Sara Wiesel Cullen

The Impact of Severe Mental Illness On Parole Decisions Social Integration Within a Prison Setting

This study examined the extent to which severe mental illness (SMI) affects parole release decisions either directly or indirectly through its association with other factors considered in the parole release decision-making process. A random sample of 407 inmates with parole release decisions in 2007 (200 with SMI and 207 without SMI) was selected from the New Jersey State Parole Board. Data on inmates’ program participation, misconduct, and job assignments while incarcerated along with levels of community support and other pertinent release factors were collected. Differences between the SMI and non-SMI groups as well as the relationships among study variables, SMI, and release decisions were examined. Findings indicate that persons with SMI were released to parole at a rate similar to that of persons without SMI. However, the presence of SMI was associated with disciplinary infractions while incarcerated, which in turn negatively affected parole release decisions. Policy implications are discussed.

Exploring the potential of stricter gun restrictions for people with serious mental illness to reduce homicide in the United States

This study explores the potential that current efforts to limit access to firearms for individuals with serious mental illness (SMI) have for reducing overall rates of murder by firearm in the United States. Official arrest, court and health records provided data on personal and offense characteristics of 95 individuals with SMI and 423 without, all of whom had been convicted of murder in the State of Indiana between 1990 and 2002. Bivariate analyses examined differences between the two groups and logistic regression models examined the relationship between SMI and offense characteristics. Compared to those without, a relatively small proportion of convicted murderers had a diagnosis indicating SMI. The presence of SMI was associated with reduced likelihood of targeting a stranger and was not associated with having multiple-victims or firearm use. Focusing on access to firearms exclusively by individuals with SMI will have little impact on multiple-victim or firearm-related homicides.

Toward Understanding Errors in Inpatient Psychiatry: A Qualitative Inquiry

While prior research has identified the impact, nature, and causes of medical error in general medical settings, little is known about errors in inpatient psychiatry. Understanding the broad range of errors that occur in inpatient psychiatry is a critical step toward improving systems of care for a vulnerable patient population. An explorative qualitative analysis of key informant interviews identified a preliminary typology of errors and the contextual factors that precipitate them in inpatient psychiatry. The types of errors and their contextual factors fall broadly within the rubric of categories identified in medicine and surgery. However, many of the specific errors and contextual factors manifest themselves differently and are shaped by the uniqueness of the inpatient psychiatric setting and patient population. Interventions geared toward improving systems of care for psychiatric patients should draw on best practices for safety in medicine and surgery, but also be complemented with new strategies specifically tailored to the inpatient psychiatric setting.

Maternal mental health and pediatric health care use among a national sample of Medicaid- and SCHIP-insured children.

While the literature has shown that health care use is associated with mental health status, little is known about the relationship between a mother’s mental health status and her children’s health care use. This study examined the association of maternal mental health status and pediatric health care for their children in a nationally representative sample of 17,830 women parenting children ages 0–17 insured through Medicaid or a State Children’s Health Insurance Program (SCHIP). Mothers with a mental health problem were significantly more likely to be poorer, single parents, with lower levels of education, fewer parenting supports, and greater difficulty coping with parenting than mothers without a mental health problem; however, they reported comparable receipt of pediatric health care for their children, indicating their resilience as caretakers. The findings also suggest that all Medicaid- or SCHIP-eligible families could benefit from targeted engagement strategies linking them with consistent and appropriate sources of pediatric health care.

Suicide in Inpatient Settings: Are Our Hospitals Safe Enough?

The authors discuss the implications of findings regarding suicides in hospitals.

Safety of Psychiatric Inpatients at the Veterans Health Administration

OBJECTIVE Although reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field. METHODS The study included a random sample of 40 psychiatric units from medical centers in the national VHA system. Standardized abstraction tools were used to assess the electronic health records from 8,005 hospitalizations. Medical record administrators screened the records for the presence of ten specific types of patient safety events, which, when present, were evaluated by physician reviewers to assess whether the event was the result of an error, whether it caused harm, and whether it was preventable. RESULTS Approximately one in five patients experienced a patient safety event. The most frequently occurring events were medication errors (which include delayed and missed doses) (17.2%), followed by adverse drug events (4.1%), falls (2.8%), and assault (1.0%). Most patient safety events (94.9%) resulted in little harm or no harm, and more than half (56.6%) of the events were deemed preventable. CONCLUSIONS Although patient safety events in VHA psychiatric inpatient units were relatively common, a great majority of these events resulted in little or no patient harm. Nevertheless, many were preventable, and the study provides data with which to target future initiatives that may improve the safety of this vulnerable patient population.

Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors

OBJECTIVES This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness. METHODS Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts. RESULTS Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes. CONCLUSIONS Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units

BACKGROUND Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHAs Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

Relationship Between Maternal Psychotic Disorders and Pediatric Health Care Guideline Adherence

Objective: Although the majority of women with serious mental illnesses (SMI) are mothers, limited research is available on the relationship between maternal SMI and pediatric health care use. Adherence with preventive care is associated not only with improved childrens health and well-being but also decreased costs to the health care system. This study examines the relationship between maternal psychotic disorders (PDs) and pediatric health care. Method: This retrospective secondary analysis of Medicaid claims compares age cohorts of children (0 to 4 years) of mothers with and without PDs. Bivariate and multivariate logistic regression models are used to examine established measures of pediatric preventive care and emergency department (ED) care among 297,866 mother-child dyads. Results: Adherence to preventive care guidelines ranged from 19% to 34% among mothers with PDs and from 24% to 32% among mothers without PDs. Mothers with PDs are 1.41 times more likely to have at least one preventive care visit in Year 0-1 (95% CI [1.20, 1.65], p < 0.0001); 0.67 times less likely to have at least one visit in Year 3-4 (95 % CI [0.54, 0.82], p < .0001); and significantly more likely to have high ED reliance for their children ages 0 to 2 years (p < .01). Conclusions: Few differences existed in pediatric health care use among Medicaid-insured mothers with and without PDs. Although preventive pediatric health care use among mothers with PDs is comparable with that of mothers without PDs, mothers with mental illness could still benefit from targeted strategies to reduce ED reliance for their young children (0 to 2 years). Social work involvement with all families living in poverty should help these families access and use preventive care for young children.

Family Community Integration and Maternal Mental Health

While the majority of women with mental health problems (MHPs) are mothers, little is known about the community integration (CI) of these women and their children. Given that poorer mental health status has been linked with lower CI, CI has become a long standing goal of mental health policy. Data from a national survey examined the association of maternal mental health status with the physical, social, and psychological integration of families. After adjusting for sociodemographics, mothers with MHPs reported similar physical integration but less social and psychological integration. Interventions focused on improving social networks, scarce resources, and neighborhood safety are needed for families impacted by maternal MHPs.