Brown, 1982 5. Wolfensberger W: The definition of normalization: update, problems, disagreements, and misunderstandings, in Normalization,Sociallntegration, and Cornmunity Services. Edited by Flynn Rj, Nitsch FE. Baltimore, University Park Press, 1980 6. Brown L, Wilcox B, Sontag E, et al: Toward the realization oftheleast restrictiveeducationalenvironmentsforseverely handicapped students, in Normalizaiion, Social Integration, and Community Services, ibid 7. Mech EV: Out-of-home placement rates. Social Services Review 57:659-667, 1983 8. Ransohoff P, Zachary LA, Gaynor j, et al: Measuring restrictiveness ofpsychiat-
nc care. Hospital and Community Psychiatry 33:361-366, 1982 9. Hargreaves WA, GaynorJ, RansohoffP, et al: Restrictiveness of care among the severely mentallydisabled. Hospital and Community Psychiatry 35:706-709, 1984 10. KillebrewjA, Harris C, Kruckeberg K: A conceptual model fordetermining the least restrictive treatment-training modality. HospitalandCommunity Psychatty 33:367-370, 1982 1 1. Almeida MC, Hawkins RP, Meadowcroft P, et al: Evaluation of foster-fimilybased treatment in comparison with
other programs:
a preliminary
j, Galaway B. Boston, Kluwer, 1989 Hawkins RP: The nature and potential of therapeutic foster fimily care programs, inTherapeutic FosterCare: Critical Issues, ibid 13. Carter RK: The Accountable Agency. Beverly Hills, Calif, Sage, 1983 14. Hawkins RP, Frernouw Wj, Reitz AL: A model useful in designing or describing evaluations of planned interventions in mental health, in Practical Program Evaluation in Youth Treatment. Edited by McSweeny Aj, Frernouw Wj, Hawkins RJ. Springfield, Ill, Thomas, 12.
1982
analysis,
15.
in The State as Parent: International Research Perspectives on Interventions With Young Persons. Edited by Hudson
Lentz FE: Evaluating outcomes in programs for behaviorally disordered children and youth. Education and Treatment
ofChildren
8:321-355,
1985
A Short-Term Psychiatric Inpatient Program for Adolescents Ilene
M.
Cathy
Gold,
M.D.
Heller,
Beth
M.Ed.
Ritorto,
B.A.
Third-party payers have become increasingly unwilling to fund long-term hospitalizationsfor adolescents. Inpatient adolescent programs have &id to develop strategies to treat this difficult patient population much more rapidly. In late 1989 a short-term adolescent treatment program, known as the STATprogram, was deiieloped and implementedataprivatepsychiatnc hospital in Massachusetts. The program aimedfor a two- to threeweek length ofstay, a reduction of 30 to SOpercent. To accomplish this
goal, the program shifted from a treatment-based approach to a f ocus on crisis management, patient evaluation and stabilization, and transition to outpatient services. Many staffconcerns were allayed during the program’s implementation. Short-term treatment for adolescents can be viable if appropriate exclusion criteria are developed for admissions and an adequate range of outpatient treatment services are available.
Medicine.
In recent years several factors have affected hospital length ofstay for adolesccnt patients. All health and mental health care delivery systems have come under greater scrutiny by managed care programs, which have attempted to control escalating health care expenditures. This scrutiny has meant denial of inpatient stays or of continued hospitalization for many adolescent psychiatric patients who are viewed as not ‘ ‘sick enough” on “acute enough.” In 1989 there was a flurry of attention in the media to alleged mappropniate hospitalization of adolescent patients (including the Geraldo
58
January
Dr. Gold
is director of adolescent Heifer is director of education department, and Ritorto is a mental health
services,
the Ms.
counselor Hospital,
lesley,
Ms.
at 203
the Charles Grove Street,
Massachusetts
Gold is also try at Boston
professor
University
12181.
River Wel-
Dr.
of psychiaSchool of
1992
VoL 43
No.
1
Rivera show Teens Behind Locked Doors, September 29, 1989, and the Sally Jessy Raphael show Kids in Mental Wards, September 12, 1989). The theme of a Newsweek article was that hospitalization of teenagers is a carefully cultivated economic market for big hospital chains (1). That same year the American Psychiatric Association issued a position paper on appropriate hospitalization for adolescents (2). The American Society ofAdolescent Psychiatry also has been developing standards for hospitalization (3). Protocols have been designed to better achieve treatment goals and to streamline the treatment process during inpatient stays (4,5).
Past studies have focused on hospitalization of children and adolescents in programs with long-term stays (6-8). Cleanly, this is not the wave of the future, and more recent studies have a different focus. The efficacy ofhospitalization for children and adolescents has been compared with that ofothcr treatment options (9). Several hospitals have reported favorable results using short-term adolescent treatment models of ap-
Hospital
and
Community
Psychiatry
proximately four weeks (10,1 1). In the 1990s, given the increasing prcssure of third-panty payers and an ethic of treating patients in the least restrictive environment, even these four-week programs may represent too long a hospital stay for society to ftind.
In response
to these
considera-
tions, in late 1989 a short-term adolescent program known as the STAT program was designed and implemented at the Charles Riven Hospital in Wellesley, Massachusetts. For several preceding years, the average length of stay in the hospital’s adolescent program was 33 days. Many patients stayed for up to 60 days. The STAT program was designed to limit hospitalization to a two- to threeweek period of stabilization and assessment, which represented a 30 to
50 percent
reduction
in length
of
In this paper,
the development
of
the STAT program is described. Staff concerns about the program and steps taken to allay these concerns arc discussed, as arc the changes necessitated in the basic program by the implementation of shorter stays for adolescents.
The setting and basic program The Charles River
Hospital
is a 62-
bed private psychiatric hospital, which has been in existence since the early 1900s. The first adolescents were admitted in 1976, but it was not until 1980 that a separate adolescent program was developed. The hospital’s basic adolescent program consists oftwo 1 5-bed, locked, co-ed units. Patients are between the ages of 12 and 19 and have a wide variety ofdiagnoses. Except for a few Medicaid patients, most admissions arc ftmded by private insurance. The basic adolescent program is based on a family treatment model, with a multidisciplinary team approach and behaviorally based milieu treatment (12). Resources are available to conduct complete psychiatric diagnostic evaluations, including and
pediatric
consulta-
iions.
Each adolescent ually by a therapist a week. Therapists
Hospital
ning. Development
the
STAT
is seen individfour or five times are from various
and Community
Psychiatry
of
program
In August 1989 the adolescent program management team was infbrmcd
stay.
neurological
disciplines. The treating therapist is called the comprehensive therapist because besides providing individual treatment, he on she is responsible for family therapy and disposition planning. Separate groups focus on special treatment needs, including sexual abuse, eating disorders, and substance abuse. Activity groups are conducted by the hospital’s nehabilitation department, and educational classes arc coordinated with local schools. The hospital’s education departmcnt coordinates meetings with local school personnel to assist in reintegration and discharge plan-
that
the
hospital
administra-
tion had negotiated contracts with third-party payers to provide shortterm adolescent hospital treatment. Since the short-term stays were to begin immediately, it was imperative that resources be organized as quickly as possible to provide 5crvices to patients covered by these payers. Staff expressed many concerns about the abbreviated length of stay, which, in retrospect, were partly due to anxiety about changing from a familiar to an unfamiliar treatment model. The concerns centered on certain areas ofprogram development. The management team wondered whether a meaningful intervention could be provided during a 30 to 50 percent shorter hospitalization. They worried about the feasibility of operating two parallel programs on the same unit. Staffwcre also concerned about patient selection criteria and the dangers of accepting a patient
who
might
be unsuitable
for dis-
charge at the end of a brief stay. Finally, staffwornied about burnout, as they felt that they would be cxpected to produce a similar result in less time. To address these concerns and to design the new program, a task force that included a representative from each discipline was formed. While the reduction in length of stay obviously mandated some dramatic
January1992
VoL43
No.1
program changes, the task force recommcndcd retaining most components because they were unwilling to compromise high-quality care. The task force was concerned that information from the admission office about new STAT patients would not be disseminated quickly enough, and the program director, a comprehensive therapist, was asked to carry a beeper. The task force considered a separate unit and milieu for STAT patients but vetoed this plan because it was felt that the milieu would become destabilized by the rapid turnover ofSTAT patients. Also, the task force felt that the burden of increased admissions and discharges should be shared by the two units. Staffwcre concerned that the need for neuropsychological and psychoeducational testing would not be identified early enough in the STAT patient’s hospitalization, and an elaborate triage system was devised to speed up the process of evaluating the testing needs of these patients. The milieu staffon the task force discussed accelerating the privilege advancement system for STAT patients so that they could attain a higher privilege level earlier in the hospitalization to prepare for discharge. The comprehensive-therapist represcntative on the task force discussed the need to complete a rapid evaluation while using therapy sessions to support useful defenses with far less uncovering work. The need for special training to prepare therapists for this different pace and style of treatment was discussed. Articles were distributed to educate staff about short-term approaches (4,6). Staff psychiatrists discussed the need to make assessments for medication recommendations much more quickly or to leave implementation and drug adjustment to the outpatient psychiatrist. The education department decided to exclude
STAT
patients
Massachusetts
from law
classes, stipulates
since that
students do not require educational services until they have missed school for 14 days or more.
Program implementation Between November 7, 1989, when the first STAT patient was admitted, and September 1990, a total of29 (9 59
percent) of the 330 adolescents admitted were in the STAT program. While the average STAT patient population was three patients a month, or 10 percent of the adolescent program’s 30 beds, STAT patients at times constituted as much as one-third of the census. During implementation of the program, many of the concerns that arose during the developmental phase were not borne out. In fact, some of the procedures that were initially frlt to be imperative, such as the beeper and the testing triage system, were soon discarded as unnecessary. The anxiety about a two-tiered treatment approach within the same milieu proved to be more in the minds ofstaffthan ofprogram patticipants. Patients were accustomed to hearing that treatment is highly individualized. The longer-stay paticnts preserved the tone of the milieu culture. The milieu staff designed a generic behaviorally based point sheet for determining how privileges are earned by STAT patients. For paticnts in the basic program, staff crcate individualized point sheets, tied to the patient’s treatment goals; developing individualized point sheets can take as long as one week. For many short-term patients, privilege level is now determined more by a time frame and less by the number of points earned on the unit. STAT patients are eligible for passes sooner to speed adjustment to outpatient 5crvices. Comprehensive therapists were able to quickly learn and practice the different treatment style and to tolerate leaving things undone, relying increasingly on outpatient treatmcnt resources. Discharge planning was complicated, however, by the lack ofstep-down programs for adolescents and the poor response time of social service agencies, which had not speeded up their intake and disposition evaluations. Psychiatrists learned to formulate diagnostic impressions and medication recommendations more quickly. Inpatient medication trials were necessarily less complete, raising the need for increased communication with outpatient psychiatrists. Because several STAT patients
stayed longer than 14 days, the hospital’s education department decided to include all STAT patients in education classes when they arc admitted. Department staff were no longer able to meet with local school personnel, and a phone call to help reintegrate STAT patients into the school system was substituted. The hospital’s rehabilitation department found that STAT patients were often discharged before they had the necessary privileges to attend off-unit groups. A rehabilitation orientation group that meets on the unit within a week of the STAT patient’s admission was instituted.
60
January
for staff members, who were used to discharging a more stable patient, was learning to tolerate delegation of treatment responsibilities. With some patients, this approach has limitations, and it is not appropriate for all patient populations. Obviously, criteria for determining which patients are better suited to a STAT approach arc important. Some preliminary exclusion criteria include a first psychotic episode, significant aggressive behavior, severe suicidality and self-injurious behaviors, and chaotic family dynamics. Patients appropriate for the STAT program include adolcscents who make impulsive, minor suicide attempts, patients with adjustment disorders, those with prcviously diagnosed major psychiatric disorders requiring medication adjustment, and more disturbed patients with involved and supportive families.
Discussion Health care professionals are well aware of their patients’ resistance to change, and they try to help them modify the rigidity oftheir defenses. It was interesting to see a similar problem with resistance and rigidity ofdefenses in a system. Historically, adolescents have been hospitalized for long periods, even as long as two to three years (1 3). At the Charles River Hospital, some patients stayed for several months. It is not surprising that a shift in perspective for the adolescent program staff was not easy. While the staff were accusturned to a specific length ofstay, patients did not have fixed expectations. Therefore, in most cases patients had less difficulty with the concept of the STAT program than did their treatment providers.
To change
from an average
To make
length
ofstay offour to five weeks to a twoto three-week hospitalization nequired a change in goals and objectives. Specifically, there was less focus on treatment and the use of uncovering modalities and a greater attempt to shore up defenses. The goal of a completed case with no loose ends at discharge was no longer realistic. Instead, the goal became a completed diagnostic evaluation, crisis management, and stabilization, with a reliance on outpatient providers and parents to continue the process after discharge. As in the model described by Doherty and colleagues (1 1), the STAT program emphasizes the hospital’s role as a consultant to parents and the community. The difficulty 1992
VoL 43
No.
1
short-term
hospitaliza-
tions effective, other treatment modalities must be made available after discharge. Some short-term hospitalizations can be avoided if a continuum ofcare is available(14). Some third-party payers are now willing to provide funding for step-down programs if hospitalizations are kept short. We have found that thirdparty reviewers are enthusiastic about the STAT program and are willing to work closely with the inpatient team to coordinate effective aftercare programs to save inpatient days. Ironically, the review process is so cumbersome, because of paperwork requirements and multiple phone calls, that it takes clinicians away from direct patient care. As many questions have been raised as answered during our initial experiences with the STAT program. Have we achieved our goal of providing crisis management, a thorough evaluation, and stabilization with appropriate transition to outpatient services? Is this program as effective as a one- to two-month stay, or does recidivism increase, as has been suggested by readmissions ofsome of the STAT patients? What are realistic inclusion and exclusion admission criteria?
We plan to follow STAT Hospital
admissions and
up the first 29
with
Community
a questionPsychiatry
name that will help us explore these issues. The follow-up study will give us the opportunity to further investigate the efficacy ofshort-tcrm hospitalizations for adolescents. Acknowledgments The J.D.,
authors Allan
thank
Gerald Ph.D.,
Meyers, M.D., and
J. Billow, William
DanielJ. Violi for their helpful contributions and John A. Fromson, M.D., medical director of the Charles River Hospital, for his continued support and encouragement. Patterson,
References 1. Darnton N: Committed Youth. News week,July 31, 1989, pp 66-72 2. Statement on Psychiatric Hospitalizationof Qildren and Adolescents. Washington, DC, American Psychiatric Assoc-
iation,June 1989 3. Hospitalization, marketing guidelines proposed. American Society for Adolescent Psychiatry Newsletter, Summer 1990, pp 3,5 4. Nurcombe B: Goal-directed treatment planning and the principles of brief hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry 28:26-30, 1989 5. Harper G: Focal inpatient treatment planning. Journal of the American Academy of Child and Adolescent Psychiatry 28: 31-37, 1989 6. Gossert J, Bamhart D, Lewis JM, et al: Follow-up ofadolescents treated in a paychiatric hospital: measurement of outcome. Southern MedicalJournal 73: 459466, 1980 7. Garber B, Poisky R: Follow-up study of hospitalized adolescents: a preliminary report. Archives of General Psychiatry 22:179-187, 1970 8. Lehman A, Strauss J, Ritzier B, et al: First-admission psychiatric ward milieutreatment: process and outcome. Archives
of General 1982
Psychiatry
39:1293-1298,
9. Goldfine
10.
11.
12.
13.
14.
P, Heath GA, Hardesty VA, et al: Alternatives to psychiatric hospitalization ftrchildren. Psychiatric Clinics of North America 8:527-535, 1985 Ney P, Mulvihill D, Hanna R: The effectiveness of child psychiatric inpatient care. Canadianjournal ofPsychiatry 29: 26-30, 1984 Doherty M, Manderson M, Carter-Ake L: Time-limited psychiatric hospitalization ofchildren: a model and three-year outcome. Hospital and Community Prychiatry 38:643-647, 1987 Mirkin M, Koman S (eds): Handbook of Adolescent and Family Therapy. New York, Gardner Press, 1985 Bleiberg E: The clinical challengeofchildren and adolescents with severe personality disorders. Bulletin of the Menninger Clinic 54:107-120, 1990 Behar L: Financing mental health services ftr children and adolescents. Bulletin of the Menninger Clinic 54:127139, 1990
Use of a Structured Interview to Diagnose Anxiety Disorders in a Minority Population Cheryl
M.
Steven
Friedman,
Ronald John Martin
M.
Paradis,
Ph.D.
Lazar,
Grubea,
Psy.D. Ph.D.
M.D.
Kesselman,
M.D.
A structured interview-the Anxiety Disorder lnterview ScheduleRevised (ADIS-R)-----was used to assess the presence ofpanic disorder and other anxiety disorders in 100 psychiatric outpatients at an inner-city municipal hospital, most of whom were black and of low
socioeconomic status. The ADIS-R identifiedseven patients as having abrimary diagnosis ofpanic disorder and 16 as having a secondary diagnosis ofpanicdisorder. None of the patients received a primary diagnosis of panic disorder from the outpatient dinical staff who did not use the ADIS-R. The authors conclude that a structured interview is an effective tool for ident:fying panic disorder in a minority population, in whom the disorder is generally underdiagnosed.
Lazar
are
also
The authors are associated with the department of psychiatry at the State University of New York (SUNY) Health Science Center at Brooldyn. Dr. Lazar is also associated with the department of neurology at the SUNY Health Science Center. Drs. Paradis and
dence to Dr. Health Science lyn, Box 1203, nue, Brooklyn,
Hospital
January
and Community
Psychiatry
department
Patients with panic disorder experience panic attacks characterized by both physical symptoms, such as tachycardia, shortness of breath, and dizziness, and cognitive symptoms, such as fear ofdeath or ofloss of control (1). Studies indicate a six-month prevalence rate in the general population ranging from 2.7 to 5.8 percent for panic disorder with agoraphobia and .6 to 1 percent for panic disorder without agoraphobia (2). Epidemiological studies indicate that the prevalence ofpanic disorder is higher among some groups, such as women, separated or divorced persons, and those with limited cducation or from lower socioeconomic groups (2-6). No significant differcnccs in the prevalence ofpanic disorder have been found between racial groups in the general population (7). Brown and associates (8) report, however, that in the general population there is a higher prevalence
with the psychology at Hospital Center in affiliated
of
Kings County Brooklyn. Address
1992
correspon-
Friedman, SUNY Center at Brook450 Qarkson AyeNew York 11203.
VoL
43
No.
1
61
nc care. Hospital and Community Psychiatry 33:361-366, 1982 9. Hargreaves WA, GaynorJ, RansohoffP, et al: Restrictiveness of care among the severely mentallydisabled. Hospital and Community Psychiatry 35:706-709, 1984 10. KillebrewjA, Harris C, Kruckeberg K: A conceptual model fordetermining the least restrictive treatment-training modality. HospitalandCommunity Psychatty 33:367-370, 1982 1 1. Almeida MC, Hawkins RP, Meadowcroft P, et al: Evaluation of foster-fimilybased treatment in comparison with
other programs:
a preliminary
j, Galaway B. Boston, Kluwer, 1989 Hawkins RP: The nature and potential of therapeutic foster fimily care programs, inTherapeutic FosterCare: Critical Issues, ibid 13. Carter RK: The Accountable Agency. Beverly Hills, Calif, Sage, 1983 14. Hawkins RP, Frernouw Wj, Reitz AL: A model useful in designing or describing evaluations of planned interventions in mental health, in Practical Program Evaluation in Youth Treatment. Edited by McSweeny Aj, Frernouw Wj, Hawkins RJ. Springfield, Ill, Thomas, 12.
1982
analysis,
15.
in The State as Parent: International Research Perspectives on Interventions With Young Persons. Edited by Hudson
Lentz FE: Evaluating outcomes in programs for behaviorally disordered children and youth. Education and Treatment
ofChildren
8:321-355,
1985
A Short-Term Psychiatric Inpatient Program for Adolescents Ilene
M.
Cathy
Gold,
M.D.
Heller,
Beth
M.Ed.
Ritorto,
B.A.
Third-party payers have become increasingly unwilling to fund long-term hospitalizationsfor adolescents. Inpatient adolescent programs have &id to develop strategies to treat this difficult patient population much more rapidly. In late 1989 a short-term adolescent treatment program, known as the STATprogram, was deiieloped and implementedataprivatepsychiatnc hospital in Massachusetts. The program aimedfor a two- to threeweek length ofstay, a reduction of 30 to SOpercent. To accomplish this
goal, the program shifted from a treatment-based approach to a f ocus on crisis management, patient evaluation and stabilization, and transition to outpatient services. Many staffconcerns were allayed during the program’s implementation. Short-term treatment for adolescents can be viable if appropriate exclusion criteria are developed for admissions and an adequate range of outpatient treatment services are available.
Medicine.
In recent years several factors have affected hospital length ofstay for adolesccnt patients. All health and mental health care delivery systems have come under greater scrutiny by managed care programs, which have attempted to control escalating health care expenditures. This scrutiny has meant denial of inpatient stays or of continued hospitalization for many adolescent psychiatric patients who are viewed as not ‘ ‘sick enough” on “acute enough.” In 1989 there was a flurry of attention in the media to alleged mappropniate hospitalization of adolescent patients (including the Geraldo
58
January
Dr. Gold
is director of adolescent Heifer is director of education department, and Ritorto is a mental health
services,
the Ms.
counselor Hospital,
lesley,
Ms.
at 203
the Charles Grove Street,
Massachusetts
Gold is also try at Boston
professor
University
12181.
River Wel-
Dr.
of psychiaSchool of
1992
VoL 43
No.
1
Rivera show Teens Behind Locked Doors, September 29, 1989, and the Sally Jessy Raphael show Kids in Mental Wards, September 12, 1989). The theme of a Newsweek article was that hospitalization of teenagers is a carefully cultivated economic market for big hospital chains (1). That same year the American Psychiatric Association issued a position paper on appropriate hospitalization for adolescents (2). The American Society ofAdolescent Psychiatry also has been developing standards for hospitalization (3). Protocols have been designed to better achieve treatment goals and to streamline the treatment process during inpatient stays (4,5).
Past studies have focused on hospitalization of children and adolescents in programs with long-term stays (6-8). Cleanly, this is not the wave of the future, and more recent studies have a different focus. The efficacy ofhospitalization for children and adolescents has been compared with that ofothcr treatment options (9). Several hospitals have reported favorable results using short-term adolescent treatment models of ap-
Hospital
and
Community
Psychiatry
proximately four weeks (10,1 1). In the 1990s, given the increasing prcssure of third-panty payers and an ethic of treating patients in the least restrictive environment, even these four-week programs may represent too long a hospital stay for society to ftind.
In response
to these
considera-
tions, in late 1989 a short-term adolescent program known as the STAT program was designed and implemented at the Charles Riven Hospital in Wellesley, Massachusetts. For several preceding years, the average length of stay in the hospital’s adolescent program was 33 days. Many patients stayed for up to 60 days. The STAT program was designed to limit hospitalization to a two- to threeweek period of stabilization and assessment, which represented a 30 to
50 percent
reduction
in length
of
In this paper,
the development
of
the STAT program is described. Staff concerns about the program and steps taken to allay these concerns arc discussed, as arc the changes necessitated in the basic program by the implementation of shorter stays for adolescents.
The setting and basic program The Charles River
Hospital
is a 62-
bed private psychiatric hospital, which has been in existence since the early 1900s. The first adolescents were admitted in 1976, but it was not until 1980 that a separate adolescent program was developed. The hospital’s basic adolescent program consists oftwo 1 5-bed, locked, co-ed units. Patients are between the ages of 12 and 19 and have a wide variety ofdiagnoses. Except for a few Medicaid patients, most admissions arc ftmded by private insurance. The basic adolescent program is based on a family treatment model, with a multidisciplinary team approach and behaviorally based milieu treatment (12). Resources are available to conduct complete psychiatric diagnostic evaluations, including and
pediatric
consulta-
iions.
Each adolescent ually by a therapist a week. Therapists
Hospital
ning. Development
the
STAT
is seen individfour or five times are from various
and Community
Psychiatry
of
program
In August 1989 the adolescent program management team was infbrmcd
stay.
neurological
disciplines. The treating therapist is called the comprehensive therapist because besides providing individual treatment, he on she is responsible for family therapy and disposition planning. Separate groups focus on special treatment needs, including sexual abuse, eating disorders, and substance abuse. Activity groups are conducted by the hospital’s nehabilitation department, and educational classes arc coordinated with local schools. The hospital’s education departmcnt coordinates meetings with local school personnel to assist in reintegration and discharge plan-
that
the
hospital
administra-
tion had negotiated contracts with third-party payers to provide shortterm adolescent hospital treatment. Since the short-term stays were to begin immediately, it was imperative that resources be organized as quickly as possible to provide 5crvices to patients covered by these payers. Staff expressed many concerns about the abbreviated length of stay, which, in retrospect, were partly due to anxiety about changing from a familiar to an unfamiliar treatment model. The concerns centered on certain areas ofprogram development. The management team wondered whether a meaningful intervention could be provided during a 30 to 50 percent shorter hospitalization. They worried about the feasibility of operating two parallel programs on the same unit. Staffwcre also concerned about patient selection criteria and the dangers of accepting a patient
who
might
be unsuitable
for dis-
charge at the end of a brief stay. Finally, staffwornied about burnout, as they felt that they would be cxpected to produce a similar result in less time. To address these concerns and to design the new program, a task force that included a representative from each discipline was formed. While the reduction in length of stay obviously mandated some dramatic
January1992
VoL43
No.1
program changes, the task force recommcndcd retaining most components because they were unwilling to compromise high-quality care. The task force was concerned that information from the admission office about new STAT patients would not be disseminated quickly enough, and the program director, a comprehensive therapist, was asked to carry a beeper. The task force considered a separate unit and milieu for STAT patients but vetoed this plan because it was felt that the milieu would become destabilized by the rapid turnover ofSTAT patients. Also, the task force felt that the burden of increased admissions and discharges should be shared by the two units. Staffwcre concerned that the need for neuropsychological and psychoeducational testing would not be identified early enough in the STAT patient’s hospitalization, and an elaborate triage system was devised to speed up the process of evaluating the testing needs of these patients. The milieu staffon the task force discussed accelerating the privilege advancement system for STAT patients so that they could attain a higher privilege level earlier in the hospitalization to prepare for discharge. The comprehensive-therapist represcntative on the task force discussed the need to complete a rapid evaluation while using therapy sessions to support useful defenses with far less uncovering work. The need for special training to prepare therapists for this different pace and style of treatment was discussed. Articles were distributed to educate staff about short-term approaches (4,6). Staff psychiatrists discussed the need to make assessments for medication recommendations much more quickly or to leave implementation and drug adjustment to the outpatient psychiatrist. The education department decided to exclude
STAT
patients
Massachusetts
from law
classes, stipulates
since that
students do not require educational services until they have missed school for 14 days or more.
Program implementation Between November 7, 1989, when the first STAT patient was admitted, and September 1990, a total of29 (9 59
percent) of the 330 adolescents admitted were in the STAT program. While the average STAT patient population was three patients a month, or 10 percent of the adolescent program’s 30 beds, STAT patients at times constituted as much as one-third of the census. During implementation of the program, many of the concerns that arose during the developmental phase were not borne out. In fact, some of the procedures that were initially frlt to be imperative, such as the beeper and the testing triage system, were soon discarded as unnecessary. The anxiety about a two-tiered treatment approach within the same milieu proved to be more in the minds ofstaffthan ofprogram patticipants. Patients were accustomed to hearing that treatment is highly individualized. The longer-stay paticnts preserved the tone of the milieu culture. The milieu staff designed a generic behaviorally based point sheet for determining how privileges are earned by STAT patients. For paticnts in the basic program, staff crcate individualized point sheets, tied to the patient’s treatment goals; developing individualized point sheets can take as long as one week. For many short-term patients, privilege level is now determined more by a time frame and less by the number of points earned on the unit. STAT patients are eligible for passes sooner to speed adjustment to outpatient 5crvices. Comprehensive therapists were able to quickly learn and practice the different treatment style and to tolerate leaving things undone, relying increasingly on outpatient treatmcnt resources. Discharge planning was complicated, however, by the lack ofstep-down programs for adolescents and the poor response time of social service agencies, which had not speeded up their intake and disposition evaluations. Psychiatrists learned to formulate diagnostic impressions and medication recommendations more quickly. Inpatient medication trials were necessarily less complete, raising the need for increased communication with outpatient psychiatrists. Because several STAT patients
stayed longer than 14 days, the hospital’s education department decided to include all STAT patients in education classes when they arc admitted. Department staff were no longer able to meet with local school personnel, and a phone call to help reintegrate STAT patients into the school system was substituted. The hospital’s rehabilitation department found that STAT patients were often discharged before they had the necessary privileges to attend off-unit groups. A rehabilitation orientation group that meets on the unit within a week of the STAT patient’s admission was instituted.
60
January
for staff members, who were used to discharging a more stable patient, was learning to tolerate delegation of treatment responsibilities. With some patients, this approach has limitations, and it is not appropriate for all patient populations. Obviously, criteria for determining which patients are better suited to a STAT approach arc important. Some preliminary exclusion criteria include a first psychotic episode, significant aggressive behavior, severe suicidality and self-injurious behaviors, and chaotic family dynamics. Patients appropriate for the STAT program include adolcscents who make impulsive, minor suicide attempts, patients with adjustment disorders, those with prcviously diagnosed major psychiatric disorders requiring medication adjustment, and more disturbed patients with involved and supportive families.
Discussion Health care professionals are well aware of their patients’ resistance to change, and they try to help them modify the rigidity oftheir defenses. It was interesting to see a similar problem with resistance and rigidity ofdefenses in a system. Historically, adolescents have been hospitalized for long periods, even as long as two to three years (1 3). At the Charles River Hospital, some patients stayed for several months. It is not surprising that a shift in perspective for the adolescent program staff was not easy. While the staff were accusturned to a specific length ofstay, patients did not have fixed expectations. Therefore, in most cases patients had less difficulty with the concept of the STAT program than did their treatment providers.
To change
from an average
To make
length
ofstay offour to five weeks to a twoto three-week hospitalization nequired a change in goals and objectives. Specifically, there was less focus on treatment and the use of uncovering modalities and a greater attempt to shore up defenses. The goal of a completed case with no loose ends at discharge was no longer realistic. Instead, the goal became a completed diagnostic evaluation, crisis management, and stabilization, with a reliance on outpatient providers and parents to continue the process after discharge. As in the model described by Doherty and colleagues (1 1), the STAT program emphasizes the hospital’s role as a consultant to parents and the community. The difficulty 1992
VoL 43
No.
1
short-term
hospitaliza-
tions effective, other treatment modalities must be made available after discharge. Some short-term hospitalizations can be avoided if a continuum ofcare is available(14). Some third-party payers are now willing to provide funding for step-down programs if hospitalizations are kept short. We have found that thirdparty reviewers are enthusiastic about the STAT program and are willing to work closely with the inpatient team to coordinate effective aftercare programs to save inpatient days. Ironically, the review process is so cumbersome, because of paperwork requirements and multiple phone calls, that it takes clinicians away from direct patient care. As many questions have been raised as answered during our initial experiences with the STAT program. Have we achieved our goal of providing crisis management, a thorough evaluation, and stabilization with appropriate transition to outpatient services? Is this program as effective as a one- to two-month stay, or does recidivism increase, as has been suggested by readmissions ofsome of the STAT patients? What are realistic inclusion and exclusion admission criteria?
We plan to follow STAT Hospital
admissions and
up the first 29
with
Community
a questionPsychiatry
name that will help us explore these issues. The follow-up study will give us the opportunity to further investigate the efficacy ofshort-tcrm hospitalizations for adolescents. Acknowledgments The J.D.,
authors Allan
thank
Gerald Ph.D.,
Meyers, M.D., and
J. Billow, William
DanielJ. Violi for their helpful contributions and John A. Fromson, M.D., medical director of the Charles River Hospital, for his continued support and encouragement. Patterson,
References 1. Darnton N: Committed Youth. News week,July 31, 1989, pp 66-72 2. Statement on Psychiatric Hospitalizationof Qildren and Adolescents. Washington, DC, American Psychiatric Assoc-
iation,June 1989 3. Hospitalization, marketing guidelines proposed. American Society for Adolescent Psychiatry Newsletter, Summer 1990, pp 3,5 4. Nurcombe B: Goal-directed treatment planning and the principles of brief hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry 28:26-30, 1989 5. Harper G: Focal inpatient treatment planning. Journal of the American Academy of Child and Adolescent Psychiatry 28: 31-37, 1989 6. Gossert J, Bamhart D, Lewis JM, et al: Follow-up ofadolescents treated in a paychiatric hospital: measurement of outcome. Southern MedicalJournal 73: 459466, 1980 7. Garber B, Poisky R: Follow-up study of hospitalized adolescents: a preliminary report. Archives of General Psychiatry 22:179-187, 1970 8. Lehman A, Strauss J, Ritzier B, et al: First-admission psychiatric ward milieutreatment: process and outcome. Archives
of General 1982
Psychiatry
39:1293-1298,
9. Goldfine
10.
11.
12.
13.
14.
P, Heath GA, Hardesty VA, et al: Alternatives to psychiatric hospitalization ftrchildren. Psychiatric Clinics of North America 8:527-535, 1985 Ney P, Mulvihill D, Hanna R: The effectiveness of child psychiatric inpatient care. Canadianjournal ofPsychiatry 29: 26-30, 1984 Doherty M, Manderson M, Carter-Ake L: Time-limited psychiatric hospitalization ofchildren: a model and three-year outcome. Hospital and Community Prychiatry 38:643-647, 1987 Mirkin M, Koman S (eds): Handbook of Adolescent and Family Therapy. New York, Gardner Press, 1985 Bleiberg E: The clinical challengeofchildren and adolescents with severe personality disorders. Bulletin of the Menninger Clinic 54:107-120, 1990 Behar L: Financing mental health services ftr children and adolescents. Bulletin of the Menninger Clinic 54:127139, 1990
Use of a Structured Interview to Diagnose Anxiety Disorders in a Minority Population Cheryl
M.
Steven
Friedman,
Ronald John Martin
M.
Paradis,
Ph.D.
Lazar,
Grubea,
Psy.D. Ph.D.
M.D.
Kesselman,
M.D.
A structured interview-the Anxiety Disorder lnterview ScheduleRevised (ADIS-R)-----was used to assess the presence ofpanic disorder and other anxiety disorders in 100 psychiatric outpatients at an inner-city municipal hospital, most of whom were black and of low
socioeconomic status. The ADIS-R identifiedseven patients as having abrimary diagnosis ofpanic disorder and 16 as having a secondary diagnosis ofpanicdisorder. None of the patients received a primary diagnosis of panic disorder from the outpatient dinical staff who did not use the ADIS-R. The authors conclude that a structured interview is an effective tool for ident:fying panic disorder in a minority population, in whom the disorder is generally underdiagnosed.
Lazar
are
also
The authors are associated with the department of psychiatry at the State University of New York (SUNY) Health Science Center at Brooldyn. Dr. Lazar is also associated with the department of neurology at the SUNY Health Science Center. Drs. Paradis and
dence to Dr. Health Science lyn, Box 1203, nue, Brooklyn,
Hospital
January
and Community
Psychiatry
department
Patients with panic disorder experience panic attacks characterized by both physical symptoms, such as tachycardia, shortness of breath, and dizziness, and cognitive symptoms, such as fear ofdeath or ofloss of control (1). Studies indicate a six-month prevalence rate in the general population ranging from 2.7 to 5.8 percent for panic disorder with agoraphobia and .6 to 1 percent for panic disorder without agoraphobia (2). Epidemiological studies indicate that the prevalence ofpanic disorder is higher among some groups, such as women, separated or divorced persons, and those with limited cducation or from lower socioeconomic groups (2-6). No significant differcnccs in the prevalence ofpanic disorder have been found between racial groups in the general population (7). Brown and associates (8) report, however, that in the general population there is a higher prevalence
with the psychology at Hospital Center in affiliated
of
Kings County Brooklyn. Address
1992
correspon-
Friedman, SUNY Center at Brook450 Qarkson AyeNew York 11203.
VoL
43
No.
1
61
