Function Related Groups (FIM-FRGs) classification system for rehabilitation facilities was replicated on length of stay and tested on resource use for rehabilitation facility patients as well as for skilled nursing facility patients. Modifications to the FIM-FRGs also were tested. The Resource Utilization Groups-Version III classification was tested on rehabilitation facility patients. RESULTS: The FIM-FRGs explained the same amount of variance in length of stay as in the original FIM-FRGs development sample (R2 hip fracture = 0.14, R2 stroke = 0.28), and similar variance in resource use. A modified version of the FIM-FRGs explained more variance in length of stay (R2 hip fracture = 0.19, R2 stroke = 0.39) and resource use (R2 hip fracture = 0.20, R2 stroke = 0.41). Neither model adequately predicted length of stay or resource use in skilled nursing facility patients. The Resource Utilization Groups-Version III rehabilitation groups accounted for little variance in rehabilitation facility patients' per-diem resource use (R2 = 0.11). CONCLUSIONS: The FIM-FRGs are valid for resource use as well as length of stay for rehabilitation facility patients, but are not valid for skilled nursing facility patients. Similarly, the Resource Utilization Groups-Version III system does not apply to rehabilitation facility patients. Related work, however, suggests that development of a single episode-based patient classification system for skilled nursing facility and rehabilitation facility patients is possible and should be pursued.     

Stroke rehabilitation: clinical predictors of resource utilization

OBJECTIVE: To identify predictors of rehabilitation hospital resource utilization for patients with stroke, using demographic, medical, and functional information available on admission. DESIGN: Statistical analysis of data prospectively collected from stroke rehabilitation patients. SETTING: Large, urban, academic freestanding rehabilitation facility. PARTICIPANTS: A total of 945 stroke patients consecutively admitted for acute inpatient rehabilitation. MAIN OUTCOME MEASURES: Resource utilization was measured by rehabilitation length of stay (LOS) and mean hospital charge per day (CPD). METHODS: Independent variables were organized into categories derived from four consecutive phases of clinical assessment: (1) patient referral information, (2) acute hospital record review and patient history, (3) physical examination, and (4) functional assessment. Predictors for LOS and CPD were identified separately using four stepwise multiple linear regression analyses starting with variables from the first category and adding new category data for each subsequent analysis. RESULTS: Severe neurologic impairment, as measured by Rasch-converted NIH stroke scale and lower Rasch-converted motor measure of the Functional Independence Measure (FIM) instrument predicted longer LOS (F2,824 = 231.9, p < .001). Lower Rasch-converted motor FIM instrument measure, tracheostomy, feeding tube, and a history of pneumonia, coronary artery disease, or renal failure predicted higher CPD (F6,820 = 90.2, p < .001). CONCLUSION: Stroke rehabilitation LOS and CPD are predicted by different factors. Severe impairment and motor disability are the main predictors of longer LOS; motor disability and medical comorbidities predict higher CPD. These findings will help clinicians anticipate resource needs of stroke rehabilitation patients using medical history, physical examination, and functional assessment.     

Living with hypoglycemia

BACKGROUND: Heart failure (HF) is one of the diagnosis leading to a high number of readmissions in our hospitals. There is some controversy about the role played by two groups of variables on the risk or readmissions: patient-dependent variables, such as clinical severity, and the characteristics of medical care during the previous admission, in terms of care quality. METHODS: Study population: admissions due to HF with home discharge. Design: case-control study. Cases: episodes followed by emergent admission within 30 days because of related diagnosis ("early readmission") (n = 51). Controls: random sample of episodes not followed by an early readmission (n = 51). Information collected: review of clinical records. Groups of predictive variables studied: demographics, clinical severity, clinical parameters prognostic of HF and characteristics of medical care. Bivariate and multivariate statistical analysis: logistic regression (LR). RESULTS: LR analysis detected only one variable predicting early readmission, the ischemic etiology. Odds ratio = 4.78 (95% CI: 1.44; 15.88). There were no differences between the study groups regarding age, sex, clinical instability at discharge, hospital stay length, severity (APACHE III and other evaluation methods) and other prognostic parameters of HF (ejection fraction, functional degree, cardiomegaly, concurrent diabetes, valvular disease, atrial fibrillation, hyponatremia, and use of anti-arrhythmic drugs). CONCLUSIONS: The risk for an early readmission is mainly explained by the clinical variables of patients, basically ischemic etiology, and not by the characteristics of medical care: clinical instability at discharge or hospital stay length.     

The lives of female physicians

Survey data from 113 female physicians, 634 male physicians, and 41 female dentists were compared. Instruments designed to assess work satisfaction, work stress, marital satisfaction, family competence, and psychiatric symptoms and treatment were used, thereby exploring important life domains concurrently. The results suggest that female physicians are much more like both male physicians and female dentists than anticipated. Generally, female physicians describe high levels of work satisfaction, moderate levels of work stress, average-to-high levels of marital satisfaction, and relatively low levels of psychiatric distress. Their lower levels of practice income remain something of an enigma as gender remains the most powerful predictor of income and is not replaced in statistical analyses by specialty, hours worked, or other significant variables. Finally, female physicians who find higher levels of satisfaction in work also report higher levels of marital satisfaction and fewer psychiatric symptoms. For these women, a highly satisfying medical career does not apparently need to be experienced at the cost of marital or personal distress.     

Changing patterns of inpatient care for children and adolescents at the Menninger Clinic, 1988–1994.

The authors describe trends in inpatient psychiatric length of stay (LOS) and admissions for the population of children and adolescents (N?=?784) at the Menninger Clinic from 1988 to 1994. During this period, median LOS declined dramatically from 7 months to 3 weeks, whereas admissions increased 4-fold. The diagnostic case mix changed substantially, with a crossover in modal principal diagnosis from personality disorder to affective disorder. Use of medications became almost universal. Diagnosis and medication use became less important determinants of LOS over time. The practical implications of these patterns include higher patient turnover, fewer inpatient clinical contact hours, and heightened importance of continuity with outpatient care. Research should center on the impact of declining LOS on clinical and functional outcomes for children and adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of the NOSIE to predict assaults among acute psychiatric patients. Nurses' Observational Scale for Inpatient Evaluation

OBJECTIVE: The study evaluated the Nurses' Observational Scale for Inpatient Evaluation (NOSIE), the Brief Psychiatric Rating Scale (BPRS), the Mini Mental State Examination (MMSE), and other measures as predictors of assaults that occurred during psychiatric hospitalization. METHODS: On admission, the MMSE was administered to 335 acutely ill psychiatric patients, and diagnostic and demographic data were recorded. Immediately after admission, patients were rated by nurses using the NOSIE and by psychologists using the BPRS. Patients who committed assaults during hospitalization (N = 47) and those who did not were compared, and relationships between several variables and assaults were evaluated by t tests, Mann-Whitney U tests, chi square tests, and analyses of variance. RESULTS: A high score on the irritability factor of the NOSIE and failure to complete the MMSE correctly predicted the occurrence or nonoccurrence of assault 81 percent of the time. None of the other variables examined were significantly related to assaults, including total scores on the BPRS and MMSE, psychiatric diagnosis, and several demographic variables. CONCLUSIONS: Scores on a test of distress level shortly after admission and failure to complete the MMSE on admission can help the clinician predict who will later engage in an assault.     

Traumatic brain injury in children and adolescents: psychiatric disorders at two years

OBJECTIVE: To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI. RESULTS: Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year. CONCLUSION: These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.     

Psychiatric diseases and their treatment in general practice in Germany. Results of a World Health Organization (WHO) study

As part of an international study initiated by the World Health Organization (WHO) about psychological disorders in primary health care, patients in the Federal Republic of Germany were compared with patients in other European centres. Patients from Germany do not differ from other European patients in respect to sociodemographic variables or psychiatric disorders. The most frequent CIDI-based diagnoses recorded in patients attending general practices are current depressive episodes (8.6%), generalized anxiety disorders (8.5%), neurasthenia (7.5%), and alcohol dependence (6.3%). In 20.9% of the patients at least one psychiatric diagnosis based on ICD-10 was recorded. In Germany significantly lower global ratings of health status are given than in other European centres although there is no difference in diagnostic prevalence rates. The recognition rate, i.e. the agreement between the CIDI-based ICD-10 diagnoses and the recognition as a case by the physician, is 56.2%-60.2%. On the other hand, the CIDI detects 90% of the patients described as psychologically ill by the physicians if subthreshold cases are also counted, or 46.4% if only defined diagnoses are taken into account. There is a significant correlation between severity of the psychiatric disorder and disability in social functioning. In Mainz and in the other European countries the disability rate of patients with a well-defined disorder is between 67.0% and 72.7%, whereas in Berlin this relation is not as clear, because especially in East Berlin there is a higher rate of unemployment in view of the political situation. Drug treatment is prescribed for 16.1% of the patients in primary care for psychiatric disorders. Half the patients recognized by physicians as cases receive medication. In the rest of Europe patients receive significantly more tranquillizers than in Germany, where the use of herbal drugs is more wide spread.