Predicting Recidivism to Psychiatric Emergency Services for System Naive Individuals

Background and Purpose: Readmission to Psychiatric Emergency Services (PES) is often an indicator that the mental health system has failed to adequately identify and treat individuals at risk for ongoing mental health crises. Inpatient admissions following PES are thought to link patients to scarce outpatient treatment resources, while outpatient services are thought to avert recidivism. To test these hypotheses, this study examined characteristics associated with PES recidivism, inpatient admission, and outpatient service use following PES admission.

Methods: Charts for three months (January 2005 – March 2005) of admissions to San Francisco's only PES were reviewed. Patient demographic and clinical characteristics were collected. Service utilization data were collected for two years prior and one year following PES admissions. Only “system naive” individuals, those with no billing records in the San Francisco Community Behavioral Health Services (CBHS) for two years prior to their index PES admission were included (N=339). Logistic regression was used to predict PES readmission in the year following the index PES admission, admission to psychiatric inpatient services following PES admission and outpatient services use in the 3 months after PES admission.

Results: Of the 339 system naive individuals admitted to PES., 49 (14.45%) were readmitted to PES within a year. Neither inpatient service use nor outpatient service use affected the odds of PES recidivism. However, readmission to PES was predicted by being black rather than white (OR=2.23) or restrained in PES (OR=2.70). 161 patients (47.49%) were admitted to inpatient psychiatric services following their index PES admission. Poor functioning, delusions, and suicidal ideation increased the odds of inpatient admission. Being black rather than white, being restrained in PES and having alcohol or drug use involved in the PES admission decreased the odds of inpatient admission. 61 (17.99%) received outpatient services in the 3 months following their index PES admission. Neither inpatient service use, nor patient characteristics were associated with outpatient service use.

Conclusion and Implications: This study tested the hypotheses that readmission to PES is prevented by outpatient service use, and that outpatient service use is facilitated by inpatient admission. Neither inpatient admission or outpatient service use was associated with reduced PES recidivism, nor did inpatient service use increase outpatient service use. However, it appears that black individuals are at higher risk of readmission to PES, but are less likely to be referred to inpatient services after an initial PES admission. Similarly, restraint use in PES was associated with higher odds of returning to PES but lower odds of admission to inpatient services. While these findings do not support the hypothesis that outpatient or inpatient service use reduces PES recidivism, there is evidence that some characteristics associated with decreased inpatient admission are associated with increased PES recidivism. Future studies should explore reasons for lower rates of inpatient admissions among black individuals and their potential connection to higher rates of PES recidivism.