Multimodal Treatment of Acute Psychiatric Illness

A Guide for Hospital Diversion

Justin Simpson, Glendon Moriarty

• Publisher: Columbia University Press
• Year: 2013
• ISBN:
  9780231536097
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

The multimodal treatment of acute psychiatric illness involves a set of integrated, systematic interventions that stabilize individuals with severe mental illness and help them avoid unnecessary psychiatric hospitalization. This volume focuses on those suffering from schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, severe anxiety, and substance dependence, and provides individual practitioners and professional teams with the tools for responding to crisis and delivering acute care. The authors bolster the text with real-world case examples, helpful diagrams, and printable worksheets.

Hospital Diversion Programs

THE EFFORT TO BRING MENTALLY ILL PERSONS out of institutions and back into the community began a number of years ago. The Community Mental Health Centers Act of 1963 was created to provide for community-based care as an alternative to institutionalization, and the process of deinstitutionalization has continued at varying levels since then (Grob, 2008). The current trend has resulted in the development of several alternatives to inpatient treatment. The goal of these programs is to stabilize in the community, and preferably in their own home, individuals who are experiencing crisis.

There is evidence to suggest hospital diversion programs will continue to grow and play a stronger role in treating severe mental illness (SMI). First, the need for effective hospital diversion and crisis stabilization programs has been a focal point of political discourse over the past few years. Virginia, like Tennessee (Tennessee, 2007) and North Carolina (North Carolina Dept. of Health and Human Services, 2005), is making significant shifts in community mental health:

[The] governor … announced today plans for restructuring Virginia’s mental health care system. The comprehensive plan redirects resources into programs that provide more community-based care for people with mental illness allowing them to receive treatment closer to their homes, families, and friends…. The community system must be enhanced to provide a “safety net” for consumers in short term-crisis. (Commonwealth of Virginia, 2001)

Second, the literature in the areas of hospital diversion and community-based mental health services is consistently growing. For instance, a peer-reviewed article search using the PsycINFO and Academic Search Premiere databases produces approximately six hundred hits for “assertive community treatment”; half of these articles were published after 2002. Third, there appears to be a consensus among researchers that it is typically more beneficial for an individual experiencing acute mental illness to receive community-based care (Ruggeri et al., 2006; Ligon & Thyer, 2000; Granello, Granello, & Lee, 1999; Warner, 1995; Merson et al., 1992).

WHY DO HOSPITAL DIVERSION PROGRAMS EXIST?

Hospital diversion or intensive community treatment programs exist for several reasons. One reason is that they can cut down on the high costs of inpatient treatment. Acute psychiatric illness episodes create financial hardships for mentally ill individuals and society in general because of both treatment costs and lost employment (Kessler et al., 2008). Another reason is that less invasive interventions, such as treatment through hospital diversion programs, are generally preferred by clients because they typically do not have to leave their home for lengthy periods of time or suffer other unnecessary disruptions in their life (Ben-Porath, Peterson, & Piskur, 2004; Ruggeri et al., 2006).

Hospital diversion programs also exist because there are simply not enough hospital beds for the large number of individuals who become mentally unstable. In the United States there was an 88 percent reduction in psychiatric hospital beds between 1955 (339 beds per 100,000 population) and 1994 (40 beds per 100,000 population) (Szmuckler & Holloway, 2001). This decline in available beds has occurred because of deinstitutionalization, which was prompted by a variety of legal, financial, advocacy, and other issues (Torrey, 1997). Unfortunately deinstitutionalization has caused an increase in the number of chronically mentally ill persons who are homeless or in jail (Lamb, 2001; Torrey, 1997).

A National Institute of Mental Health (NIMH) panel summarized the negative consequences of deinstitutionalization and the climate in which hospital diversion programs were born as follows:

The institutionalization of severely mentally ill people, particularly in hospital back wards, constituted a form of societal paternalism in which many persons suffered bleak, meaningless lives. With deinstitutionalization and the lack of a community support system, many former patients and others with severe mental illnesses have been given nearly absolute individual liberty but at a very high price. Now that patients can be committed to treatment services only if they are extremely and imminently dangerous to themselves or society, our society allows individuals incapable of realistic planning to struggle through life and wander the streets. Like ships without rudders, homeless people with severe mental illness are free, but at significant risk to life and without much hope of happiness. (Attkisson et al., 1992)

The current state of mental health care is not as bleak because several community supports are now in place. However, there is room for substantial growth.

Legal cases such as L. C. and E. W. v. Olmstead, in which two female patients who no longer needed inpatient care were not discharged because of a lack of community program availability, prompted the United States Supreme Court to rule that individuals must be treated by way of community-based programs whenever possible (Heath, 2005). Various economic and political influences have also facilitated the growth of community-based care for individuals with mental illness. Advances in pharmacology, advocacy movements involving groups like the National Alliance on Mental Illness (NAMI), and state and federal budget crises are among these influences (Menikoff, 1999a).

Hospital diversion programs are frequently used to help individuals transition from an inpatient setting to the community, as this can be a very difficult period of time. Many times these individuals are not fully stabilized (Bruchner & Yoon, 2009; Kaliski, 1997). Also, those who have been hospitalized for extended periods may become accustomed to or dependent on constant care and attention and may have difficulty readjusting to community life (Hocking, Phare, & Wilson, 2005; Proehl, 1938). In many cases the individual might not receive professional follow-up care for weeks following discharge from the hospital (Predictors, 2007). Because of these challenges, there is an increased risk of relapse, decompensation, and suicide attempts or other problematic behaviors (Torrey, 1997).

The use of hospital diversion programs is essential to every community. The many benefits include decreased mental health care costs as costly hospital visits are avoided, and increased safety for all persons in the community as mentally ill persons are treated before their condition leads to illegal activities. These programs not only benefit communities as a whole; more important, they often produce significant improvement in functioning and life satisfaction for their consumers. Lamb (2001:5) writes, “In the community, most of these [chronically mentally ill] patients can have something very precious—their liberty, to the extent that they can handle it. Furthermore, if we provide the resources, they can realize their potential to attain some of life’s milestones.”

Another reason these programs are necessary is their ability to relieve some of the burden placed on family members of the severely mentally ill. As Torrey (1997:77) notes, “One of the most difficult experiences for families with a mentally ill member is watching the person deteriorate psychiatrically without being able to do anything about it because of stringent involuntary commitment laws.” Not only can hospital diversion programs take the place of hospitalization, in many cases they can better equip the family in their effort to care for ill relatives. Still, it becomes evident when comparing the NIMH statement with Lamb’s that treating mentally ill individuals in the community is beneficial only if the proper supports are in place.

The literature on the topic of community versus institutional care is exhaustive. Many writers have addressed and various studies have targeted the pros and cons of each treatment method (Ruggeri et al., 2006; Ligon & Thyer, 2000; Granello, Granello, & Lee, 1999; Torrey, 1997; Warner, 1995). There appears to be a consensus that it is typically more beneficial and less detrimental for an individual experiencing acute mental illness to receive community-based care. This is the case only when the treatment in the community is appropriate and accessible. When describing the basic needs of people in the community with severe mental illness, Lamb (2001:7) claims, “Adequate, comprehensive, and accessible psychiatric and rehabilitative services need to be available and, when necessary, provided through outreach programs.” The literature indicates that, for several reasons, our nation’s cities and communities must provide adequate treatment for mentally ill citizens both in hospitals and in the community.

TYPES OF HOSPITAL DIVERSION PROGRAMS

A variety of hospital diversion programs are currently operating, and each has its strengths and limitations. All share the same goal of helping people thrive in the community and avoid institutionalization. Four of the most popular and well-researched programs are described in this section.

Assertive Community Treatment

One of the most popular community-based models for hospital diversion is the program for assertive community treatment (PACT), also called assertive community treatment (ACT) teams. Stein and Santos (1998:2) claim, “ACT is best conceptualized as a service delivery vehicle or system designed to furnish the latest, most effective and efficient treatments, rehabilitation, and support services conveniently as an integrated package.” Much of the work performed by ACT/PACT staff involves case management and other supportive activities. This includes, among many other things, advocacy, completing applications for financial assistance, providing transportation to medical appointments, calling in and picking up prescriptions, and teaching daily living skills. However, there is still a large opportunity for interactions that are more clinical in nature because of the severity of illness, comorbid substance use and personality disturbance, and occurrence of daily life stressors that are common among ACT clients. One of the most significant ways in which ACT differs from traditional case management is that ACT staff directly provide treatment and rehabilitation.

ACT/PACT programs consist of multidisciplinary teams that provide services to individuals with severe mental illness who have not responded well to other forms of treatment, often because of noncompliance or difficulty accessing services. Typical ACT clients have primary mental health diagnoses on the schizophrenia or mood disorder spectrum. It is also common for them to have other comorbid conditions, such as substance abuse issues (Bond et al., 2001). Their mental illness and other characteristics, such as low income, limited support, unemployment, poor housing, and lack of transportation significantly reduce accessibility to needed mental health treatment. Thus a system of care that is mobile and comprehensive (i.e., similar to a psychiatric hospital) is indicated. A complete ACT team usually consists of a psychiatrist, psychologist, or clinical social worker; vocational rehabilitation specialist; substance abuse counselor; nurse; peer support specialists; and administrative assistants. These teams proactively meet with their clients in the community and provide a number of services.

Assertive community treatment is not just a philosophy or specific staff structure; it also consists of a particular protocol for service delivery that has been shown to be effective (Bond et al., 2001). The key components include multidisciplinary staffing, integration of services, a team approach, low patient-staff ratios, community contacts, medication management, focus on everyday problems in living, rapid access to client emergencies, assertive outreach, individualized services, and time-unlimited services (Bond et al., 2001). ACT also promotes recovery through community integration, vocational assistance, restoring family relationships, and providing opportunities for clients to lead groups and become peer support specialists.

Leonard Stein, Mary Ann Test, and their colleagues developed this model of treatment approximately thirty years ago in Madison, Wisconsin (Stein & Test, 1980). Since then ACT teams have been established across the globe (Bond et al., 2001). Various adaptations have been made to the original model in places with a geographic and demographic profile that differs from that of Madison.

Mobile Crisis Home Treatment

Mobile crisis home treatment (MCHT) teams, also called mobile crisis units or emergency services programs, generally provide services that are more focused on crisis assessment and referral to hospitals or other treatment settings. Their services are time limited, but just like an ACT program, services are provided twenty-four hours a day, and most of the interventions occur in the client’s home. MCHT is most helpful for clients who are typically noncompliant with treatment recommendations and do not necessarily need to leave their home to become stable (i.e., their home environment is not the primary cause of or a significant contributor to their instability) (Heath, 2005). These teams help to reduce unnecessary arrests or medical attention (such as costly emergency room visits) by closely coordinating their services with police and emergency medical workers (Scott, 2000).

One of the disadvantages of MCHT and ACT programs is that they typically do not provide the needed structure and activity scheduling that severely mentally ill clients often need (Heath, 2005). They are also limited by their inability to provide interpersonal support, although some ACT programs offer group therapy and social outings. Even so, clients often prefer these programs because they are the least restrictive and most convenient.

Partial Hospitalization

Partial hospitalization and psychosocial rehabilitation programs attempt to provide the structure, activity, interpersonal contact, and monitoring that clients typically receive in an inpatient setting. These programs are helpful in that they can provide respite from a stressful home environment for the client and a break for family members who are caring for the individual (Heath, 2005). They also offer group therapy, job training, education, and opportunities for community integration.

Unfortunately many individuals who are experiencing acute symptomatology may be disruptive during the daily activities or not be able to tolerate the amount of activity and interpersonal contact that occurs during the four to five hours of the program. Furthermore these programs provide little benefit to clients who have difficulty communicating with others or do not have the insight necessary to participate in either process or education groups. Another aspect of these programs is that clients can drop out or be discharged owing to poor attendance, behavior problems, or the inability to demonstrate that they are benefiting. Typically a good screening process prior to admission to the program will prevent some of these incidences, but in the cases where an individual is discharged he or she may lose the important monitoring aspect of the program and be permitted to decompensate further and without notice.

Crisis Stabilization

Crisis stabilization programs typically come in two forms: home based and center based. Center-based programs offer twenty-four-hour monitoring of individuals who are experiencing acute psychiatric disturbance, require substance detoxification, or pose a mild to moderate suicide or homicide risk. These individuals typically do not meet criteria for hospitalization because they have not been shown to be an imminent danger to themselves or others, but they will require inpatient care if the stabilization program is not successful. These programs are also used as a step-down program from inpatient treatment.

Home-based crisis stabilization programs are similar to ACT and MCHT programs in that they provide interventions in the client’s home and assist clients with getting to their medical and psychiatric appointments or other services that will facilitate their stabilization. Typically the programs are staffed by individuals with bachelor’s or master’s degrees in mental health or social work. Some programs have an integrated treatment team comprising nurses, psychologists, social workers, counselors, or rehabilitation workers. Staff members assess the referred individual’s crisis situation and determine the person’s appropriateness for crisis stabilization. If the individual does not yet meet criteria for inpatient care and does not require twenty-four-hour monitoring but needs a level of care that is more intensive than other programs (e.g., ACT or intensive case management), he or she will be admitted. This may also be an option for the individual who cannot participate in partial hospitalization.

Each hospital diversion program has a unique role in the mental health care system, and each is necessary for continuity of care. The common denominator is that ACT, MCHT, partial hospitalization, and crisis stabilization staff are frequently confronted with unstable or decompensating clients who need a higher level of clinical assistance until they are restored to their normal level of functioning. Fortunately studies targeting the effectiveness of these programs are beginning to emerge.

DO HOSPITAL DIVERSION PROGRAMS WORK?

In general there is evidence that community-based treatment might be more desired and more effective than hospital-based care for some clients. Findings from one study suggest that users of a service with a well-developed community-oriented approach and with crisis intervention outside the hospital setting are more satisfied with the emergency interventions than are users of a mental health service relying mostly on hospital facilities during emergencies (Ruggeri et al., 2006). Another study compared early intervention by community services and standard hospital treatment. One hundred patients ages 16 to 65 years who were experiencing a psychiatric emergency were treated by either a multidisciplinary community-based team (n = 48) or conventional hospital-based psychiatric services (n = 52) and assessed over a three-month period. Patients referred to the community-based service showed greater improvement in symptoms and were more satisfied with services than were those in the hospital-based service. In fact, patients treated in the hospital spent eight times as many days as psychiatric inpatients as those treated in the community-based service (Merson et al., 1992).

The only hospital diversion program that has received significant attention in the literature is assertive community treatment. Partial hospitalization programs have been around for a few decades, but very few studies have looked at these programs. Likewise, crisis stabilization programs have received very little attention. The likely explanation is that crisis stabilization programs are relatively new, and the number of partial hospitalization and crisis stabilization programs has not been large enough to warrant empirical investigation.

Several studies have demonstrated the efficacy of the assertive community treatment model as an intervention for the severely mentally ill. Specifically it has been found to reduce the frequency of hospitalization (Bonsack et al., 2005; Ben-Porath, Peterson, & Piskur, 2004; Blow et al., 2000; Chinman et al., 1999; Tibbo, Chue, & Wright, 1999; Essock, Frisman, & Kontos, 1998; Stein & Test, 1980), improve quality of life (Chinman et al., 1999), decrease homelessness (McBride et al., 1998), and lower overall mental health care costs (Latimer 2011, 2005, 1999; Essock, Frisman, & Kontos, 1998). Crisis stabilization programs have also effectively reduced hospitalization (Reding & Raphelson, 1995; Zealberg, Santos, & Fisher, 1993), and partial hospitalization programs have been found to be effective in reducing hospitalization and decreasing symptom severity among individuals with severe mental illness (Husted & Wentler, 2000; Granello, Granello, & Lee, 1999).

There have been mixed results...

Table of contents

• Cover 
• Title Page
• Copyright
• Dedication
• Contents 
• Preface
• 1. Hospital Diversion Programs
• 2. Integrative And Multimodal Treatment
• 3. Severe Mental Illness Treatment Literature: An Overview
• 4. Multimodal Acute Care
• 5. Fundamental Tools and Techniques
• 6. Schizophrenia and Schizoaffective Disorder
• 7. Major Depression and Bipolar Disorder
• 8. PTSD and Panic Disorder
• 9. Substance-Related Disorders
• 10. Important Treatment Considerations
• Appendix A: Crisis Action Plan
• Appendix B: Thought Change Worksheet
• Appendix C: Stress-Vulnerability Model Diagrams
• References
• Index