Abstract
We have noticed an increase in the number of patients who go through the court-ordered evaluation (COE) process but are not placed on a court-ordered treatment, and who then return to the hospital on another COE petition within one year from their initial discharge. The aim of this study is to examine what factors might be involved in rehospitalization in this population of psychiatric patients. The records of 146 readmitted patients and 146 randomized patients not readmitted were compared for various risk factors. Data were analyzed using univariate and mutivariate procedures. All patients who had diagnoses of substance-induced mood or psychotic disorders were readmitted within one year. Other risk factors included younger age, seriously mentally ill (SMI) status, longer length of stay and having a psychotic or schizophrenia spectrum disorder. Substance-induced mood or psychotic disorder may play significant roles for patients who are rehospitalized within a year of initial COE.
Key words: Civil commitment, court mandated, involuntary treatment, rehospitalization, risk factors, seriously mentally ill
Introduction
With deinstitutionalization of persons with mental illness, more and more mentally ill people live in the community. People with severe mental illness have a course characterized by periods of symptom exacerbation, and they are often noncompliant with treatment, resulting in frequent relapses, which lead to a greater risk of rehospitalization (Green, 1988; Haywood et al., 1995). The rates of rehospitalization vary widely, ranging from 22 to 80% (Bernardo & Forchuk, 2001; Jaramillo-Gonzalez, Sanchez-Pedraza, & Herazo, 2014; Priebe et al., 2009; Yussuf et al., 2008), and this variability has been attributed to different factors and needs to be considered in the context of the individual health care system. The highest rehospitalization rates of 80% were correlated with diagnoses including substance use disorder, schizophrenia, and bipolar disorder (Jaramillo-Gonzalez et al., 2014), while the lower rates were found to be correlated with prior history of admission and multiple admissions, diagnosis of schizophrenia, and longer length of stay. Other studies have demonstrated a variety of risk factors for rehospitalization that include demographic factors of younger age (Bernardo & Forchuk, 2001; Green, 1988), male gender (Houston & Mariotto, 2001), unmarried (Feigon & Hays, 2003) and unemployed (Rosca et al., 2006). The diagnoses associated with rehospitalizations include schizophrenia, bipolar disorder, or schizoaffective disorder and personality disorders (Rosca et al., 2006). Substance use is often comorbid (Haywood et al., 1995). One study (Boaz et al., 2013) found that both a shorter hospital stay and a shorter duration of being on psychotropic medications were associated with an increased risk of readmission, suggesting that patients may not have been sufficiently stabilized on their medications. The study also found that people with greater medical comorbidities were at long-term risk of rehospitalization. Similarly, in a naturalistic cohort study of patients with bipolar mania, Li, Lin, & Wu, (2018) found a 77.6% rate of rehospitalization that was significantly associated with psychotic features at baseline, discharge against medical advice, and more previous hospitalizations (Munk-Jørgensen, Mortensen, & Machón, 1991). Other risks include lack of psychosocial supports, inadequate community services, and nonadherence with medications (Barekatain, Maracy, Hassannejad, & Hosseini, 2013; Green, 1988; Haywood et al., 1995; Lfson et al., 1999; Priebe et al., 2009; Schmutte et al. 2010; Vijayalakshmi, Reddy, Salaam, & Himakar, 2015).
Most of the states in the United States have laws for involuntary commitment (Swartz & Swanson 2004). These laws have been controversial, with their use and efficacy contested by civil rights groups. Both mental health advocates and consumers oppose civil or involuntary treatment and argue that it infringes on the civil liberties of mental health consumers, are coercive in nature and may alienate patients from seeking treatment (Geller, 2006; Manohan, Swartz, & Bonnie, 2003; Swartz et al., 2010). However, involuntary commitment has been associated variably with decreased rehospitalization rates and shorter length of stay in some studies (Geller, 2006; Manohan et al., 2003; Swartz et al., 2010) and increased rates of rehospitalization in other studies (Geller, 2006; Manohan et al., 2003; Pfiffner et al., 2014; Swartz et al., 1999, 2010). Outpatient commitment is written in the statutes in most states, and there is legal support for evaluating the need for involuntary psychiatric treatment. The evaluation period varies from state to state, lasting from 72 hours in some states to 10 business days in other states before making a decision about mandated psychiatric treatment. The statutes across states also vary in terms of their timelines and types of treatment, with some states like New York that stop short of forcing medications (Swartz & Swanson, 2004) and other states like Arizona that can force medications on an outpatient basis for a year.
This study took place in in Arizona, United States, which has a longer timeline to determine whether or not an individual meets the criteria for involuntary commitment, including forced medication. During the court-ordered evaluation (COE) period lasting for 72 hours, the treating psychiatrist can at any time determine that the person does not need mandated treatment. However, if two independent doctors believe the person has a mental illness and needs psychiatric treatment, and there are two independent witnesses who will attest to the patient’s behavior prior to the emergency hospitalization, the patient then undergoes a court hearing to determine whether they meet the legal criteria for involuntary commitment or court-ordered treatment (COT). Thus, the patient may be discharged from the hospital prior to the court hearing because doctors did not identify the need for involuntary treatment, or the judge determined that the individual does not meet legal criteria for involuntary treatment, or there were not two witnesses to testify in court about their behavior, or the patient/patient family was able to convince the doctor of their willingness for voluntary treatment. The COT may be dismissed in court for a variety of reasons that include; the petitioners refused to attend the court hearing, the patient’s attorney was able to provide a compelling case to the judge about why the patient did not need civil commitment, or the patient/patient family convinced the judge that the patient would voluntarily follow through with therapy.
The hospital in which this study took place is designed as a hospital for the COE/COT process. Its purpose is primarily for the COE/COT process and for stabilization. Patients who need extended care are referred to appropriate treatment settings once stabilized on medications. Thus, most patients stay approximately two weeks.
We have noticed an increase in the number of people who go through the COE process but are not placed on a COT, and who then return to the hospital on another COE petition within one year from their initial discharge from the hospital. We found no study that examines this subset of people. The purpose of this study was to identify factors in this subset of patients that may affect their readmission in order to determine what was needed in this group with regards to outpatient interventions that would help them stay in the community and not return to the hospital.
Method
Participants
A list of patients who were released from the COE process was obtained from the county superior court, which is housed in the hospital adjudicating the petitions for civil commitment, for a one-year period of time from 1 March 2012 until 1 March 2013. Patients are on a COE phase for 72 hours, during which they are assessed by two independent psychiatrists to determine the criteria for a COT. The criteria include the presence of a treatable mental illness and if they meet one of the standards: danger to self, danger to others, perisistently or acutely disabled, and gravely disabled. Patients who do not meet criteria were released from the COE, while those who were identified as having a mental disorder went to court within four to six business days where the judge determined whether they met the COT criteria. Of the total 1230 patients who were released from the COE during our study time period, 146 patients were readmitted to the same hospital within a year of their initial discharge from the hospital. These readmitted patients were on another COE. This group became our readmitted group. A comparison or control group of 146 patients was selected using a statistical randomizer from the group of 1174 patients who were released from COE status but were not readmitted to the hospital within a year from their initial discharge.
Procedure
Patients in this study were admitted to a public community county hospital for involuntary evaluation. This hospital is the only hospital in the county that has a court that determines the court-ordered evaluation for involuntary commitment. The inpatient psychiatric population of the hospital is predominantly patients who are involuntary, and most of them have a serious mental illness. The hospital houses the mental health court, which is a Superior Court in the county adjudicating the petitions for civil commitment. The list of all patients who are petitoned in the county is maintained by the court. The readmission list was obtained from the records of the mental health court.
Data were gathered from the hospital electronic medical charts of patients in both groups for the index hospitalization and included the following: age, sex, ethnicity, marital status, time from discharge to readmission, length of hospitalization stay, diagnosis on discharge, comorbid substance use, medical conditions, family history of mental illness, family history of substance use, health insurance status, seriously mentally ill (SMI) status, adherence to psychiatric medication prior to admission, if the patient was discharged on a long-acting injectible medication, and if a follow-up appointment with an outpatient provider was made prior to discharge. The data were extracted manually from the electronic medical records. The variables were selected based upon previous studies that evaluated factors associated with psychiatric hospitalization readmissions and with the variables available in our database.
With regard to psychiatric diagnoses, only the primary Axis I Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM–IV) (American Psychiatric Association, 2000) psychiatric diagnosis and a substance use diagnosis, if given at discharge during the index hospitalization, were included in the analysis. Rare psychiatric diagnoses – that is, those with small numbers – were counted as ‘other’ and were excluded from our analysis.
Statistical analysis
Data were analyzed using univariate and mutivariable regressions. Univariate analysis was first used to identify characteristic predictors imbalanced between readmitted and never-admitted groups, and thus putatively associated with rehospitalization. Those that showed an association with rehospitalization (p < .10) were entered into a logistic regression using a forward stepwise selection process. An alpha of .05 was selected to indicate statistical significance for a factor/covariate to be retained in the multivariable model. Distribution of diagnoses within the readmitted group and the control group was evaluated using Fisher’s Exact test and t test. SPSS Version 22 (IBM Corp., Armonk NY) was used for statistical analysis.
Results
Descriptive analysis
Table 1 provides a summary of the socio-demographic and clinical characteristics for the readmitted and control groups. Six of the 14 collected factors/covariates showed significant differences between the readmitted group and the control group at the .05 level. Those in the readmitted group were significantly younger (34.0 ± 12.4 years) than those in the control group (37.4 ± 12.8 years). Patients readmitted had a longer length of hospitalization (7.4 ± 4.0 days) than those in the control group (6.3 ± 3.3 days). The control group of patients were more likely to have insurance, more likely to have SMI status, more likely to be discharged on a long-acting injectable medication and more likely to have had a follow-up outpatient appointment scheduled after discharge. The two groups did not show statistical differences for sex, marital status, homelessness, medical comorbidities or family history of mental or medical illnesses.
Table 1.
Demographic characteristics of readmitted patients and control group.
| Variable | Readmitted |
Control |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| M | SD | N | % | M | SD | N | % | P | |
| Age (years) | 34.0 | 12.4 | 37.3 | 12.8 | .024 | ||||
| Gender (males) | 87 | 59.6 | 78 | 53.4 | .345 | ||||
| Marital status | .174 | ||||||||
| Single | 97 | 66.4 | 85 | 58.2 | |||||
| Divorced/widowed | 24 | 16.4 | 23 | 15.8 | |||||
| Married | 25 | 17.1 | 38 | 26.0 | |||||
| Ethnicity | |||||||||
| Caucasian | 62 | 42.5 | 60 | 41.1 | N/A | ||||
| African American | 23 | 15.8 | 7 | 4.8 | |||||
| Hispanic | 19 | 13.0 | 13 | 8.9 | |||||
| Others | 6 | 4.1 | 2 | 1.4 | |||||
| Not reported | 36 | 24.7 | 64 | 43.8 | |||||
| Housing (homeless) | 32 | 23.9 | 35 | 24.6 | .882 | ||||
| Medical comorbidity | 93 | 63.7 | 53 | 24.6 | .717 | ||||
| Family history of mental illness present | 76 | 52.8 | 66 | 47.5 | .507 | ||||
| Family history of substance use present | 62 | 46.6 | 56 | 40.0 | .270 | ||||
| Insurance | 79 | 54.1 | 62 | 42.5 | .046 | ||||
| SMI status | 57 | 39.0 | 21 | 14.4 | <.001 | ||||
| Treatment adherence | 30 | 22.1 | 37 | 25.5 | .497 | ||||
| Length of hospitalization (days) | 7.4 | 4.0 | 6.3 | 3.3 | .007 | ||||
| Discharged on an LAI | 12 | 8.2 | 4 | 2.7 | .040 | ||||
| Follow-up on discharge | 87 | 59.6 | 57 | 39.0 | <.001 | ||||
Note: Court-ordered evaluation patients readmitted at least once: n = 146; control group who were never readmitted: n = 146. SMI = seriously mentally ill; LAI = long acting injecable.
Ethnicity was unreported in the electronic records in 24.7% of readmitted patients and 43.6% of controls. When reported, Caucasians were the predominant ethnicity in both groups, (42.5% in subjects and 41.1% controls), followed by African-Americans (15.8% in readmitted group and 4.8% in controls) and Hispanics (13% in readmitted group and 8.9% in controls). These percentages are similar to the overall hospital population in that Caucasians are the predominant ethnicity followed by African American and Hispanic populations.
Analysis of admitting diagnoses effect on time to readmit was limited to those five diagnostic categories comprising at least 10% of total diagnoses. Average plus or minus standard deviation time to readmit was 107 ± 101 days for the patients with admit diagnoses on the schizophrenia spectrum disorder, 88 ± 73 days for those with bipolar disorders, 134 ± 96 days for those with psychotic not otherwise specified (NOS), 103 ± 81 days for those with mood NOS, and 102 ± 89 days for those with substance-induced mood/psychosis (p = .50). The five diagnostic groups had a combined time to readmit of 105 ± 88 days.
Table 2 provides a breakdown of diagnoses between both groups. Most striking is the finding that all patients with an index discharge diagnosis of substance-induced mood disorder or substance-induced psychotic disorder (n = 37) were readmitted. A substance-induced mood or psychotic disorder were, therefore, highly associated with readmission. The diagnosis of a comorbid substance use disorder was not a distinguishing characteristic of those patients who were readmitted within a year of their index hospitalization. Distribution of diagnoses differs between the readmitted group and the control group (p < .001). The readmitted group had significantly more individuals with a primary diagnosis of a schizophrenia-spectrum disorder or a psychotic disorder than the control group (29 and 20 compared to 9 and 7). The readmitted group had significantly more people with diagnoses of polysubstance dependence, major depressive and other depressive disorders, intermittent explosive disorder and other diagnoses.
Table 2.
Index admission discharge diagnosis and characteristics of readmitted patients and control group.
| Admit diagnosis | Readmitted | Control group | p | ||
|---|---|---|---|---|---|
| N | % | N | % | ||
| Bipolar disorder – manic, depressed, mixed, not otherwise specified | 30 | 20.8 | 26 | 19.4 | .55 |
| Polysubstance dependence | 4 | 2.8 | 39 | 29.1 | <.001 |
| Mood disorder not otherwise specified | 19 | 13.2 | 21 | 15.7 | .7336 |
| Schizophrenia, schizoaffective, schizophreniform, delusional disorder | 29 | 20.1 | 9 | 6.7 | <.001 |
| Substance-induced mood or psychotic disorder | 37 | 25.7 | 0 | 0 | <.001 |
| Psychotic disorder not otherwise specified | 20 | 13.9 | 7 | 5.2 | .009 |
| Major depressive disorders, depressive disorders not otherwise specified | 4 | 2.8 | 21 | 15.7 | <.001 |
| Intermittent explosive disorder | 1 | 0.7 | 11 | 8.2 | .003 |
| Other diagnoses | 2 | 1.4 | 12 | 8.2 | .006 |
| Comorbid substance abuse/dependence | 93 | 63.7 | 90 | 61.6 | .7166 |
Note: Court-ordered evaluation patients, readmitted at least once: n = 146; control group, never readmitted: n = 146.
The results of the final logistic regression model are provided in Table 3. For purposes of the analysis, patients with substance-induced mood or psychotic disorder were omitted because they had no variability in the outcome (readmission status) – all were readmitted. The odds ratio for these diagnoses was not estimable. For the purposes of this logistic model, the bipolar group was used as the reference. The characteristics showing an association with being readmitted within one year of an initial hospitalization include having SMI status at discharge, having a psychotic disorder diagnosis and having a schizophrenia diagnosis. Consistent with the result from Fisher’s Exact test, the odds ratio (OR) statistics show that presence of a psychotic disorder (OR = 3.35, p = .03) or a schizophrenia disorder (OR = 2.277, p = .04) predicted a higher rehospitalization rate. SMI status at admission also increased the chance of rehospitalization (OR = 3.28, p < .001). In contrast, having a depressive disorder (OR = 0.24, p < .02), polysubstance dependence (OR = 0.11, p < .001) or intermittent explosive disorder (OR = 0.11, p = .04) and young age (OR = 0.97, p = .01) significantly lowered the risk of rehospitalization. Though included in the final logistic regression model, mood disorder did not appear to be independently associated with rehospitalization risk.
Table 3.
Results of stepwise logistic regression.
| Variable | p | OR | 95% CI for OR |
|
|---|---|---|---|---|
| Lower | Upper | |||
| SMI at admit | .00 | 3.28 | 3.28 | 6.66 |
| Age | .01 | 0.97 | 0.95 | 0.99 |
| Admit diagnosis | .00 | |||
| Reference: bipolar, manic, mixed, depressed, NOS | 1.00 | |||
| Psychotic NOS | .03 | 3.35 | 1.16 | 9.67 |
| Schizophrenia, schizoaffective, schizophreniform, delusional disorder | .04 | 2.77 | 1.06 | 7.20 |
| Mood disorder NOS | .94 | 0.97 | 0.41 | 2.27 |
| Major depressive disorder, dysthymic disorder, depressive disorder NOS | .02 | 0.24 | 0.07 | 0.83 |
| Polysubstance dependence | .00 | 0.11 | 0.03 | 0.35 |
| Intermittent explosive disorder | .04 | 0.11 | 0.01 | 0.93 |
Note: The most notable risk factor that all patients with a substance-induced mood disorder or a substance-induced psychotic disorder were readmitted could not be included in the table due to no statistical variability. SMI = seriously mentally ill; NOS = not otherwise specified; OR = odds ratio; CI = confidence interval.
Discussion
The purpose of this study was to determine characteristics that describe patients who are readmitted to an inpatient psychiatric hospital within one year of having their initial court order for treatment dropped with no subsequent mandated treatment. We found that all patients who were readmitted to the hospital within one year of their initial hospitalization had a substance-induced mood disorder or a substance-induced psychotic disorder. While previous studies have examined factors leading to rehospitalization, none have found that substance-induced psychotic or mood disorders are a primary factor in people who are rehospitalized. Additionally, the patients who were readmitted were younger, had insurance, met criteria for SMI status, had longer length of stays, were discharged on a long-acting injectable medication, had a follow-up psychiatric appointment scheduled for after their discharge, and were more likely to have a psychotic disorder or schizophrenia-spectrum disorder. Although being initially admitted with a substance-induced mood disorder or a substance-induced psychotic disorder is the most significant finding of this study, younger age, having insurance, having met the criteria for SMI services and having a psychotic disorder or schizophrenia-spectrum disorder are highly associated with readmission within one year of the initial admission. Our findings suggest that patients with a diagnosis of a mood disorder, polysubstance dependence, depressive disorders or intermittent explosive disorders, appear to be at low risk for readmission to the hospital within one year from their index admission.
Several studies have attempted to identify characteristics involved in rehospitalization in psychiatric patients. The results are mixed; our study is consistent with some but not all studies. There are mixed results with regard to substance use. Some studies found that substance use was a factor associated with rehospitalization (Barekatain, Maracy, Hassannejad, & Hosseini, 2013; Vijayalakshmi et al., 2015) while others found that substance use was not associated with readmission (Jaramillo-Gonzalez et al., 2014; Schmutte, Dunn, & Sledge, 2010). Our finding that substance use is not associated with rehospitalization adds to the latter’s findings.
Consistent with our findings, several studies found that the diagnosis of schizophrenia is associated with rehospitalization (Barekatain et al., 2013; Vijayalakshmi et al., 2015). Other psychiatric disorders like depression and bipolar disorder were found to be factors in readmissions (Jaramillo-Gonzalez et al., 2014), while our study found these disorders were not factors in readmission.
Demographic factors have also been found to be correlated with readmission. Like Vijayalakshmi, et al. (2015), we found that younger age at first admission was also associated with readmission. However, they found other factors that were associated with rehospitalization that we did not find, such as gender and marital status. Additionally, unlike the findings of Oyfee, Kurs, Gelkopf, Melamed, and Bleich (2009), we found no differences in sex between patients with frequent rehospitalizations versus patients who had no readmissions over a two-year period of time.
The findings that readmitted patients have insurance and have been found to have SMI status may be a factor of our system rather than a contributing factor to readmission. In our hospital system, all people admitted to the hospital are screened for SMI status and for criteria to obtain state insurance. Thus, depending upon their initial symptoms, people can meet the criteria for SMI status, but not necessarily meet the legal criteria for a COT. Additionally, if their financial situation meets the criteria for state health insurance, they continue to keep this insurance over a period of time, including at readmission in our study.
In general, our data suggest that patients who have the most serious mental illnesses and are younger may be more difficult to effectively treat once back in the community. This hypothesis stems from the fact that the readmitted group had a higher incident of psychotic/schizophrenic disorders, had longer length of stays (meaning that they took longer to stabilize), were discharged on long-acting injectable medications, and had met criteria for severe mental illness (SMI) status. Intuitively, this makes sense that people with the most severe mental illnesses may be more difficult to treat in the community and thus more likely to return for rehospitalization.
However, our data suggest that patients with substance-induced mood disorder or substance-induced psychotic disorder may be as important as the group of people with the most severe mental illnesses and should not be overlooked because of the substance use involvement but should be evaluated carefully. In fact, our data show that substance use in and of itself is not a risk factor for readmission. It is possible that those people who experience mood disorders or psychotic disorders when under the influence of alcohol or other substances may have an underlying vulnerability to more severe psychiatric disorders. Substance use or abuse may in some way trigger underlying mechanisms that lead to or unmask both mood and psychotic disorders that then become uncontrolled and lead to problematic behaviors in the community.
Our findings suggest that patients who are assessed as having a substance-induced psychotic or mood disorder may need a more stringent discharge plan that provides higher levels of support for sobriety and more frequent interactions with mental health. With identification, they can receive services and supports during and after their hospitalization that may reduce their risk of rehospitalization. In fact, our study findings suggest that future research in this population of people with substance-induced mood and substance-induced psychotic disorders is warranted.
Potential limitations of this study include that we did not match the control group with the second hospitalization group. Thus, there is the possibility that other characteristics were not accounted for in our sample. This research could be improved with another study that used the same design but that included a matched control group with the second rehospitalization group. Additionally, our population may not be applicable to other populations, in that many of the states vary in terms of defining laws for mandated psychiatric treatment. We were unable to determine the exact reason why the COE was dismissed by the court in all cases because these data were not available in the court records. Regardless of the reason the case was dropped, the dropped cases present potential confounding factors for our data in that some of the patients may have had characteristics that were unaccounted for and potentially led to inaccuracies in our data. Furthermore, our data came from an administrative database and were entirely retrospective in nature. Our resulting analyses were limited to the available data and may not be generalizable.
In conclusion, our study suggests that substance-induced psychotic disorder and substance-induced mood disorder may need to be taken much more seriously by those who treat psychiatric patients. These individuals may have a particular vulnerability to developing psychotic or mood disorders that are serious and long term. We suggest that more community support be put in place for these individuals as soon as they are identified. Education for the patients, support for sobriety including random drug checks, more frequent visits with psychiatry services and clinical teams that meet with the patient weekly may be the first step in warding off more serious mental illnesses and rehospitalizations. Our study also suggests that further study on substance-induced psychotic or mood disorders may be necessary to better understand how these particular individuals are affected by the use of substances in ways that most people are not affected.
Acknowledgments
This paper was previously presented at Academic Excellence Day, Phoenix, AZ, April 2015.
Ethical standards
Declaration of conflicts of interest
Shabnam Sood has declared no conflicts of interest
Gilbert Ramos has declared no conflicts of interest
Nancy Van Der Veer has declared no conflicts of interest
Curt Bay has declared no conflicts of interest
B. Rose Kaur has declared no conflicts of interest
Amr Nasef has declared no conflicts of interest
Napatkamon Ayutyanot has declared no conflicts of interest
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Maricopa Integrated Health Systems Institutional Review Board, MIHS IRB) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was not obtained from all individual participants included in the study as it was a chart review and granted the exempt status by the Institutional Review Board (IRB), reference number 2014-006.
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