Relationship between climate and psychiatric inpatient length of stay in Veterans Health Administration hospitals.

OBJECTIVE: The study examined whether climate has an impact on inpatient psychiatric length of stay in Veterans Health Administration hospitals (VHA). METHOD: Data from the National Weather Service for eight climate variables for the locations of 134 VHA hospitals nationwide were factor analyzed, resulting in two climate factors representing temperature and precipitation. Factor scores were correlated with psychiatric mean lengths of stay from 1994 to 1998 for 99 VHA hospitals with inpatient psychiatric services and for the 22 VHA regional divisions (Veterans Integrated Service Networks). RESULTS: Climate factors correlated modestly but significantly with length of stay, with correlations ranging from -0. 25 to -0.37 at the hospital level and from -0.38 to -0.45 at the VHA regional level; hospitals in warmer and drier climates had shorter lengths of stay. Medical centers in colder climates had the longest lengths of stay in winter and fall. The significant correlation between climate and length of stay was not affected by recent reductions in length of stay in VHA hospitals. CONCLUSIONS: Higher clinical costs associated with longer lengths of stay in colder climates have implications for budget planning. Climate factors must also be recognized for their potential effect on performance monitoring systems focused on hospital utilization. Researchers must continue to consider broader contextual variables such as climate if they are to fully understand the determinants of health care utilization and psychiatric hospitalization costs.

Patients' threats. Expanded definition of assault.

Most studies of patient assaults against staff operationally define violence as episodes of unwanted physical or sexual contact. This study empirically assessed a broader range of patient violence by including verbal and nonverbal threats in addition to sexual and physical assaults. Preliminary data from a statewide survey suggested that patient threats were frequent events. Data from a team of staff assaulted by patients in one hospital suggested that some verbal threats produced as much psychological distress for staff victims as did some physical assaults. These findings suggest the need to consider including threats in future studies of patient assaults.

MMPI/MMPI-2: comparisons of amnesic patients.

The amnesic population provides a unique opportunity to examine the reliability of clinical tests because amnesics do not consciously recollect initial testing sessions. In this study, amnesic subjects were studied to examine the reliability between the Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI-2. Findings indicated that there were no statistical differences between versions of the MMPI and further revealed that many of the scales were significantly correlated. Amnesic patients produced elevated scores on subscales two (depression) and eight (schizophrenia), not unlike various other groups of neurologically impaired individuals. This indicates that MMPI and MMPI-2 scores in these patient populations may reflect the medical and psychosocial effects of brain damage rather than premorbid personality dysfunction. A close evaluation of amnesics' performance, in conjunction with the critical items they endorsed, offers insight into the personality traits of the amnesic patient population. The relative stability of performance across personality tests administered over several weeks is relevant to the formation and stability of the amnesic's concept of self.

Case mix in the "downsizing" state hospital.

OBJECTIVE: The study examined whether local variations in levels of community-based services affect the case mix of state hospitals undergoing census reduction. METHODS: Trends in case mix over a 14-year period were analyzed at two Massachusetts state hospitals, one of which underwent more rapid census reduction due to expanded community resources in the catchment area it served. Data on patients' hospital use and on sociodemographic and diagnostic characteristics obtained from 1977, 1986, and 1991 assessments of the hospitals' populations were compared. These time points represented the beginning, midpoint, and end of the census reduction period. Data from 1991 on patients' behavioral and functional status were also examined. RESULTS: Parallel trends on many dimensions were evident at the two hospitals as their censuses fell. By 1986 the hospital operating in the area with greater community services had fewer elderly and long-stay patients but a higher number of admissions per patient. In 1991 this hospital's population also had more patients with high-risk violent behaviors and lower levels of functioning. CONCLUSIONS: Although alternative treatment settings allow diversion of many types of patients from state hospitals, expanded community-based services and alternative inpatient beds have not diverted some patient subgroups, including recidivists and patients with behaviors that present risks in other settings. Plans for meeting the clinical needs and behavioral challenges posed by such patients must be part of any further deinstitutionalization or privatization efforts.

Effects of disability compensation on participation in and outcomes of vocational rehabilitation.

OBJECTIVE: The authors sought to determine the relationship between receipt of disability compensation and participants' success in a vocational rehabilitation program. METHODS: Administrative data for 22,515 individuals who participated in the Veterans Health Administration compensated work therapy program between 1993 and 1998 were analyzed. Six dependent variables were compared between participants who were receiving disability compensation and those who were not: duration of participation in compensated work therapy, number of hours worked per week, mean hourly earnings, total income from compensated work therapy, dropout rate, and competitive employment status at discharge. Regression equations were determined for each dependent variable to assess associations with the degree of disability, the amount of disability compensation, and the type of compensation program. RESULTS: Participants who were receiving disability benefits worked fewer hours in compensated work therapy each week, earned less income, had a higher dropout rate, and were less likely to be competitively employed at discharge. The amount of compensation and the type of program were modestly but significantly associated with participation in compensated work therapy and with outcome. CONCLUSIONS: Unintended effects of disability compensation programs discourage full participation in vocational rehabilitation and result in poorer rehabilitation outcomes.

Housing placement and subsequent days homeless among formerly homeless adults with mental illness.

OBJECTIVE: The study examined the influence of group or individual housing placement and consumer characteristics on the number of days subsequently homeless among formerly homeless mentally ill persons. METHODS: A total of 303 homeless shelter residents with severe mental illness were screened for dangerousness, 118 were randomly assigned to either independent apartment or staffed group living sites, and 110 were followed for 18 months. Study participants' sociodemographic characteristics, diagnosis, and residential preferences and the residential recommendations made by clinicians were measured at baseline. RESULTS: Overall, 76 percent of the study participants were housed at the end of the 18-month follow-up period, although 27 percent had experienced at least one episode of homelessness during the period. The number of days homeless was greater for individuals assigned to independent apartments than for those placed in staffed group homes, but only for members of minority groups. Substance abuse was the strongest individual-level predictor of days homeless. Individuals whom clinicians identified as needing group living experienced more days homeless, irrespective of the type of housing they received. Consumers who stated a strong preference for independent living had more days homeless than those who were amenable to staffed group homes. CONCLUSIONS: Although consumers more frequently prefer independent living, placement in staffed group housing resulted in somewhat fewer days homeless for some groups of consumers. Further experience of homelessness by formerly homeless mentally ill individuals may be reduced by providing effective substance abuse treatment and by paying special attention to consumers identified by clinicians to be at particular risk for housing loss.

Replicated declines in assault rates after implementation of the Assaulted Staff Action Program.

A program to address the psychological sequelae of patients' assaults on psychiatric health care staff--the Assaulted Staff Action Program (ASAP)--was previously shown to be associated with a notable decline in the assault rate at the state hospital where it was implemented. This study examined whether these findings would be replicated when ASAP was introduced at three additional state hospitals. Assault rates during the three months before implementation were compared with rates in the first four quarters after implementation. Each facility reported a similar significant decline in rates during the first quarter after implementation and no additional declines in the next three quarters.

Differentiating post-traumatic stress disorder (PTSD) from major depression (MDD) and generalized anxiety disorder (GAD).

Questions about the differential diagnosis of Post-Traumatic Stress Disorder (PTSD) have been raised since this category was reformulated in DSM-III (APA, 1980). Clinicians have reported difficulties distinguishing PTSD from other categories, particularly from Major Depressive and Generalized Anxiety Disorders (MDD and GAD). Diagnostic validity can be established in several ways (e.g., through clinical descriptive studies, laboratory experiments, family history studies, etc.). In this paper, we describe one approach to validation thus far not applied to PTSD: This approach centers directly on whether clinicians can distinguish PTSD from other diagnostic categories. Experienced clinicians were asked to rate the extent to which a common set of 90 symptom items characterized PTSD, MDD, and GAD. Ratings were analyzed with multivariate and univariate analyses of variance and covariance, multiple discriminant function analysis, and factor analysis; moreover, characteristics of rates were examined for possible influences. Results indicated that clinicians readily distinguish PTSD from MDD and GAD as well as MDD from GAD. Findings are presented in terms of univariate analyses, 34 best discriminating items, and factors specifying dimensions differentiating the syndromes of PTSD, MDD, and GAD. Rater characteristics did not influence diagnostic accuracy, although significant differences in magnitude of symptom intensity were found.

The effect of increased cocaine use on drug treatment.

Trends in primary illicit drug use were monitored in an inpatient drug treatment program over a 10-year period, along with illicit drug used in a methadone maintenance program over a six-year period. The percentage of cocaine users admitted for inpatient treatment showed an increase for each six-month interval over the past three-year period. Cocaine was found to be the most frequently used illicit drug by methadone maintenance clients, and its continued use disrupted both inpatient and outpatient treatment. Implications for treatment are discussed.

Four addictions: the MMPI and discriminant function analysis.

Over the past twenty years many MMPI studies of substance abuse have investigated the complex relationship between personality profile and drug of choice. This work has repeatedly established that alcoholics, heroin, cocaine and polydrug addicts share 4-2/2-4 (Psychopathy and Depression) or 4-8/8-4 (Psychopathy and Thought Disorder) MMPI profiles, but that the substance abuse populations differ in the plane of severity in that general profile. The alcoholics occupy the least disturbed sector, the polydrug abusers the most disturbed level and the heroin and cocaine addicts positions of moderate disturbance. The vast majority of studies, however, cite only group means to buttress their conclusions. Our work probed more deeply into the data using Discriminant Function Analysis. With this methodology we discovered important differences between the groups, previously hidden, which may carry differential treatment implications.

Characteristics of substance-abusing persons with schizophrenia: the paradox of the dually diagnosed.

Previous studies have noted the paradox of the dually-diagnosed (serious mental illness and substance abuse) in which the dually-diagnosed are judged to be both behaviorally more disorganized and simultaneously more socially competent. This study sought to further assess this paradox with a large sample size and a comprehensive assessment approach. In this study, the dually-diagnosed (N = 233) differed significantly from the non-dually-diagnosed (N = 262) in the symptom paradox. The dually-diagnosed were judged both more behaviorally disorganized and socially intact. The comprehensive assessment approach yielded empirical data in support of three possible hypotheses to explain the paradox. The implications of the findings and the three possible hypotheses are discussed.

The long-term impact of child abuse on religious behavior and spirituality in men.

OBJECTIVE: Two hypotheses were tested: (1) In a sample of adult men, past experience of child abuse (sexual, physical, or emotional) will be related to higher levels of reported alienation from religion and God as shown in lower rates of current religious behavior, higher frequency of spiritual "injury," and lower stability of religious behavior and experiences; (2) More "severe" forms of abuse will be associated with higher indicators of alienation. METHOD: Data were collected from 1,207 male veterans, 527 (43.7%) of whom reported being abused as a child. Each subject completed the Spiritual Issues Assessment, a large survey which includes data about: (1) KASL Religiosity Index; (2) The Spiritual Injury Scale; and (3) Religious items from the Westberg Personal Health Inventory. RESULTS: A history of sexual abuse was related to significantly greater spiritual injury and lower stability of spiritual behaviors and experiences, but not to overall rate of current religious behavior. Surprisingly, abuse was related to increased frequency of prayer and of "spiritual experience." Multivariate analyses indicate that the effect size is relatively small and the type of abuse was less important than the presence of any form of abuse. CONCLUSIONS: The findings suggest that the impact of childhood abuse is more complex than initially hypothesized. While abuse seems to be related to continuing spiritual injury and distress, it is also related to higher levels of some spiritual activities and experiences which are usually associated with positive spirituality.

Coping and defending styles among Vietnam combat veterans seeking treatment for posttraumatic stress disorder and substance use disorder.

A review of the literature on coping processes in addiction disorders yields at least two notions: one, that substance abuse is associated with less efficient, avoidant ways of coping with problems in living; and two, that substance abusers with a background of traumatic and stressful experiences are readily distinguishable by even more avoidant coping styles. These notions were tested in the form of three hypotheses: (1) substance abusers in general employ more avoidant coping styles than do nonaddicted groups; (2) Vietnam combat veterans meeting DSM-III criteria for both substance use disorder and posttraumatic stress disorder (PTSD) evidence significantly more avoidant coping styles than do Vietnam combat veterans meeting criteria only for substance use disorder but not PTSD--particularly when dealing with internal states of anxiety; and (3) for those meeting both substance use disorder and PTSD criteria, black Vietnam combat veterans (who presumably have encountered more stress, as minority group members) evidence more avoidant coping styles than do white Vietnam combat veterans. These three hypotheses were tested with Peck's (1981) newly developed Individual Styles of Coping, measuring four stages in the coping process for five behavioral contexts. All three hypotheses were confirmed. Results were discussed as confirming recent changes in DSM-III-Revised (1987) criteria, emphasizing generalized avoidance manuevers as criterial, in part, for diagnosing PTSD (in addition to behaviors of specific avoidance of traumatic memories). Theoretical implications about a traumatogenic dimension for substance abuse among some Vietnam combat veterans were discussed, as well as ramifications for treatment programming.

Critical incident stress management (CISM): the assaultive psychiatric patient.

Critical Incident Stress Management (CISM; Everly & Mitchell, 1999) is an integrated, multicomponent crisis intervention approach that is helpful in mitigating and preventing the potentially adverse consequences associated with critical incidents. The CISM model may serve a valuable heuristic purpose in the planning and development of CISM approaches in a wide variety of organizations and industries. This paper reports on the use of the CISM approach (Everly & Mitchell, 1999) as a guide or template in developing an enhanced and updated Assaulted Staff Action Program (ASAP; Flannery, 1998) approach to service delivery. ASAP is a voluntary, peer-help, CISM approach for staff who are assaulted by patients. The updating of its comprehensive services was necessitated by recent research and clinical experience on the changing nature of the assaultive psychiatric patient.

The Assaulted Staff Action Program (ASAP) and declines in the prevalence of assaults: community-based replication.

The Assaulted Staff Action Program (ASAP) has been associated with sharp reductions in the frequency of patient assaults on staff in four state hospital settings. Recent national trends in healthcare have resulted in an emphasis on community-based services. This case study sought to assess the effects of ASAP and findings of reduced assaults in a community-based program. In a single-case design, in which the facility served as its own control, an ASAP program was fielded in a community mental health center. A similar sharp reduction in violence was observed. The implications of the findings are presented.

Cyclical variations in psychiatric patient-to-staff assaults: preliminary inquiry.

This study examined possible cyclical variations in psychiatric patient assaults against staff. A statistically significant greater number of assaults occurred during hotter months. Possible explanations are presented.

Validity and clinical scale comparisons between the MMPI and MMPI-2 with psychiatric inpatients.

This study was designed to investigate the comparability of the original MMPI (1950) and the MMPI-2 (1989) with a psychiatric patient population. 34 male and 3 female patients, shortly after admission to one of two acute psychiatry units, completed the old and revised versions of the MMPI. Paired t tests indicated but scant differences for raw scores, while many more differences were found among T scores for validity, clinical, and supplemental scales. Analyses, however, showed all scales on the two forms to be highly correlated. Analysis of the high-point and two-point codes across the two administrations also showed relative stability, although the proportion of Scales 2 (Depression) and 8 (Schizophrenia) decreased, while those for Scales 6 (Paranoia) and 7 (Psychasthenia) increased markedly in the MMPI-2 protocols. Examination of each version's discriminability among mood- and thought-disordered subsamples suggested that the MMPI provides slightly better delineation between diagnostic classes. Discriminant function analyses showed that there were essentially no differences between the two forms in the accurate classification of clinical and nonclinical groups. The findings reported here provide support for the MMPI-2; despite modification, the newer form retains the advantages of the original MMPI. Differences found here may be unique to psychiatric patients and their patterns of MMPI/MMPI-2 equivalence and may not generalize to other special populations.