Psychosomatics 2013:]:]]]–]]]
& 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Medical Status and Care of Psychiatric Patients in a Day Treatment Program Sarah Honsvall Rosemas, M.P.H., Michael K. Popkin, M.D.
Objective: Given the limited literature reporting on the medical comorbidity of patients attending psychiatric day treatment, we studied the medical status and care of a cohort of 100 patients for 1 year following enrollment in a day treatment program at a public sector hospital. Methods: Data were abstracted from electronic medical records retrospectively for the year following day treatment enrollment. Study variables included lifetime medical and psychiatric diagnoses documented in the medical record, patient measures performed during the study year (including laboratory, diagnostic, and physical measures), current medication, and encounters within the hospital system. Results: Despite an average age of only 41 years for the cohort, 80% had 1 or more major medical diagnoses. For the 57 subjects with
laboratory studies performed during the 1-year study interval, more than half had abnormal results. Fortythree subjects had no laboratory studies during the study interval. Forty-four were seen in the emergency room and an equal number in the medicine clinic. Conclusions: The occurrence of medical co-morbidity in this population was alarmingly high. The vigor of medical care provided was greater than one would expect for a psychiatric population averaging 41 years of age, although there were inadequacies reflecting a lack of standardized medical assessment at entry to day treatment. We propose a reconceptualization for day treatment, incorporating full medical screening as a standard component of entrance into day treatment. (Psychosomatics 2013; ]:]]]–]]])
BACKGROUND
health conditions are associated with modifiable risk factors, and patients with severe mental illness have 1.5–2.0 times the prevalence of hypertension, dyslipidemia, diabetes, and obesity.4 A range of variables may contribute to the excess morbidity and mortality in this population, including an “unhealthy lifestyle, inadequate access to good quality physical healthcare, and a culture of not taking physical disease into consideration when treating psychiatric patients.”5
It has been widely reported that patients with mental illness suffer early mortality compared with the general population.1–5 This affects a large proportion of the US population; the 12-month prevalence rate for any DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) psychiatric disorder is 26%, and 5%–10% of the US population suffers from severe mental illness including schizophrenia, bipolar disorder, and depression.4,6 Those with mental illness have a two to three times greater mortality rate compared with the general population, with a mortality gap of 8–25 years.1–3,5 Studies have found that 60%–95% of excess deaths in persons with mental illness were due to medical as opposed to unnatural causes such as suicide.1,3 Many of the contributing Psychosomatics ]:], ] 2013
Received September 23, 2013; revised October 22, 2013; accepted October 23, 2013. From Department of Psychiatry, Hennepin County Medical Center, Minneapolis, MN. Send correspondence and reprint requests to Sarah Honsvall Rosemas, M.P.H., Department of Psychiatry, Hennepin County Medical Center, 701 Park Ave, Suite S1.210, Minneapolis, MN 55415; e-mail: [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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Medical Status and Care in Day Treatment The use of certain antipsychotics has also been associated with metabolic risk factors for obesity, dyslipidemia, and diabetes.7,8 The past several decades have seen an increase in the number of people with mental illness receiving treatment while living at home, partly because of the trend toward the closure of mental health institutions since the 1960s.9,10 During this period, a variety of psychiatric services developed to fill the gap between inpatient and outpatient care.11 These services offer a less restrictive alternative to full hospitalization while providing a greater intensity of treatment than available through standard outpatient care alone.10 Programs within this spectrum vary in terms of staff, duration, target population, and integration with medical services; they also vary in nomenclature, taking on such names as day hospital, day treatment, partial hospital, day center, and day care.11 Generally, these psychiatric services provide multidisciplinary programming for patients with severe mental illness, with “regular opening hours and patient participation of at least 2 days per week, with most of the participation periods of at least 3 hours but less than 12 hours,” and with the duration of participation ranging from several weeks to indefinite.11 The terms “day hospital,” “partial hospital,” and “day treatment” commonly refer to programs that are integrated within medical institutions, have medical personnel on staff, and provide time-limited and more acute care.9,12 “Day center” and “day care” generally refer to programs run by nonmedical community services and those which provide long-term support.9 However, these terms are not clearly defined, which has led to ambiguity and confusion in the literature.9 Using Medline, a literature search was performed that identified 7 papers in the last decade examining day treatment programs located within medical institutions.10–16 Most of this research compares day treatment programs with other modalities of psychiatric care—such as hospitalization or standard outpatient care—in terms of improvement in social functioning and psychiatric symptoms. Of the 7 studies, we were able to identify 2 that attempted to characterize the medical status of, or the medical services provided to, day treatment patients.12,13 Interestingly, both studies involved day treatment programs for chemical dependency. Recognizing the need for data on the medical status and care of the chronically mentally ill, in this 2
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retrospective chart review study we sought to examine these factors in psychiatric patients enrolled in the outpatient day treatment program physically located within a large urban safety net hospital. METHODS Study Subjects Study subjects consisted of 100 consecutive admissions to the day treatment program enrolled between January 1, 2010 and May 4, 2010. Referrals to the program were made by a psychiatrist or by the patient themselves; however, being followed up by a psychiatrist was a prerequisite for the day treatment program. Only patients who were 18 years of age or older were enrolled in the program. For this study, there were no exclusion criteria so as to maximize study generalizability. Institutional review board approval was granted before the extraction of data from medical records. The mean age of the study subjects was 40.8 years (standard deviation ¼ 11.4). Gender distribution was quite equal, with 52 women and 48 men. Of the 100 subjects, 55 were white, 40 African American, 2 Hispanic, 2 Native American, and 1 multiracial. More than half of the subjects (n ¼ 52) were covered by Medicaid, while 23 subjects carried Medicare, 8 subjects had commercial insurance, and 2 held private insurance. Fifteen subjects had no insurance coverage. Average attendance in the day treatment program was 34.8 days (standard deviation ¼ 32.5); 45 patients attended the program for less than 20 days, while 55 patients attended for 20 or more days. Day Treatment Program The day treatment program accommodated 90 patients and was physically located within a hospital in Minneapolis, MN. It used a shared medical records system with all other departments in the hospital system as well as affiliated clinics. The program did not receive state funding. Day treatment consisted of three 45-minute group therapy sessions per day, Monday through Friday. Four tracks were available to patients: Mental Illness and Chemical Dependency, Mood Disorder, Psychotic Disorder, and Personality Disorder. Day treatment staff included social workers, psychologists, nurses, occupational therapists, recreational therapists, and mental health associates; no medical doctors Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin staffed the program at the time of this study. Subjects were expected to continue to work with their own outpatient psychiatrist outside of day treatment, as medication management was not provided in day treatment. At the time of this study, with the exception of emergencies, medical care was not delivered within the unit. However, day treatment staff “coordinated care with other providers” within the hospital system. Subsequently, a medical internist has been added to the staff within the day treatment unit for a half day per week. Data Abstraction Information was abstracted from electronic medical records retrospectively, during February through June 2012. Medical records from all inpatient and outpatient psychiatric and medical departments in the hospital and affiliated clinics were available; however, medical records from any outside providers were not available to the authors. There was no interventional aspect of this study. Patient records were reviewed by the first author. Records were followed from the first day of enrollment in day treatment until a year later. The key identifying patients and their study identification numbers were kept physically separate from the database, in a separate file on password-protected computers accessed by the authors. The database did not include identifying patient information such as names or medical record numbers. Four categories represent the study variables: (1) Lifetime diagnoses Psychiatric disorders were categorized based on the DSM-IV classification. Nonpsychiatric medical conditions were grouped into categories, e.g., cardiovascular, pulmonary, and gastrointestinal disorders; both chronic and acute medical illnesses were included in this study. Subjects were considered positive for a diagnostic category if 1 or more of the conditions within the class were represented in the lifetime medical record; multiple conditions within a diagnostic category were only counted once. Subjects were classified as obese based on a diagnosis of obesity or an average body mass index (BMI) Z 30 kg/m2 during the study period. Subjects were considered hypertensive based on a diagnosis of hypertension in the medical record. (2) Patient measures Laboratory studies: laboratory panels were considered abnormal if 1 or more values were Psychosomatics ]:], ] 2013
outside the hospital laboratory range of normal values. Diagnostic studies: computed tomographies of the head, magnetic resonance imagings of the head, electrocardiograms, and Dyskinesia Identification System Condensed User Scale (DISCUS) studies (Kalachnik 1993) were classified as normal or abnormal according to their formal interpretations. Physical measures: An average BMI for the study period was calculated using the first recorded value for each month of the study year. BMI was considered abnormal if the average was Z30 kg/m2. (3) Medications The number of distinct medications prescribed per psychiatric and nonpsychiatric medication class was recorded for each subject. Medications were classified as shown in Table 3. Different dosages of the same medication were not counted as additional medications, nor were prescription refills. Medications prescribed before the study period that continued into the study period were included. Depot (injection) medications and medications prescribed on an “as-needed” basis were included. (4) Encounters All completed and failed outpatient appointments during the study year were recorded. In regard to day treatment, attendance at any 1 of the 3 group sessions in a day was classified as a completed appointment. Inpatient visits during the study year were recorded; Psychiatric and nonpsychiatric hospitalizations during the 2 months before day treatment enrollment were also noted, as many patients enroll in day treatment closely following an inpatient stay. Statistical Analysis The association between the number of psychiatric medications prescribed and the number of medical (nonpsychiatric) diagnoses was analyzed with linear regression using SAS Version 9.3. RESULTS Lifetime Diagnoses All 100 patients had 1 or more lifetime psychiatric diagnoses documented in the medical record; for the www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment 100 patients there were a total of 298 discrete psychiatry diagnoses (Table 1). The most common psychiatric diagnoses were mood disorders (89 patients), anxiety disorders (46), personality disorders (40), substance dependence (30), and psychosis (28). Fifty-nine patients had 3 or more psychiatric diagnoses.
TABLE 1.
Lifetime Psychiatric and Medical (Nonpsychiatric) Diagnoses No. of Patients
Psychiatric diagnoses Any psychiatric diagnosis Mood disorder Bipolar disorder Major depressive disorder Mood disorder NOS Anxiety Personality disorder Substance dependence Psychosis Schizoaffective Schizophrenia Substance-induced psychosis Psychosis NOS Childhood disorder Adjustment disorder Cognitive disorder Eating disorder Sleep disorder Dissociative disorder Gender identity disorder Impulse control disorder Sexual dysfunction Somatoform disorder Medical (nonpsychiatric) diagnoses Any medical (nonpsychiatric) diagnosis Obesity Cardiovascular disorder Hypertension Pulmonary disorder Gastrointestinal disorder Metabolic/endocrine disorder Diabetes Neurologic disorder Seizure disorder Infectious disease Genitourinary disorder Hematologic disorder Malignancies Renal disorder Rheumatoid/collagen vascular
100 89 31 54 4 46 40 30 28 16 5 0 7 26 12 8 7 5 2 2 2 1 0 80 44 36 27 25 22 21 9 20 5 16 11 10 5 5 3
Number of patients with 1 or more lifetime diagnoses in each diagnostic category (N ¼ 100). Multiple conditions within a diagnostic category were only counted once. NOS ¼ not otherwise specified.
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Of the 100 patients, 80 had 1 or more lifetime medical (nonpsychiatric) diagnoses; these 80 patients had a total of 218 discrete medical diagnoses. The most common diagnostic category amongst the 100 patients was obesity (44 patients); interestingly, 13 of these patients had an average BMI Z 30 kg/m2 yet no diagnosis of obesity was noted in the medical record. Other common diagnoses were cardiovascular disorders (36), pulmonary disorders (25), gastrointestinal disorders,22 metabolic/endocrine disorders,21 and neurologic disorders.20 Thirty-seven patients had 3 or more medical (nonpsychiatric) diagnoses. Patient Measures During the Study Year Laboratory studies were performed for 57 patients during the study year—the 12 months following day treatment enrollment—with an average of 13.5 studies per patient amongst those with 1 or more studies (Table 2). One or more abnormal results were seen in 79% of these patients; 56% of all laboratory studies were considered abnormal. Electrocardiograms were performed on 25 patients, and 64% of these patients had 1 or more studies interpreted as abnormal. Seven patients had 1 or more computed tomographies of the head performed, and 3 of them had an abnormality reported. Magnetic resonance imagings of the head were performed on 2 patients, and both yielded abnormal results. DISCUS scores17 were assessed for only 11 patients, and the scores ranged from 0–12. Blood pressure readings were recorded for 84 patients. Eighty-two patients had 1 or more BMI calculations, and 48% of them had an average BMI of 30 kg/m2 or higher. The average BMI among all 82 patients was 31.5 kg/m2. Medications Prescribed During the Study Year Ninety-eight patients were prescribed 1 or more medications during the study period; these patients were prescribed an average of 6.2 medications (standard deviation ¼ 4.0). For 36 patients (37%), medication noncompliance was noted in the medical record during the study year. Ninety-six patients were prescribed 1 or more psychiatric medications, with an average of 3 medications per patient (Table 4). The most common psychiatric medications were antidepressants (78 patients) Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin TABLE 2.
Patient Measures During the Study Year
Laboratory studies Any laboratory study Basic metabolic panel Complete blood count Renal panel Hepatic panel CBC differential Lipid panel A1c Thyroid panel Creatine phosphokinase
Diagnostic studies EKG Head CT Head MR DISCUS Physical measures BMI Diastolic blood pressure
No. of Patients
No. of Studies
Total No. of Abnormal Studies N (%)
57
771
428 (56)
47
140
60 (43)
46
149
116 (78)
45 32 31 24 15 5 5
131 67 82 27 20 9 7
No. of Patients
No. of Studies
25 7 2 11
60 8 2 12
82 84
204 888
53 33 49 19 9 4 2
(40) (49) (60) (70) (45) (44) (29)
No. of Patients With an Abnormal Result N (%) 16 (64) 3 (43) 2 (100) Range of scores: 0–12 39 (48) n/a
Patients with 1 or more patient measures within each category during the study year; total number of studies among all 100 patients; rate of abnormal findings in the patient population. BMI was considered abnormal if the average reading over the study year was Z30 kg/m2. EKG, head CT, and head MR were classified as normal or abnormal according to their formal interpretations. Laboratory study abnormalities were determined based on the hospital laboratory range of normal values. A1c ¼ glycosylated hemoglobin; BMI ¼ body mass index; CBC ¼ complete blood count; CT ¼ computed tomography; DISCUS ¼ Dyskinesia Identification System Condensed User Scale; EKG ¼ electrocardiogram; MR ¼ magnetic resonance.
and antipsychotics (68 patients). The number of psychiatric medications prescribed was significantly associated with the number of medical (nonpsychiatric) diagnoses (P ¼ 0.024). Eighty-four patients were prescribed 1 or more nonpsychiatric medications, with an average of Psychosomatics ]:], ] 2013
TABLE 3.
Medication Classes
Psychiatric medications Anxiolytics Antidepressants Antipsychotics Mood stabilizers Psychostimulants Medical (nonpsychiatric) medications Antibiotics Anti-inflammatory agents Arthritis Fibromyalgia Antiretrovirals Cardiovascular agents Antianginals Anticoagulants Antihypertensives Hypolipidemics Agents with CNS activity Alcohol cessation medications Anticonvulsants Antiparkinsonians Hypnotic sedatives Migraine medications Muscle relaxants Narcoleptics Neuropathic pain medications Endocrine agents/hormones Diabetes medications Estrogen replacement therapy Thyroid medications GI agents Antiemetics Laxatives GERD medications Respiratory agents Asthma medications/bronchodilators COPD medications Urinary tract agents Incontinence medications Not included: pain medications, ophthalmic solutions, topical treatments, laxatives, birth control, fungal infection medications, nicotine, vitamins, and over-the-counter allergy medications. CNS ¼ central nervous system; COPD ¼ chronic obstructive pulmonary disease; GERD ¼ gastroesophageal reflux disease; GI ¼ gastrointestinal.
4 medications per patient. The most common nonpsychiatric medications were agents with central nervous system activity (see roster Table 3), which 66 patients were prescribed. Encounters Within the Hospital System Thirty-six patients were admitted to the inpatient psychiatry unit during the 2 months preceding day www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment TABLE 4.
Medication Use No. of Patients
Psychiatric medications Any 96 Antidepressant 78 Antipsychotic 68 Anxiolytic 22 Mood stabilizer 23 Psychostimulant 1
TABLE 5. Mean No. of Prescriptions
SD per Patient
2.9 1.4 1.4 1.2 1.0 1.0
1.5 0.7 0.7 0.5 0.2 0
Medical (nonpsychiatric) medications Any 84 3.9 Agents with CNS 66 1.9 activity Antibiotic 29 1.4 Gastrointestinal 27 1.4 agent Cardiovascular 24 2.3 agent Antihypertensive 23 1.7 Respiratory agent 21 1.4 Anti-inflammatory 13 1.2 Endocrine/ 12 1.9 hormone Urinary tract agent 4 1.0 Antiretroviral 1 1.0
3.4 1.3 0.8 0.7 1.6 1.2 0.9 0.4 1.0 0 0
Patients with 1 or more prescription within each medication category during the 12-month study period; mean quantity of prescribed medications per patient was calculated amongst those with at least 1 prescription within each category. CNS ¼ central nervous system; SD ¼ standard deviation.
treatment enrollment, while 14 were admitted to the psychiatry unit during the study year (Table 5). Twenty-eight patients had 1 or more visits to acute psychiatry services (the psychiatric emergency department) during the study year. Fifty-one patients presented for a psychiatry clinic visit although 60 patients were referred, yielding a patient fail rate of 15%. Ten patients were admitted to a medicine unit during the study year, and 44 patients had 1 or more emergency department visits. Forty-four patients visited the medicine clinic although 52 had been referred, yielding a fail rate of 15.4%. Sixty-two patients visited a medical specialty clinic during the study year. DISCUSSION On examining the medical records of 100 consecutive admissions to a psychiatric day treatment program in an urban public medical center, 2 major sets of 6
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Encounters Within Hospital System No. of Mean No. of Patients Encounters
SD
In the 2 months before day treatment enrollment Psychiatric 36 1.0 0 hospitalization Medical 4 1.0 0 hospitalization
Range per Patient 1 1
In the 12 months following day treatment enrollment Psychiatric encounters Day 100 34.8 32.5 1–124 treatment Psychiatry 51 7.5 7.0 1–28 clinic Acute 28 1.7 1.1 1–5 psychiatric services Mental health 21 4.8 2.7 1–12 center Psychiatric 14 1.2 0.4 1–2 hospitalizations Partial 12 2.3 3.2 1–12 hospital Medical (nonpsychiatric) encounters Medicine 44 3.7 2.4 1–10 clinic Emergency 44 3.3 2.3 1–9 department Medical 10 2.1 2.2 1–8 hospitalizations Medical 62 5.6 4.9 1–21 specialty clinics Patients with 1 or more encounters in psychiatric and other medical departments within the hospital system; means were calculated amongst those with at least 1 encounter in each category. SD ¼ standard deviation.
observations emerge. First, there is a surprising amount of medical co-morbidity in a relatively young cohort. Second, though many subjects had evidence of different components of medical evaluation and testing, a sizeable number did not. Many subjects did not have the benefit of even the most basic of measures during the year in question. The records reflect the absence of a standardized approach to medical assessment of a population now appreciated to be at significantly increased risk for premature mortality. The subjects of the study averaged 41 years of age and participated an average of 35 days in the day treatment program. As major psychiatric illness generally has its onset in the period between the late teens and late twenties, this day treatment population is on average 10–20 years post onset of psychiatric conditions.18,19 Despite their relatively young age, marked Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin medical co-morbidities were identified in this cohort. Table 1 details the array of medical disorders present in the subjects. Between 20 and 44 subjects were diagnosed (by our medical colleagues) with each of the following medical disorders: cardiovascular, pulmonary, gastrointestinal, endocrine, neurologic, and obesity. Koran et al.,20 reporting on a sample of 529 psychiatric patients drawn from California's mental health system found 39% “had an active, important physical disease.” They noted that active physical disease was significantly more common in state hospital patients (57%) and less common in day treatment patients (28%) and skilled nursing facility patients (25%). Koran et al. included a table of previous studies of physical disease in psychiatric patients with prevalence rates predominantly ranging from 26%–56%. Hall et al.21 studied 100 state hospital patients and found 80% with medical illnesses. They identified 186 specific medical illnesses. Carney et al.22 studied 1074 patients with schizophrenia, with an average age of 40 years; this cohort had 33% with 3 or more major medical co-morbidities. Though the prevalence rates differ, these studies (like our work) speak to the variety of medical illness encountered in psychiatric patients. The available laboratory studies also indicate the quantity and variety of medical comorbidities in this sample of patients. Fifty-seven subjects had a total of 771 laboratory studies performed in the year in question; 56% of all studies were considered abnormal. Overall, 40% of renal panels, 49% of hepatic panels, 43% of basic metabolic panels, 78% of complete blood counts, and 70% of lipid panels included abnormal results. For 16 of the 25 subjects having an electrocardiogram performed, abnormalities including QT prolongation, left ventricular hypertrophy, bundle branch block, left atrial enlargement, and nonspecific T wave changes were detected. The observed renal, hepatic, and cardiac abnormalities are particularly worrisome, especially given the age of the cohort. We sought to quantify the level of medical care received by this population using several variables, including medication prescription, patient measures, and encounters within the hospital system. The vigor of care was greater than might be expected for a cohort averaging 41 years of age. Of the 100 subjects, 44 were seen in a medicine clinic in the study year, while an equal number presented in the emergency room. Overall, 62 visited specialty clinics and 10 had a Psychosomatics ]:], ] 2013
medical hospitalization. Concurrent psychiatric care showed that 51% of subjects were seen in the hospital's outpatient clinic, 28% were seen in its Acute Psychiatric Service, and 14% were psychiatrically hospitalized. A large quantity of medication was prescribed to the sample of patients. During the study year, an average of 3 psychiatric medications and 4 nonpsychiatric medications were prescribed per patient. The significant association between the number of psychiatric medications and the number of medical (nonpsychiatric) diagnoses (P ¼ 0.024) complements existing literature on the metabolic risks that some psychiatric medications pose.7,8 The companion set of observations involves the absence of medical attention or evaluation for nearly half the sample. No laboratory studies were performed for 43 day treatment subjects, 16 patients had no blood pressure or vital sign readings, and 18 had no BMI measurements. Though 68 subjects were receiving antipsychotic medications, only 11 had a Dyskinesia Identification System Condensed User Scale (test of extrapyramidal side effects) in the medical record.17 The risk of metabolic syndrome dictates that patients treated with antipsychotics should have periodic screening of lipids, fasting blood sugar, and blood pressure. It is conceivable that some of the omissions were because of brevity of stay in the day treatment program; 45 patients attended less than 20 days. However, there was clearly a lack of standardized approach to the assessment of patients' medical status upon enrollment into the day treatment program. For example, routine laboratory studies were not secured at admission or shortly thereafter. Likewise, concurrent attendance at an outpatient clinic did not insure medical assessment. At the time of this study, patients were not seen by a medical doctor within the day treatment program itself. As shown in Table 5 however, 44 patients were seen in the medicine clinic during the study year. Examining a psychiatric day treatment patient population serves as a window into the intermediate part of the sequence between the onset of psychiatric issues and early mortality. Our data demonstrates that 10–20 years from onset, there are already strong indications of factors posing increased risk for serious medical conditions. Day treatment programs are an ideal venue to bring the medical care to this population that has been lacking. Patients present routinely in day treatment for a matter of weeks to months, and patients with serious and persistent mental illness are often www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment disinterested in or noncompliant with referral to primary care providers. Embedding medical services in day treatment programs is a logical and important step. Our data show a high prevalence of medical issues in the day treatment subjects; one can imagine how much comorbidity would be identified with a fully systematic approach to medical observation. In response to these findings, we propose a reconceptualization of day treatment integrating a proactive approach to medical evaluation in addition to standard psychiatric care. Subsequent to this study, we embedded an internist in the day treatment program on a weekly basis. All patients enrolling in day treatment now receive a thorough medical assessment and are referred for follow-up to either medical or primary care clinics as needed. These are proactive strategies directed at risk reduction, as opposed to waiting for these patients to become medically symptomatic. Several limitations must be considered for this study. As our sample comes from an urban, safety net
hospital setting, geographic and socioeconomic homogeneity may limit the generalizability of this study. The sample size is limited (N ¼ 100) and the lack of a control group prevents comparison of our findings to those not enrolled in a day treatment program. Selection bias may have been operative to the extent that the program coordinator exercises discretion in who is admitted to the program, although we are not able to discern this. Further, the validity of our results depends upon our ability to discern information from the electronic medical records, and reliability may be limited by any inconsistency amongst providers in the thoroughness of medical record documentation. We were able to capture only the medical information gathered at this institution; other medical assessments or interventions may have been given by outside providers during the study year. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References 1. Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC: Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care 2011; 49(6):599–604 2. Felker B, Yazel J, Short D: Mortality and medical comorbidity among psychiatric patients: a review. Psychiatr Serv 1996; 47(12):1356–1363 3. Parks J, Svendsen D, Singer P, Foti ME: Morbidity and mortality in people with serious mental illness. National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council; 2006 4. Newcomer JW, Hennekens CH: Severe mental illness and risk of cardiovascular disease. J Am Med Assoc 2007; 298 (15):1794–1796 5. Wahlbeck K, Westman J, Nordentoft M, Gissler M, Laursen TM: Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. Br J Psychiatry 2011; 199:453–458 6. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005; 62:617–627 7. American Diabetes Association. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27(2):596–601 8. Newcomer JW: Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005; 19:1–93 9. Catty JS, Burns T, Comas A, Poole Z: Day centres for severe mental illness. Cochrane Database Syst Rev 2007(1):1–16
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10. Shek E, Stein AT, Shansis FM, Marshall M, Crowther R, Tyrer P: Day hospital versus outpatient care for people with schizophrenia. Cochrane Database Syst Rev 2009(4):1–51 11. Schene AH: The effectiveness of psychiatric partial hospitalization and day care. Curr Opin Psychiatry 2004; 17: 303–309 12. Kastukas L, Witbrodt J, French MT: Outcomes and costs of day hospital treatment and nonmedical day treatment for chemical dependency. J Stud Alcohol 2004; 65:371–382 13. O'Toole TP, Conde-Martel A, Young JH, Price J, Bigelow G, Ford DE: Managing acutely ill substance-abusing patients in an integrated day hospital outpatient program. J Gen Intern Med 2006; 21:570–576 14. Marshall M, Crowther R, Almaraz-Serrano AM, et al: Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev 2003(1):1–52 15. Kallert TW, Priebe S, McCabe R, et al: Are day hospitals effective for acutely ill psychiatric patients? A European multicenter randomized controlled trial J Clin Psychiatry 2007; 68:278–287 16. Priebe S, McCabe R, Schutzwohl M, et al: Patient characteristics predicting better treatment outcomes in day hospitals compared with inpatient wards. Psychiatr Serv 2011; 62: 278–284 17. Kalachnik JE, Sprague RL: The Dyskinesia Identification System Condensed User Scale (DISCUS): reliability, validity, and a total score cut-off for mentally ill and mentally retarded populations. J Clin Psychol 1993; 49(2): 77–189
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Honsvall Rosemas and Popkin 18. Hafner H, Maurer K, Loffler W, et al: The epidemiology of early schizophrenia. Influence of age and gender on onset and early course. Br J Psychiatry 1994; 23(Suppl): 29–38 19. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62 (6):593–602
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20. Koran LM, Sox HC Jr, Marton S, et al: Medical evaluation of psychiatric patients. Arch Gen Psychiatry 1989; 46:733–740 21. Hall RCW, Gardner ER, Stickney SK, LeCann AF, Popkin MK: Physical illness manifesting as psychiatric disease. Arch Gen Psychiatry 1980; 37:989–995 22. Carney CP, Jones L, Woolson RF: Medical comorbidity in women and men with schizophrenia: a population-based study. J Gen Intern Med 2006; 21:1133–1137
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& 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Original Research Reports Medical Status and Care of Psychiatric Patients in a Day Treatment Program Sarah Honsvall Rosemas, M.P.H., Michael K. Popkin, M.D.
Objective: Given the limited literature reporting on the medical comorbidity of patients attending psychiatric day treatment, we studied the medical status and care of a cohort of 100 patients for 1 year following enrollment in a day treatment program at a public sector hospital. Methods: Data were abstracted from electronic medical records retrospectively for the year following day treatment enrollment. Study variables included lifetime medical and psychiatric diagnoses documented in the medical record, patient measures performed during the study year (including laboratory, diagnostic, and physical measures), current medication, and encounters within the hospital system. Results: Despite an average age of only 41 years for the cohort, 80% had 1 or more major medical diagnoses. For the 57 subjects with
laboratory studies performed during the 1-year study interval, more than half had abnormal results. Fortythree subjects had no laboratory studies during the study interval. Forty-four were seen in the emergency room and an equal number in the medicine clinic. Conclusions: The occurrence of medical co-morbidity in this population was alarmingly high. The vigor of medical care provided was greater than one would expect for a psychiatric population averaging 41 years of age, although there were inadequacies reflecting a lack of standardized medical assessment at entry to day treatment. We propose a reconceptualization for day treatment, incorporating full medical screening as a standard component of entrance into day treatment. (Psychosomatics 2013; ]:]]]–]]])
BACKGROUND
health conditions are associated with modifiable risk factors, and patients with severe mental illness have 1.5–2.0 times the prevalence of hypertension, dyslipidemia, diabetes, and obesity.4 A range of variables may contribute to the excess morbidity and mortality in this population, including an “unhealthy lifestyle, inadequate access to good quality physical healthcare, and a culture of not taking physical disease into consideration when treating psychiatric patients.”5
It has been widely reported that patients with mental illness suffer early mortality compared with the general population.1–5 This affects a large proportion of the US population; the 12-month prevalence rate for any DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) psychiatric disorder is 26%, and 5%–10% of the US population suffers from severe mental illness including schizophrenia, bipolar disorder, and depression.4,6 Those with mental illness have a two to three times greater mortality rate compared with the general population, with a mortality gap of 8–25 years.1–3,5 Studies have found that 60%–95% of excess deaths in persons with mental illness were due to medical as opposed to unnatural causes such as suicide.1,3 Many of the contributing Psychosomatics ]:], ] 2013
Received September 23, 2013; revised October 22, 2013; accepted October 23, 2013. From Department of Psychiatry, Hennepin County Medical Center, Minneapolis, MN. Send correspondence and reprint requests to Sarah Honsvall Rosemas, M.P.H., Department of Psychiatry, Hennepin County Medical Center, 701 Park Ave, Suite S1.210, Minneapolis, MN 55415; e-mail: [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
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Medical Status and Care in Day Treatment The use of certain antipsychotics has also been associated with metabolic risk factors for obesity, dyslipidemia, and diabetes.7,8 The past several decades have seen an increase in the number of people with mental illness receiving treatment while living at home, partly because of the trend toward the closure of mental health institutions since the 1960s.9,10 During this period, a variety of psychiatric services developed to fill the gap between inpatient and outpatient care.11 These services offer a less restrictive alternative to full hospitalization while providing a greater intensity of treatment than available through standard outpatient care alone.10 Programs within this spectrum vary in terms of staff, duration, target population, and integration with medical services; they also vary in nomenclature, taking on such names as day hospital, day treatment, partial hospital, day center, and day care.11 Generally, these psychiatric services provide multidisciplinary programming for patients with severe mental illness, with “regular opening hours and patient participation of at least 2 days per week, with most of the participation periods of at least 3 hours but less than 12 hours,” and with the duration of participation ranging from several weeks to indefinite.11 The terms “day hospital,” “partial hospital,” and “day treatment” commonly refer to programs that are integrated within medical institutions, have medical personnel on staff, and provide time-limited and more acute care.9,12 “Day center” and “day care” generally refer to programs run by nonmedical community services and those which provide long-term support.9 However, these terms are not clearly defined, which has led to ambiguity and confusion in the literature.9 Using Medline, a literature search was performed that identified 7 papers in the last decade examining day treatment programs located within medical institutions.10–16 Most of this research compares day treatment programs with other modalities of psychiatric care—such as hospitalization or standard outpatient care—in terms of improvement in social functioning and psychiatric symptoms. Of the 7 studies, we were able to identify 2 that attempted to characterize the medical status of, or the medical services provided to, day treatment patients.12,13 Interestingly, both studies involved day treatment programs for chemical dependency. Recognizing the need for data on the medical status and care of the chronically mentally ill, in this 2
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retrospective chart review study we sought to examine these factors in psychiatric patients enrolled in the outpatient day treatment program physically located within a large urban safety net hospital. METHODS Study Subjects Study subjects consisted of 100 consecutive admissions to the day treatment program enrolled between January 1, 2010 and May 4, 2010. Referrals to the program were made by a psychiatrist or by the patient themselves; however, being followed up by a psychiatrist was a prerequisite for the day treatment program. Only patients who were 18 years of age or older were enrolled in the program. For this study, there were no exclusion criteria so as to maximize study generalizability. Institutional review board approval was granted before the extraction of data from medical records. The mean age of the study subjects was 40.8 years (standard deviation ¼ 11.4). Gender distribution was quite equal, with 52 women and 48 men. Of the 100 subjects, 55 were white, 40 African American, 2 Hispanic, 2 Native American, and 1 multiracial. More than half of the subjects (n ¼ 52) were covered by Medicaid, while 23 subjects carried Medicare, 8 subjects had commercial insurance, and 2 held private insurance. Fifteen subjects had no insurance coverage. Average attendance in the day treatment program was 34.8 days (standard deviation ¼ 32.5); 45 patients attended the program for less than 20 days, while 55 patients attended for 20 or more days. Day Treatment Program The day treatment program accommodated 90 patients and was physically located within a hospital in Minneapolis, MN. It used a shared medical records system with all other departments in the hospital system as well as affiliated clinics. The program did not receive state funding. Day treatment consisted of three 45-minute group therapy sessions per day, Monday through Friday. Four tracks were available to patients: Mental Illness and Chemical Dependency, Mood Disorder, Psychotic Disorder, and Personality Disorder. Day treatment staff included social workers, psychologists, nurses, occupational therapists, recreational therapists, and mental health associates; no medical doctors Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin staffed the program at the time of this study. Subjects were expected to continue to work with their own outpatient psychiatrist outside of day treatment, as medication management was not provided in day treatment. At the time of this study, with the exception of emergencies, medical care was not delivered within the unit. However, day treatment staff “coordinated care with other providers” within the hospital system. Subsequently, a medical internist has been added to the staff within the day treatment unit for a half day per week. Data Abstraction Information was abstracted from electronic medical records retrospectively, during February through June 2012. Medical records from all inpatient and outpatient psychiatric and medical departments in the hospital and affiliated clinics were available; however, medical records from any outside providers were not available to the authors. There was no interventional aspect of this study. Patient records were reviewed by the first author. Records were followed from the first day of enrollment in day treatment until a year later. The key identifying patients and their study identification numbers were kept physically separate from the database, in a separate file on password-protected computers accessed by the authors. The database did not include identifying patient information such as names or medical record numbers. Four categories represent the study variables: (1) Lifetime diagnoses Psychiatric disorders were categorized based on the DSM-IV classification. Nonpsychiatric medical conditions were grouped into categories, e.g., cardiovascular, pulmonary, and gastrointestinal disorders; both chronic and acute medical illnesses were included in this study. Subjects were considered positive for a diagnostic category if 1 or more of the conditions within the class were represented in the lifetime medical record; multiple conditions within a diagnostic category were only counted once. Subjects were classified as obese based on a diagnosis of obesity or an average body mass index (BMI) Z 30 kg/m2 during the study period. Subjects were considered hypertensive based on a diagnosis of hypertension in the medical record. (2) Patient measures Laboratory studies: laboratory panels were considered abnormal if 1 or more values were Psychosomatics ]:], ] 2013
outside the hospital laboratory range of normal values. Diagnostic studies: computed tomographies of the head, magnetic resonance imagings of the head, electrocardiograms, and Dyskinesia Identification System Condensed User Scale (DISCUS) studies (Kalachnik 1993) were classified as normal or abnormal according to their formal interpretations. Physical measures: An average BMI for the study period was calculated using the first recorded value for each month of the study year. BMI was considered abnormal if the average was Z30 kg/m2. (3) Medications The number of distinct medications prescribed per psychiatric and nonpsychiatric medication class was recorded for each subject. Medications were classified as shown in Table 3. Different dosages of the same medication were not counted as additional medications, nor were prescription refills. Medications prescribed before the study period that continued into the study period were included. Depot (injection) medications and medications prescribed on an “as-needed” basis were included. (4) Encounters All completed and failed outpatient appointments during the study year were recorded. In regard to day treatment, attendance at any 1 of the 3 group sessions in a day was classified as a completed appointment. Inpatient visits during the study year were recorded; Psychiatric and nonpsychiatric hospitalizations during the 2 months before day treatment enrollment were also noted, as many patients enroll in day treatment closely following an inpatient stay. Statistical Analysis The association between the number of psychiatric medications prescribed and the number of medical (nonpsychiatric) diagnoses was analyzed with linear regression using SAS Version 9.3. RESULTS Lifetime Diagnoses All 100 patients had 1 or more lifetime psychiatric diagnoses documented in the medical record; for the www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment 100 patients there were a total of 298 discrete psychiatry diagnoses (Table 1). The most common psychiatric diagnoses were mood disorders (89 patients), anxiety disorders (46), personality disorders (40), substance dependence (30), and psychosis (28). Fifty-nine patients had 3 or more psychiatric diagnoses.
TABLE 1.
Lifetime Psychiatric and Medical (Nonpsychiatric) Diagnoses No. of Patients
Psychiatric diagnoses Any psychiatric diagnosis Mood disorder Bipolar disorder Major depressive disorder Mood disorder NOS Anxiety Personality disorder Substance dependence Psychosis Schizoaffective Schizophrenia Substance-induced psychosis Psychosis NOS Childhood disorder Adjustment disorder Cognitive disorder Eating disorder Sleep disorder Dissociative disorder Gender identity disorder Impulse control disorder Sexual dysfunction Somatoform disorder Medical (nonpsychiatric) diagnoses Any medical (nonpsychiatric) diagnosis Obesity Cardiovascular disorder Hypertension Pulmonary disorder Gastrointestinal disorder Metabolic/endocrine disorder Diabetes Neurologic disorder Seizure disorder Infectious disease Genitourinary disorder Hematologic disorder Malignancies Renal disorder Rheumatoid/collagen vascular
100 89 31 54 4 46 40 30 28 16 5 0 7 26 12 8 7 5 2 2 2 1 0 80 44 36 27 25 22 21 9 20 5 16 11 10 5 5 3
Number of patients with 1 or more lifetime diagnoses in each diagnostic category (N ¼ 100). Multiple conditions within a diagnostic category were only counted once. NOS ¼ not otherwise specified.
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Of the 100 patients, 80 had 1 or more lifetime medical (nonpsychiatric) diagnoses; these 80 patients had a total of 218 discrete medical diagnoses. The most common diagnostic category amongst the 100 patients was obesity (44 patients); interestingly, 13 of these patients had an average BMI Z 30 kg/m2 yet no diagnosis of obesity was noted in the medical record. Other common diagnoses were cardiovascular disorders (36), pulmonary disorders (25), gastrointestinal disorders,22 metabolic/endocrine disorders,21 and neurologic disorders.20 Thirty-seven patients had 3 or more medical (nonpsychiatric) diagnoses. Patient Measures During the Study Year Laboratory studies were performed for 57 patients during the study year—the 12 months following day treatment enrollment—with an average of 13.5 studies per patient amongst those with 1 or more studies (Table 2). One or more abnormal results were seen in 79% of these patients; 56% of all laboratory studies were considered abnormal. Electrocardiograms were performed on 25 patients, and 64% of these patients had 1 or more studies interpreted as abnormal. Seven patients had 1 or more computed tomographies of the head performed, and 3 of them had an abnormality reported. Magnetic resonance imagings of the head were performed on 2 patients, and both yielded abnormal results. DISCUS scores17 were assessed for only 11 patients, and the scores ranged from 0–12. Blood pressure readings were recorded for 84 patients. Eighty-two patients had 1 or more BMI calculations, and 48% of them had an average BMI of 30 kg/m2 or higher. The average BMI among all 82 patients was 31.5 kg/m2. Medications Prescribed During the Study Year Ninety-eight patients were prescribed 1 or more medications during the study period; these patients were prescribed an average of 6.2 medications (standard deviation ¼ 4.0). For 36 patients (37%), medication noncompliance was noted in the medical record during the study year. Ninety-six patients were prescribed 1 or more psychiatric medications, with an average of 3 medications per patient (Table 4). The most common psychiatric medications were antidepressants (78 patients) Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin TABLE 2.
Patient Measures During the Study Year
Laboratory studies Any laboratory study Basic metabolic panel Complete blood count Renal panel Hepatic panel CBC differential Lipid panel A1c Thyroid panel Creatine phosphokinase
Diagnostic studies EKG Head CT Head MR DISCUS Physical measures BMI Diastolic blood pressure
No. of Patients
No. of Studies
Total No. of Abnormal Studies N (%)
57
771
428 (56)
47
140
60 (43)
46
149
116 (78)
45 32 31 24 15 5 5
131 67 82 27 20 9 7
No. of Patients
No. of Studies
25 7 2 11
60 8 2 12
82 84
204 888
53 33 49 19 9 4 2
(40) (49) (60) (70) (45) (44) (29)
No. of Patients With an Abnormal Result N (%) 16 (64) 3 (43) 2 (100) Range of scores: 0–12 39 (48) n/a
Patients with 1 or more patient measures within each category during the study year; total number of studies among all 100 patients; rate of abnormal findings in the patient population. BMI was considered abnormal if the average reading over the study year was Z30 kg/m2. EKG, head CT, and head MR were classified as normal or abnormal according to their formal interpretations. Laboratory study abnormalities were determined based on the hospital laboratory range of normal values. A1c ¼ glycosylated hemoglobin; BMI ¼ body mass index; CBC ¼ complete blood count; CT ¼ computed tomography; DISCUS ¼ Dyskinesia Identification System Condensed User Scale; EKG ¼ electrocardiogram; MR ¼ magnetic resonance.
and antipsychotics (68 patients). The number of psychiatric medications prescribed was significantly associated with the number of medical (nonpsychiatric) diagnoses (P ¼ 0.024). Eighty-four patients were prescribed 1 or more nonpsychiatric medications, with an average of Psychosomatics ]:], ] 2013
TABLE 3.
Medication Classes
Psychiatric medications Anxiolytics Antidepressants Antipsychotics Mood stabilizers Psychostimulants Medical (nonpsychiatric) medications Antibiotics Anti-inflammatory agents Arthritis Fibromyalgia Antiretrovirals Cardiovascular agents Antianginals Anticoagulants Antihypertensives Hypolipidemics Agents with CNS activity Alcohol cessation medications Anticonvulsants Antiparkinsonians Hypnotic sedatives Migraine medications Muscle relaxants Narcoleptics Neuropathic pain medications Endocrine agents/hormones Diabetes medications Estrogen replacement therapy Thyroid medications GI agents Antiemetics Laxatives GERD medications Respiratory agents Asthma medications/bronchodilators COPD medications Urinary tract agents Incontinence medications Not included: pain medications, ophthalmic solutions, topical treatments, laxatives, birth control, fungal infection medications, nicotine, vitamins, and over-the-counter allergy medications. CNS ¼ central nervous system; COPD ¼ chronic obstructive pulmonary disease; GERD ¼ gastroesophageal reflux disease; GI ¼ gastrointestinal.
4 medications per patient. The most common nonpsychiatric medications were agents with central nervous system activity (see roster Table 3), which 66 patients were prescribed. Encounters Within the Hospital System Thirty-six patients were admitted to the inpatient psychiatry unit during the 2 months preceding day www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment TABLE 4.
Medication Use No. of Patients
Psychiatric medications Any 96 Antidepressant 78 Antipsychotic 68 Anxiolytic 22 Mood stabilizer 23 Psychostimulant 1
TABLE 5. Mean No. of Prescriptions
SD per Patient
2.9 1.4 1.4 1.2 1.0 1.0
1.5 0.7 0.7 0.5 0.2 0
Medical (nonpsychiatric) medications Any 84 3.9 Agents with CNS 66 1.9 activity Antibiotic 29 1.4 Gastrointestinal 27 1.4 agent Cardiovascular 24 2.3 agent Antihypertensive 23 1.7 Respiratory agent 21 1.4 Anti-inflammatory 13 1.2 Endocrine/ 12 1.9 hormone Urinary tract agent 4 1.0 Antiretroviral 1 1.0
3.4 1.3 0.8 0.7 1.6 1.2 0.9 0.4 1.0 0 0
Patients with 1 or more prescription within each medication category during the 12-month study period; mean quantity of prescribed medications per patient was calculated amongst those with at least 1 prescription within each category. CNS ¼ central nervous system; SD ¼ standard deviation.
treatment enrollment, while 14 were admitted to the psychiatry unit during the study year (Table 5). Twenty-eight patients had 1 or more visits to acute psychiatry services (the psychiatric emergency department) during the study year. Fifty-one patients presented for a psychiatry clinic visit although 60 patients were referred, yielding a patient fail rate of 15%. Ten patients were admitted to a medicine unit during the study year, and 44 patients had 1 or more emergency department visits. Forty-four patients visited the medicine clinic although 52 had been referred, yielding a fail rate of 15.4%. Sixty-two patients visited a medical specialty clinic during the study year. DISCUSSION On examining the medical records of 100 consecutive admissions to a psychiatric day treatment program in an urban public medical center, 2 major sets of 6
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Encounters Within Hospital System No. of Mean No. of Patients Encounters
SD
In the 2 months before day treatment enrollment Psychiatric 36 1.0 0 hospitalization Medical 4 1.0 0 hospitalization
Range per Patient 1 1
In the 12 months following day treatment enrollment Psychiatric encounters Day 100 34.8 32.5 1–124 treatment Psychiatry 51 7.5 7.0 1–28 clinic Acute 28 1.7 1.1 1–5 psychiatric services Mental health 21 4.8 2.7 1–12 center Psychiatric 14 1.2 0.4 1–2 hospitalizations Partial 12 2.3 3.2 1–12 hospital Medical (nonpsychiatric) encounters Medicine 44 3.7 2.4 1–10 clinic Emergency 44 3.3 2.3 1–9 department Medical 10 2.1 2.2 1–8 hospitalizations Medical 62 5.6 4.9 1–21 specialty clinics Patients with 1 or more encounters in psychiatric and other medical departments within the hospital system; means were calculated amongst those with at least 1 encounter in each category. SD ¼ standard deviation.
observations emerge. First, there is a surprising amount of medical co-morbidity in a relatively young cohort. Second, though many subjects had evidence of different components of medical evaluation and testing, a sizeable number did not. Many subjects did not have the benefit of even the most basic of measures during the year in question. The records reflect the absence of a standardized approach to medical assessment of a population now appreciated to be at significantly increased risk for premature mortality. The subjects of the study averaged 41 years of age and participated an average of 35 days in the day treatment program. As major psychiatric illness generally has its onset in the period between the late teens and late twenties, this day treatment population is on average 10–20 years post onset of psychiatric conditions.18,19 Despite their relatively young age, marked Psychosomatics ]:], ] 2013
Honsvall Rosemas and Popkin medical co-morbidities were identified in this cohort. Table 1 details the array of medical disorders present in the subjects. Between 20 and 44 subjects were diagnosed (by our medical colleagues) with each of the following medical disorders: cardiovascular, pulmonary, gastrointestinal, endocrine, neurologic, and obesity. Koran et al.,20 reporting on a sample of 529 psychiatric patients drawn from California's mental health system found 39% “had an active, important physical disease.” They noted that active physical disease was significantly more common in state hospital patients (57%) and less common in day treatment patients (28%) and skilled nursing facility patients (25%). Koran et al. included a table of previous studies of physical disease in psychiatric patients with prevalence rates predominantly ranging from 26%–56%. Hall et al.21 studied 100 state hospital patients and found 80% with medical illnesses. They identified 186 specific medical illnesses. Carney et al.22 studied 1074 patients with schizophrenia, with an average age of 40 years; this cohort had 33% with 3 or more major medical co-morbidities. Though the prevalence rates differ, these studies (like our work) speak to the variety of medical illness encountered in psychiatric patients. The available laboratory studies also indicate the quantity and variety of medical comorbidities in this sample of patients. Fifty-seven subjects had a total of 771 laboratory studies performed in the year in question; 56% of all studies were considered abnormal. Overall, 40% of renal panels, 49% of hepatic panels, 43% of basic metabolic panels, 78% of complete blood counts, and 70% of lipid panels included abnormal results. For 16 of the 25 subjects having an electrocardiogram performed, abnormalities including QT prolongation, left ventricular hypertrophy, bundle branch block, left atrial enlargement, and nonspecific T wave changes were detected. The observed renal, hepatic, and cardiac abnormalities are particularly worrisome, especially given the age of the cohort. We sought to quantify the level of medical care received by this population using several variables, including medication prescription, patient measures, and encounters within the hospital system. The vigor of care was greater than might be expected for a cohort averaging 41 years of age. Of the 100 subjects, 44 were seen in a medicine clinic in the study year, while an equal number presented in the emergency room. Overall, 62 visited specialty clinics and 10 had a Psychosomatics ]:], ] 2013
medical hospitalization. Concurrent psychiatric care showed that 51% of subjects were seen in the hospital's outpatient clinic, 28% were seen in its Acute Psychiatric Service, and 14% were psychiatrically hospitalized. A large quantity of medication was prescribed to the sample of patients. During the study year, an average of 3 psychiatric medications and 4 nonpsychiatric medications were prescribed per patient. The significant association between the number of psychiatric medications and the number of medical (nonpsychiatric) diagnoses (P ¼ 0.024) complements existing literature on the metabolic risks that some psychiatric medications pose.7,8 The companion set of observations involves the absence of medical attention or evaluation for nearly half the sample. No laboratory studies were performed for 43 day treatment subjects, 16 patients had no blood pressure or vital sign readings, and 18 had no BMI measurements. Though 68 subjects were receiving antipsychotic medications, only 11 had a Dyskinesia Identification System Condensed User Scale (test of extrapyramidal side effects) in the medical record.17 The risk of metabolic syndrome dictates that patients treated with antipsychotics should have periodic screening of lipids, fasting blood sugar, and blood pressure. It is conceivable that some of the omissions were because of brevity of stay in the day treatment program; 45 patients attended less than 20 days. However, there was clearly a lack of standardized approach to the assessment of patients' medical status upon enrollment into the day treatment program. For example, routine laboratory studies were not secured at admission or shortly thereafter. Likewise, concurrent attendance at an outpatient clinic did not insure medical assessment. At the time of this study, patients were not seen by a medical doctor within the day treatment program itself. As shown in Table 5 however, 44 patients were seen in the medicine clinic during the study year. Examining a psychiatric day treatment patient population serves as a window into the intermediate part of the sequence between the onset of psychiatric issues and early mortality. Our data demonstrates that 10–20 years from onset, there are already strong indications of factors posing increased risk for serious medical conditions. Day treatment programs are an ideal venue to bring the medical care to this population that has been lacking. Patients present routinely in day treatment for a matter of weeks to months, and patients with serious and persistent mental illness are often www.psychosomaticsjournal.org
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Medical Status and Care in Day Treatment disinterested in or noncompliant with referral to primary care providers. Embedding medical services in day treatment programs is a logical and important step. Our data show a high prevalence of medical issues in the day treatment subjects; one can imagine how much comorbidity would be identified with a fully systematic approach to medical observation. In response to these findings, we propose a reconceptualization of day treatment integrating a proactive approach to medical evaluation in addition to standard psychiatric care. Subsequent to this study, we embedded an internist in the day treatment program on a weekly basis. All patients enrolling in day treatment now receive a thorough medical assessment and are referred for follow-up to either medical or primary care clinics as needed. These are proactive strategies directed at risk reduction, as opposed to waiting for these patients to become medically symptomatic. Several limitations must be considered for this study. As our sample comes from an urban, safety net
hospital setting, geographic and socioeconomic homogeneity may limit the generalizability of this study. The sample size is limited (N ¼ 100) and the lack of a control group prevents comparison of our findings to those not enrolled in a day treatment program. Selection bias may have been operative to the extent that the program coordinator exercises discretion in who is admitted to the program, although we are not able to discern this. Further, the validity of our results depends upon our ability to discern information from the electronic medical records, and reliability may be limited by any inconsistency amongst providers in the thoroughness of medical record documentation. We were able to capture only the medical information gathered at this institution; other medical assessments or interventions may have been given by outside providers during the study year. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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10. Shek E, Stein AT, Shansis FM, Marshall M, Crowther R, Tyrer P: Day hospital versus outpatient care for people with schizophrenia. Cochrane Database Syst Rev 2009(4):1–51 11. Schene AH: The effectiveness of psychiatric partial hospitalization and day care. Curr Opin Psychiatry 2004; 17: 303–309 12. Kastukas L, Witbrodt J, French MT: Outcomes and costs of day hospital treatment and nonmedical day treatment for chemical dependency. J Stud Alcohol 2004; 65:371–382 13. O'Toole TP, Conde-Martel A, Young JH, Price J, Bigelow G, Ford DE: Managing acutely ill substance-abusing patients in an integrated day hospital outpatient program. J Gen Intern Med 2006; 21:570–576 14. Marshall M, Crowther R, Almaraz-Serrano AM, et al: Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev 2003(1):1–52 15. Kallert TW, Priebe S, McCabe R, et al: Are day hospitals effective for acutely ill psychiatric patients? A European multicenter randomized controlled trial J Clin Psychiatry 2007; 68:278–287 16. Priebe S, McCabe R, Schutzwohl M, et al: Patient characteristics predicting better treatment outcomes in day hospitals compared with inpatient wards. Psychiatr Serv 2011; 62: 278–284 17. Kalachnik JE, Sprague RL: The Dyskinesia Identification System Condensed User Scale (DISCUS): reliability, validity, and a total score cut-off for mentally ill and mentally retarded populations. J Clin Psychol 1993; 49(2): 77–189
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