Aftercare for Psychiatric Patients: Does It Prevent Rehospitalization? EDWARD
W.
MCCRANIE,
PH.D.
Assistant Professor Department of Psychiatry Medical College of Georgia Augusta, Georgia TERRENCE A. Assistant Professor
MIZELL,
PH.D.
Department of Sociology University ofSouth Alabama Mobile, Alabama Focusing
on a sample
of 421
patients
who
made
from
one to 65 visits to an aftercare clinic, the authors replicated and extended an investigation of the effectiveness of psychiatric aftercare for patients discharged from hospital
settings.
rehospitalized nod. The significant
A total of 167 of the patients were least once during the follow-up pefindings of both studies suggest that there is a relationship between an increasing number at
of aftercare visits and a reduced likelihood of rehospitalization, especially among the more chronic patients. The authors emphasize the need for further studies in which patients are interviewed directly about their perceptions of aftercare. recent years there has been an increasing emphasis providing psychiatric aftercare for patients discharged from hospital settings. A major goal of such services has been to maintain patients in the community and to prevent rehospitalization. However, research attempting to evaluate the effectiveness of such aftercare has produced contradictory findings. In an early study of aftercare clinic effectiveness, for example, Hornstra and McPartland found a significant relationship between receipt of aftercare and lowered recidivism. Those patients referred to an aftercare clinic (N = 224) were less likely than those not referred (N = 222) to be rehospitalized within a one-year follow-up period.’ In a later study, Anthony and Buell compared UIn
on
Dr. McCranie’s address Georgia 30902. 1 H. K. Hornstra and
Aftercare,” International 1963, pp. 135-142.
584
is T.
Medical S.
Journal
HOSPITAL
College
McPartland, of Social
of
Georgia,
“Aspects Psychiatry,
& COMMUNITY
of Vol.
Augusta, Psychiatric 9, Spring
PSYCHIATRY
aftercare attenders (N = 39) to nonattenders (N = 40) and also found a significant relationship between receipt of aftercare and reduced likelihood of rehospitalization fOr a six-month follow-up period.’ In contrast to those studies, however, other investigations have found no relationship between receipt of aftercare and reduced recidivism and, in some cases, have found higher rates of hospital readmission for those who received aftercare services. For example, Mayer, Hotz, and Rosenblatt compared aftercare attenders (N 155) and nonattenders (N 81 ) and found no significant difference in rates of rehospitalization for a one-year period. They also found that, among attenders, those making three or more aftercare visits were more likely to be rehospitalized than were those making only one or.two visits.’ Besides evaluating the effect of aftercare services in preventing rehospitalization, some researchers have also been interested iri investigating what role patientrelated factors such as motivation play in explaining differential clinic attendance and effectiveness. Research directed to that issue, which has focused mainly on correlating patient demographic characteristics with the tendency either to attend or not to attend aftercare, has also produced contradictory results. Mayer, Hotz, and Rosenblatt found that aftercare attenders were more likely to be older white married women while nonattenders were younger black single men living alone.4 In contrast, Anthony and Buell found that aftercare attenders and nonattenders did not differ significantly when compared on ten demographic characteristics.5 In a recent investigation, Kirk reviews several of those and other studies. He argues that because different researchers use different methodologies, lengths of follow-up, type and size of patient samples, and treat-
2 W. A. Anthony and G. J. Buell, “Psychiatric Aftercare Clinic Effectiveness as a Function of Patient Demographic Characteristics,” Journal of Consulting and Clinical Psychology, Vol. 41, August 1973, pp. 116-119. J. E. Mayer, M. Hotz, and A. Rosenblatt, “The Readmission Patterns of Patients Referred to Aftercare Clinics,” Journal of the Bronx State Hospital, Vol. 1, Fall 1973, pp. 180-188. Ibid. 6 Anthony and Buell, op. cit.
ment settings, no easy reconciliation of their diverse findings appears possible. He also points out that some investigators define receipt of aftercare in dichotomous terms, such as attendance versus nonattendance, making it impossible to evaluate the relative effectiveness of differential amounts of services. To assess the effects of that variable, Kirk used a longer follow-up period (two to three years) than is typical of many past studies, looking first at the relationship between aftercare attendance or nonattendance and rehospitalization, and then at the relationship between number of visits and recidivism. He found that aftercare attenders (N 319) had a higher rate of rehospitalization during the two- to three-year follow-up period than those who did not attend (N = 260). Taking the number of visits into account, he found that patients who attended from one to ten aftercare sessions were the most likely to be rehospitalized. As the number of visits increased from 11, the likelihood of recidivism steadily decreased.’ To assess the influence of patient-related factors in determining effectiveness, Kirk then examined the relationship between number of visits and rehospitalization, controlling for patient chronicity, the most consistent demographic predictor of recidivism in several previous studies.7” In line with this pattern, chronic patients were found to have the highest rate of rehospitalization during the follow-up period. (Chronicity was measuredby an index based on number of previous hospitalizations, length of last hospitalization, psychotic versus nonpsychotic diagnosis, and employment status.) The more chronic patients were also more likely to attend aftercare sessions, a pattern that explains, in part, the lower rate of rehospitalization among nonattenders. In addition, it was found that among attenders with low levels of chronicity, an increasing number of aftercare visits had little effect in reducing the likelihood of rehospitalizaticin. In contrast, among attenders with high levels of chronicity, the readmission rate dropped steadily as the number of visits increased from six. As Kirk points out, the factors that might explain these patterns are unclear, and only limited conclusions can be drawn. He suggests that long-term aftercare attendance may be more effective in preventing rehOspitalization among more chronic patients, and that individuals who seek out aftercare may be more socialized into the patient role. Our study partly replicates and extends Kirk’s analy-
#{149} S. A. Kirk, “Effectiveness of Community Services for Discharged Mental Hospital Patients,” American Journal of Orthopsychiatry, Vol. 46, October 1976, pp. 646-659. ‘A. Rosenblatt and J. E. Mayer, “The Recidivism of Mental Patients,” American Journal of Orthopsychiatry, Vol. 44, October 1974, pp. 697-706. $ G. J. Buell and W. A. Anthony, “The Relationship Between Patient Demographic Characteristics and Psychiatric Rehabilitation Outcome,” Community Mental Health Journal, Vol. 11, Summer 1975, pp. 208-214.
sis by reporting data gathered on a large sample of aftercare-clinic attenders followed over a comparable time period. We addressed two questions: does the likelihood of rehospitalization decrease as the number of aftercare contacts increase, and what happens to that relationship among different demographic subgroups of patients? STUDY
METHOD
AND
FINDINGS
We collected data in 1972 from the records of an aftercare clinic affiliated with the psychiatry department of a state medical school in the southeastern United States. The clinic focused primarily on drug maintenance therapy. The patients, who had been referred from a nearby state mental hospital, were seen an average of once every one to three months. The study sample consisted of all patients who had made at least one clinic visit between July 1, 1967, and December 31, 1970 (N 421). Patients were followed from the time of their first aftercare visit until December 31, 1971, resulting in follow-up periods varying from one to four and a half years. Information was obtained from the patients’ files on several variables, including sex, race, age, education, marital status, diagnosis, number of aftercare visits as of December 31, 1971, and number of times rehospitalized as of that date. An analysis of the demographic characteristics of the study patients at the time of their first visit showed that, on the average, attenders. were female, white, and unmarried (single, divorced, or widowed) and had less than a high school education. The age distribution between those under and those over 40 years was even, and almost half the sample had been diagnosed as psychotic (all schizophrenic). Nonpsychotic diagnoses included alcoholism without chronic brain syndrome, drug dependence, neurotic anxiety or depression, adjustment reaction of childhood or adolescence, and various personality disorders. For the total sample of 421 patients, the number of aftercare visits during the study period ranged from one to 65, with a mean of 11.1 visits. A total of 167 patients (40 per cent) had been rehospitalized at least once as of December 31, 1971. A control for length of follow-up revealed no significant differences in this proportion’ = 3.46, p < .40). Thirty-six per cent of those patients beginning aftercare in 1967 (N = 60) had been rehospitalized, compared with 42 per cent of those beginning aftercare in 1968 (N = 144), 34 per cent of those beginning in 1969 (N = 101), and 45 per cent of those beginning in 1970 (N = 116). In general, these recidivism rates are somewhat higher than those reported fQr aftercare attenders in some previous studies.’ In looking at the relationship between the number of visits and rehospitalization, we divided the number of visits into three categories-one to nine, ten to 17, and W. A. Anthony et al., “Efficacy of Psychiatric Psychological Bulletin, Vol. 78, December 1972,
VOLUME
29 NUMBER
9 SEPTEMBER
1978
pp.
Rehabilitation,” 447-456.
585
18 or more-and found a pattern similar to that seen by Kirk. Of 242 patients who made from one to nine visits, 114 were rehospitalized and 128 were not. Of 85 patients who made from ten to 17 visits, 31 were rehospitalized and 54 were not. Of 94 patients who made 18 visits or more, 23 were rehospitalized and 71 were not. Thus as the number of visits increased from ten, the likelihood of rehospitalization steadily decreased. As Kirk suggests, the most tempting initial interpretation of that finding is that aftercare services are directly related to prevention of rehospitalization. Such an interpretation appears incomplete, however, when patient demographic characteristics are taken into account. Using a chi-square analysis, for example, we found that various patient demographic characteristics correlated with recidivism and with number of aftercare visits. In regard to recidivism, females (p < .01), blacks (p < 01 ), and individuals over 40 years of age (p < 10), were less likely to be rehospitalized. Diagnosis showed no significant relationship to rehospitalization. For number of visits, females (p < .001), blacks (p < .05), individuals over 40 years of age (p < .05), and psychotics (p < .001) were more likely to attend aftercare ten times or more. Education and marital status showed no significant relationship to recidivism or to number of visits. Those patterns suggest a more complex interpretation in which patient demographic characteristics are seen as intervening factors influencing both the inclination to attend aftercare and the response to the services provided. Table 1 presents data on the relationship between number of visits, dichotomized into nine or less versus ten or more, and rehospitalization when diagnosis, sex, race, and age are controlled. Two different patterns are evident. First, rates of rehospitalization were highest among those attending nine or fewer aftercare sessions, with only slight or moderate differences among demographic subgroups.
In contrast, among those attending ten or more aftercare sessions, patient demographic characteristics were strongly related to recidivism. Among nonpsychotics, males, and whites, for example, rates of rehospitalization were only moderately and insignificantly reduced by long-term attendance. Among younger individuals, long-term attendance had no effect on prevention of rehospitalization. Among psychotics, females, blacks, and older people, however, rates of rehospitalization were substantially and significantly reduced by coming to aftercare sessions ten or more times. In short, in this particular sample of aftercare attenders, psychotics, females, blacks, and older individuals were more likely to continue in aftercare and also to benefit more from such continued participation in terms of prevention of rehospitalization.
.
‘
TABLE number
1 Proportion of visits
of patients
Patien
rehospitalized
lto9
lOormore visits %
N
Nonpsychotic
150
N
%
x’ 1.48, p < .30 9.69, p < .01
45
74
35
87
51
105
28
Male
116
51
54
43
Female
125
43
126
White Black
172
49
111
37
69
41
69
20
Psychotic
on
ts rehospitalized
visits Characteristics
based
25
.‘7l,p
W.
MCCRANIE,
PH.D.
Assistant Professor Department of Psychiatry Medical College of Georgia Augusta, Georgia TERRENCE A. Assistant Professor
MIZELL,
PH.D.
Department of Sociology University ofSouth Alabama Mobile, Alabama Focusing
on a sample
of 421
patients
who
made
from
one to 65 visits to an aftercare clinic, the authors replicated and extended an investigation of the effectiveness of psychiatric aftercare for patients discharged from hospital
settings.
rehospitalized nod. The significant
A total of 167 of the patients were least once during the follow-up pefindings of both studies suggest that there is a relationship between an increasing number at
of aftercare visits and a reduced likelihood of rehospitalization, especially among the more chronic patients. The authors emphasize the need for further studies in which patients are interviewed directly about their perceptions of aftercare. recent years there has been an increasing emphasis providing psychiatric aftercare for patients discharged from hospital settings. A major goal of such services has been to maintain patients in the community and to prevent rehospitalization. However, research attempting to evaluate the effectiveness of such aftercare has produced contradictory findings. In an early study of aftercare clinic effectiveness, for example, Hornstra and McPartland found a significant relationship between receipt of aftercare and lowered recidivism. Those patients referred to an aftercare clinic (N = 224) were less likely than those not referred (N = 222) to be rehospitalized within a one-year follow-up period.’ In a later study, Anthony and Buell compared UIn
on
Dr. McCranie’s address Georgia 30902. 1 H. K. Hornstra and
Aftercare,” International 1963, pp. 135-142.
584
is T.
Medical S.
Journal
HOSPITAL
College
McPartland, of Social
of
Georgia,
“Aspects Psychiatry,
& COMMUNITY
of Vol.
Augusta, Psychiatric 9, Spring
PSYCHIATRY
aftercare attenders (N = 39) to nonattenders (N = 40) and also found a significant relationship between receipt of aftercare and reduced likelihood of rehospitalization fOr a six-month follow-up period.’ In contrast to those studies, however, other investigations have found no relationship between receipt of aftercare and reduced recidivism and, in some cases, have found higher rates of hospital readmission for those who received aftercare services. For example, Mayer, Hotz, and Rosenblatt compared aftercare attenders (N 155) and nonattenders (N 81 ) and found no significant difference in rates of rehospitalization for a one-year period. They also found that, among attenders, those making three or more aftercare visits were more likely to be rehospitalized than were those making only one or.two visits.’ Besides evaluating the effect of aftercare services in preventing rehospitalization, some researchers have also been interested iri investigating what role patientrelated factors such as motivation play in explaining differential clinic attendance and effectiveness. Research directed to that issue, which has focused mainly on correlating patient demographic characteristics with the tendency either to attend or not to attend aftercare, has also produced contradictory results. Mayer, Hotz, and Rosenblatt found that aftercare attenders were more likely to be older white married women while nonattenders were younger black single men living alone.4 In contrast, Anthony and Buell found that aftercare attenders and nonattenders did not differ significantly when compared on ten demographic characteristics.5 In a recent investigation, Kirk reviews several of those and other studies. He argues that because different researchers use different methodologies, lengths of follow-up, type and size of patient samples, and treat-
2 W. A. Anthony and G. J. Buell, “Psychiatric Aftercare Clinic Effectiveness as a Function of Patient Demographic Characteristics,” Journal of Consulting and Clinical Psychology, Vol. 41, August 1973, pp. 116-119. J. E. Mayer, M. Hotz, and A. Rosenblatt, “The Readmission Patterns of Patients Referred to Aftercare Clinics,” Journal of the Bronx State Hospital, Vol. 1, Fall 1973, pp. 180-188. Ibid. 6 Anthony and Buell, op. cit.
ment settings, no easy reconciliation of their diverse findings appears possible. He also points out that some investigators define receipt of aftercare in dichotomous terms, such as attendance versus nonattendance, making it impossible to evaluate the relative effectiveness of differential amounts of services. To assess the effects of that variable, Kirk used a longer follow-up period (two to three years) than is typical of many past studies, looking first at the relationship between aftercare attendance or nonattendance and rehospitalization, and then at the relationship between number of visits and recidivism. He found that aftercare attenders (N 319) had a higher rate of rehospitalization during the two- to three-year follow-up period than those who did not attend (N = 260). Taking the number of visits into account, he found that patients who attended from one to ten aftercare sessions were the most likely to be rehospitalized. As the number of visits increased from 11, the likelihood of recidivism steadily decreased.’ To assess the influence of patient-related factors in determining effectiveness, Kirk then examined the relationship between number of visits and rehospitalization, controlling for patient chronicity, the most consistent demographic predictor of recidivism in several previous studies.7” In line with this pattern, chronic patients were found to have the highest rate of rehospitalization during the follow-up period. (Chronicity was measuredby an index based on number of previous hospitalizations, length of last hospitalization, psychotic versus nonpsychotic diagnosis, and employment status.) The more chronic patients were also more likely to attend aftercare sessions, a pattern that explains, in part, the lower rate of rehospitalization among nonattenders. In addition, it was found that among attenders with low levels of chronicity, an increasing number of aftercare visits had little effect in reducing the likelihood of rehospitalizaticin. In contrast, among attenders with high levels of chronicity, the readmission rate dropped steadily as the number of visits increased from six. As Kirk points out, the factors that might explain these patterns are unclear, and only limited conclusions can be drawn. He suggests that long-term aftercare attendance may be more effective in preventing rehOspitalization among more chronic patients, and that individuals who seek out aftercare may be more socialized into the patient role. Our study partly replicates and extends Kirk’s analy-
#{149} S. A. Kirk, “Effectiveness of Community Services for Discharged Mental Hospital Patients,” American Journal of Orthopsychiatry, Vol. 46, October 1976, pp. 646-659. ‘A. Rosenblatt and J. E. Mayer, “The Recidivism of Mental Patients,” American Journal of Orthopsychiatry, Vol. 44, October 1974, pp. 697-706. $ G. J. Buell and W. A. Anthony, “The Relationship Between Patient Demographic Characteristics and Psychiatric Rehabilitation Outcome,” Community Mental Health Journal, Vol. 11, Summer 1975, pp. 208-214.
sis by reporting data gathered on a large sample of aftercare-clinic attenders followed over a comparable time period. We addressed two questions: does the likelihood of rehospitalization decrease as the number of aftercare contacts increase, and what happens to that relationship among different demographic subgroups of patients? STUDY
METHOD
AND
FINDINGS
We collected data in 1972 from the records of an aftercare clinic affiliated with the psychiatry department of a state medical school in the southeastern United States. The clinic focused primarily on drug maintenance therapy. The patients, who had been referred from a nearby state mental hospital, were seen an average of once every one to three months. The study sample consisted of all patients who had made at least one clinic visit between July 1, 1967, and December 31, 1970 (N 421). Patients were followed from the time of their first aftercare visit until December 31, 1971, resulting in follow-up periods varying from one to four and a half years. Information was obtained from the patients’ files on several variables, including sex, race, age, education, marital status, diagnosis, number of aftercare visits as of December 31, 1971, and number of times rehospitalized as of that date. An analysis of the demographic characteristics of the study patients at the time of their first visit showed that, on the average, attenders. were female, white, and unmarried (single, divorced, or widowed) and had less than a high school education. The age distribution between those under and those over 40 years was even, and almost half the sample had been diagnosed as psychotic (all schizophrenic). Nonpsychotic diagnoses included alcoholism without chronic brain syndrome, drug dependence, neurotic anxiety or depression, adjustment reaction of childhood or adolescence, and various personality disorders. For the total sample of 421 patients, the number of aftercare visits during the study period ranged from one to 65, with a mean of 11.1 visits. A total of 167 patients (40 per cent) had been rehospitalized at least once as of December 31, 1971. A control for length of follow-up revealed no significant differences in this proportion’ = 3.46, p < .40). Thirty-six per cent of those patients beginning aftercare in 1967 (N = 60) had been rehospitalized, compared with 42 per cent of those beginning aftercare in 1968 (N = 144), 34 per cent of those beginning in 1969 (N = 101), and 45 per cent of those beginning in 1970 (N = 116). In general, these recidivism rates are somewhat higher than those reported fQr aftercare attenders in some previous studies.’ In looking at the relationship between the number of visits and rehospitalization, we divided the number of visits into three categories-one to nine, ten to 17, and W. A. Anthony et al., “Efficacy of Psychiatric Psychological Bulletin, Vol. 78, December 1972,
VOLUME
29 NUMBER
9 SEPTEMBER
1978
pp.
Rehabilitation,” 447-456.
585
18 or more-and found a pattern similar to that seen by Kirk. Of 242 patients who made from one to nine visits, 114 were rehospitalized and 128 were not. Of 85 patients who made from ten to 17 visits, 31 were rehospitalized and 54 were not. Of 94 patients who made 18 visits or more, 23 were rehospitalized and 71 were not. Thus as the number of visits increased from ten, the likelihood of rehospitalization steadily decreased. As Kirk suggests, the most tempting initial interpretation of that finding is that aftercare services are directly related to prevention of rehospitalization. Such an interpretation appears incomplete, however, when patient demographic characteristics are taken into account. Using a chi-square analysis, for example, we found that various patient demographic characteristics correlated with recidivism and with number of aftercare visits. In regard to recidivism, females (p < .01), blacks (p < 01 ), and individuals over 40 years of age (p < 10), were less likely to be rehospitalized. Diagnosis showed no significant relationship to rehospitalization. For number of visits, females (p < .001), blacks (p < .05), individuals over 40 years of age (p < .05), and psychotics (p < .001) were more likely to attend aftercare ten times or more. Education and marital status showed no significant relationship to recidivism or to number of visits. Those patterns suggest a more complex interpretation in which patient demographic characteristics are seen as intervening factors influencing both the inclination to attend aftercare and the response to the services provided. Table 1 presents data on the relationship between number of visits, dichotomized into nine or less versus ten or more, and rehospitalization when diagnosis, sex, race, and age are controlled. Two different patterns are evident. First, rates of rehospitalization were highest among those attending nine or fewer aftercare sessions, with only slight or moderate differences among demographic subgroups.
In contrast, among those attending ten or more aftercare sessions, patient demographic characteristics were strongly related to recidivism. Among nonpsychotics, males, and whites, for example, rates of rehospitalization were only moderately and insignificantly reduced by long-term attendance. Among younger individuals, long-term attendance had no effect on prevention of rehospitalization. Among psychotics, females, blacks, and older people, however, rates of rehospitalization were substantially and significantly reduced by coming to aftercare sessions ten or more times. In short, in this particular sample of aftercare attenders, psychotics, females, blacks, and older individuals were more likely to continue in aftercare and also to benefit more from such continued participation in terms of prevention of rehospitalization.
.
‘
TABLE number
1 Proportion of visits
of patients
Patien
rehospitalized
lto9
lOormore visits %
N
Nonpsychotic
150
N
%
x’ 1.48, p < .30 9.69, p < .01
45
74
35
87
51
105
28
Male
116
51
54
43
Female
125
43
126
White Black
172
49
111
37
69
41
69
20
Psychotic
on
ts rehospitalized
visits Characteristics
based
25
.‘7l,p
