William H. Sledge

A Comparison of the Structured Clinical Interview for DSM-III-R and Clinical Diagnoses

The relationship between diagnoses generated by the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID) and by nonstructured psychiatric interviews was examined. The purposes were to evaluate which DSM-III-R diagnoses were most reliably chosen, and to compare diagnostic practices between two clinical sites. Diagnoses generated by researchers using the patient version of the SCID and by psychiatric interviews were compared for 100 patients. The participants had been randomly assigned to one of two acute treatment sites within the same institution, as part of a larger study of an alternative to inpatient hospitalization. Overall reliability between the SCID and the clinicians, as determined by weighted Kappa, was poor. There was considerable variability among the major diagnostic categories, with higher agreement for schizophrenia and bipolar disorder than for others. The agreement for schizoaffective disorder was extremely low. There were also significant differences in the patterns of diagnoses between the two sites. The patient version of the SCID appears to produce results that are very different from clinical practice, which, in turn, may be influenced strongly by location.

Effectiveness of Peer Support in Reducing Readmissions of Persons With Multiple Psychiatric Hospitalizations

OBJECTIVE The study examined the feasibility and effectiveness of using peer support to reduce recurrent psychiatric hospitalizations. METHODS A randomized controlled design was used, with follow-up at nine months after an index discharge from an academically affiliated psychiatric hospital. Patients were 18 years or older with major mental illness and had been hospitalized three or more times in the prior 18 months. Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38), and assessed at nine months. RESULTS Participants who were assigned a peer mentor had significantly fewer rehospitalizations (.89 ± 1.35 versus 1.53 ± 1.54; p=.042 [one-tailed]) and fewer hospital days (10.08 ± 17.31 versus 19.08 ± 21.63 days; p<.03, [one tailed]). CONCLUSIONS Despite the studys limitations, findings suggest that use of peer mentors is a promising intervention for reducing recurrent psychiatric hospitalizations for patients at risk of readmission.

Affective reactivity of language in schizophrenia.

Thirty acutely schizophrenic inpatients each provided two speech samples: one on affectively negative, “high-stress” topics and one on affectively positive, “low-stress” topics. We analyzed these using two different, established methods for assessment of deviance in natural language, including clinical measures of thought disorder and linguistic measures of reference performance. For the group as a whole, the speech on negative topics contained more disorder than did the speech on positive topics, as rated both clinically and linguistically, and these differences were sizeable and highly significant. Level of language disturbance and degree of affective reactivity of language symptoms correlated positively with severity of the positive syndrome but were not associated in either direction with negative syndrome severity. Affective reactivity of symptoms is discussed as a variable potentially relevant to studies of psychophysiology and subtyping in schizophrenia.

Proactive Psychiatric Consultation Services Reduce Length of Stay for Admissions to an Inpatient Medical Team

BACKGROUND Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. OBJECTIVE To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. METHODS LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. RESULTS Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. CONCLUSIONS Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.

Predicting Time to Readmission in Patients With Recent Histories of Recurrent Psychiatric Hospitalization: A Matched-Control Survival Analysis

The most robust predictor of future psychiatric hospitalization is the number of previous admissions. About half of psychiatric inpatients with histories of repeated hospitalizations are readmitted within 12 months. This study sought to determine which patient characteristics predicted time-to-readmission within 12 months after controlling for the number of previous hospitalizations in 75 adults with recent histories of recurrent admissions and 75 matched controls. Results revealed multiple clinical and demographic between-group differences at index hospitalization. However, the only predictors of shorter time-to-readmission in multivariate Cox proportional hazards were unemployment (hazards ratio = 9.26) and residential living status (hazards ratio = 2.05) after controlling for prior hospitalizations (hazard ratio = 1.24). Unemployment and residential living status were not proxies of psychosis or moderated by illness severity or comorbid substance use. Results suggest that early psychiatric readmission may be more influenced by residential and employment status than by severe mental illness.

Coping and recovery styles in the Vietnam era prisoner of war.

Of the nearly 600 Vietnam War American prisoners of war (POWs), 332 were United States Air Force flyers who had suffered maltreatment, confinement, and boredom for months to years. We examined four coping styles of USAF POWs related to successful/ unsuccessful coping and resistance stance during captivity and cognitive integration of the prisoner experience after repatriation. Findings indicate that no coping style is clearly associated with an increased risk of postrepatriation psychiatric morbidity. Postrepatriation MMPI scales indicate personality differences between individuals in the various coping groups.

An analysis of grammatical deviance occurring in spontaneous schizophrenic speech

Abstract It has often been claimed that schizophrenic speech reflects episodic disturbances in utilization of linguistic rules referable to dominant hemisphere dysfunction. These claims, however, have generally been argued on the basis of speech samples gleaned from single case studies. Insofar as normal speech also reflects errors of various sorts, it has been impossible, on the basis of these data, to argue that breakdowns of grammatical structure evinced by some schizophrenics necessarily reflect specific linguistic pathology. In order to more carefully determine the specificity of linguistic deviance produced by schizophrenic speakers, an analysis of spontaneous conversational speech was developed. The analysis was designed to locate and classify grammatical deviance by differentiating “normal dysfluency”, lexical selection problems, and syntactic difficulties. A measure of “severity” of syntactic deviance was generated which reflected the degree that the “target” of the manifest utterance was ambiguous. The analysis was applied blindly to transcribed speech produced by eleven schizophrenic patients and a comparison group of nine nonschizophrenic psychiatric patients. Schizophrenics produced grammatical deviance at a much greater rate than nonschizophrenics, and tended to produce more severe errors. The analysis described may be useful for quantifying and characterizing spontaneously produced paragrammatisms generated by other classes of speakers as well.

Characteristics of Inpatients With a History of Recurrent Psychiatric Hospitalizations: A Matched-Control Study

OBJECTIVE This study examined the association between patient characteristics and inpatient hospitalization among patients with a history of recurrent psychiatric hospitalizations (two or more hospitalizations in the 18 months before the index hospitalization) (N=75) and patients without such a history (N=75). METHODS Characteristics at the time of the index hospitalization and 48-month inpatient utilization rates (24 months before and 24 months after the index hospitalization) were extracted from medical records. Backwards stepwise regression models were used to identify characteristics independently associated with inpatient utilization. RESULTS Psychotic disorder and unemployment at the time of index hospitalization were independently associated with higher inpatient utilization over the 48 months. Only the number of hospitalizations in the prior 24 months predicted the number of readmissions after the index hospitalization. CONCLUSIONS Psychosis and unemployment seem to have an independent effect on the number of hospitalizations.

Resilience in Organ Transplantation: An Application of the Connor-Davidson Resilience Scale (CD-RISC) With Liver Transplant Candidates.

End-stage liver disease (ESLD) is a chronic and debilitating condition associated with substantial psychological stress, morbidity, and mortality. The Connor–Davidson Resilience Scale (CD–RISC; Connor & Davidson, 2003) is a commonly used resilience measure. This research examined the validity of the CD–RISC among ESLD patients (N = 120) using exploratory factor analysis. Results supported a single-factor solution after removing poorly loading items. The CD–RISC also was correlated with measures of depression, anxiety, quality of life, social support, age, and cognitive ability, thus providing evidence to support its construct validity. Future research should confirm this factor structure and examine its predictive validity prior to widespread use among ESLD patients. This research represents the first step in this process and proposes an alternative version of the CD–RISC for this population.

“I'm Talking About Pain”: Sickle cell disease patients with extremely high hospital use

BACKGROUND A small minority of sickle cell disease patients accounts for the majority of inpatient hospital days. Admitted as often as several times a month, over successive years, this cohort of patients has not been studied in depth despite their disproportionate contribution to inpatient hospital costs in sickle cell disease. OBJECTIVE To characterize the subjective experience of extremely high hospital use in patients with sickle cell disease, and generate hypotheses about the antecedents and consequences of this phenomenon. DESIGN Qualitative study involving in-depth, open-ended interviews using a standardized interview guide. SETTING A single urban academic medical center. PARTICIPANTS Eight individuals, of varying age and gender, identified as the sickle cell disease patients who are among the highest hospital use patients over a 3-year period. RESULTS A common narrative emerged from the interview transcripts. Participants were exposed to the hospital environment and intravenous (IV) opioids at a young age, and this exposure was associated with extremely high hospital use in adulthood, evident in descriptions of multiple dimensions of their lives: pain and opioid medication use, interpersonal relationships, and personal development. CONCLUSIONS Our results suggest a systematic, self-reinforcing process of isolation from mainstream society, support structures, and caregivers, based on increasing hospitalization, growing dependency on opioid medications, as well as missed developmental milestones. Further study and interventions should be geared towards breaking this spiraling cycle with long-term strategies in disease management and social integration.