Predicting and Preventing the Risk of Psychiatric Rehospitalization among Children and Adolescents

Purpose: The readmission of children and adolescents into inpatient psychiatric facilities is considered an adverse outcome given the cost, restrictive nature and questionable outcomes of psychiatric hospitalizations. Research on the reasons for psychiatric readmission among youth and ways to prevent it remains scant. This study examined risk and determinants of re-hospitalization of children and adolescents within two years of first psychiatric hospitalization. It further tested the effect of partial hospitalization services on the risk of readmission after controlling for relevant clinical and psychosocial risk factors as well as other post-discharge services.

Methods: Two-hundred study participants were randomly drawn from a sampling frame of over 4000 former child and adolescent patients who were first psychiatrically hospitalized between 1/1/02 and 12/31/05 at a major psychiatric inpatient facility in the Southwest region of the US. The final sample was 57% female and predominantly white; the mean age at first hospitalization was 14.3 (SD=1.15). The data collection process included structured telephone interviews (based on the Child and Adolescent Services Assessment [CASA]) with caregivers of former child/adolescent patients to gather post-discharge services data. A second phase included case abstractions to collect clinical and historical risk factor information. Poisson regression as well as survival analysis were used to determine both the rate at which readmission occurred as well as the hazard of a youth being readmitted for a second time. Covariates included in each model included sociodemographic characteristics (gender, SES), clinical factors (diagnosis, GAF scores at admission, treatment completion, family history of mental illness), psychosocial risk factors (abuse history, drug /alcohol use, family involvement, family structure, living situation) as well as post-discharge service utilization.

Results: Two-thirds of the sample had experienced psychiatric readmissions with an average of 2.8 readmissions (SD=3.11) after two years since being first admitted. Post-hospitalization mental health services involved a range of services (partial hospitalization, mental health outpatient, medication, counseling) with mental health outpatient services being attended by 80% of the sample. One-third of the youth participated in partial hospitalization services following discharge from the inpatient unit. Poisson regression findings indicate that the rate of readmission increases significantly with several clinical variables (GAF scores at admission [B=0.26; SE=.07], age at first admission [B=-.87; SE=.34], treatment completion [B=-.63; SE=.12) whereas psychosocial risk factors did not explain an increased rate of readmission. However, participation in partial hospitalization following initial discharge significantly reduced the rate of readmission [B=-2.33; SE=.99] even after controlling for receipt of other follow-up services. Survival analysis findings show that the survival rate after two years drops to .33 with the hazard of experiencing a readmission being greatest during the first six months following discharge.

Conclusion: Findings from this analysis point to the clinical severity of youth admitted to psychiatric hospitals, and to youth with the most impaired functioning also at elevated risk for readmission even after controlling for psychosocial risk factors. The finding that participation in partial hospitalization can significantly reduce the risk of readmission is a promising one. Findings of this study will be used to strengthen this treatment component.