Sheldon I. Miller

Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment.

The behavioral (e.g., repetitive questioning, hitting) and psychological (e.g., delusions, anxieties) signs and symptoms of dementia can result in suffering, premature institutionalization, increased costs of care, and significant loss in the quality of life for the patient and his or her family and caregivers.

The prediction of short-stay psychiatric inpatients

In a study of 252 consecutive, non-repeating psychiatric admissions at a community hospital, patients who were hospitalized for six days or less were identified. Using the Severity of Psychiatric Illness, these cases were predicted with both a sensitivity and specificity of about 75 %. Short-stay patients were more acutely suicidal, had greater substance abuse complications, tended to be resistant to the treatment program, and had lower levels of family involvement. Programming and policy implications of these findings are discussed.

Serotonin reuptake inhibitors and the adequacy of antidepressant treatment.

Objective: To determine whether the use of serotonin reuptake inhibitors (SSRIs) improves antidepressant medication prescribing patterns for both psychiatric and non-psychiatric physicians. Data Sources/Setting: Drug utilization review of 4,103 prescriptions for antidepressant medications with patients diagnosed with depressive disorders over an eighteen-month period from the formulary records of a large insurance company. Design: Using standards developed for clinical guidelines, variation in trial and treatment adequacy between drug types and physician specialty was studied. Principal Findings: Thirty-five percent of initial antidepressant trials were not prescribed for an adequate duration or at an adequate dosage level. SSRIs were more likely to be prescribed adequately than any other antidepressant reviewed. Psychiatrists were more likely to prescribe antidepressants at an adequate dosage level, whereas non-psychiatric physicians were more likely to attain adequate duration of treatment. Conclusions: A greater reliance on SSRIs may increase the likelihood of maintaining adequacy in antidepressant treatments. Although higher in cost than other treatment choices, their lower side effect profile is likely to maximize patient satisfaction and physician and patient adherence to guidelines. In order to ensure effective and efficient antidepressant usage, such patterns must be identified and appropriate performance improvement strategies (e.g., Total Quality Improvement, critical pathways) may be employed.

The treatment of dangerous patients in managed care: Psychiatric hospital utilization and outcome

The legal criteria for civil commitment dictates that individuals must be mentally ill, and either a danger to themselves, a danger to others, or substantially impaired in their ability to provide for their basic needs. These criteria, which have been adopted as medical necessity criteria by managed care programs, may result in a change in the clinical mix of the psychiatric inpatient population. The present study assesses the incidence of dangerousness among psychiatric inpatients and compares dangerous and nondangerous patients in terms of characteristics and treatment outcomes. The results indicate that for a large regional managed care program, 30% of psychiatric inpatients have a history of dangerousness in the past year. Patients who are rated as dangerous to others during admission have higher rates of complications for treatment and psychiatric disorders such as residential and vocational instability, family disruption, and higher premorbid dysfunction. They are also more likely to engage in disruptive and aggressive behavior during their hospital stays. Despite the higher incidence of acute and long-term dysfunction for dangerous patients, their hospitalization length of stay was comparable to that of patients not rated as dangerous.

Characteristics of short-stay admissions to a psychiatric inpatient service

Since the rapid expansion of managed care coupled with dramatic reductions in lengths of inpatient stays, there is widespread concern that the emphasis on cost containment is eclipsing attention to patient care. The present study was undertaken to evaluate speculations that the majority of short-stay (less than 48 hours) admissions to a psychiatric inpatient service at a large teaching hospital in the midwestern United States consisted of public pay patients who were rapidly transferred to area state hospitals. Using two case mix measures, severity of illness and changes in acuity and clinical outcomes of a sample of short-stay (n = 77) and longer stay (n = 145) admissions were compared. Short-stay admissions, although similar to longer stay patients in terms of demographics, Axis I diagnosis, payer status, and appropriateness of admission, are clinically distinct. The use of nonhospital alternatives in treating a subsample of suicidal patients and the implications for improved mental health service delivery are discussed.