Regional

differences

in

psychiatric

disorders

in

Chile

Background

Psychiatric

epidemiological

surveys

in

developing

countries

are

rare

and

are

frequently

conducted

in

regions

that

are

not

necessarily

representative

of

the

entire

country

In

addition

in

large

countries

with

dispersed

populations

national

rates

may

have

low

value

for

estimating

the

need

for

mental

health

services

and

programs

Cross-national

psychiatric

epidemiological

prevalence

studies

using

similar

diagnostic

instruments

have

resulted

in

disparate

rates

for

specific

disorders

-LSB-

-RSB-

The

reasons

for

these

differences

in

rates

have

been

attributed

to

methodological

issues

between

studies

socio-demographic

factors

such

as

socio-economic

status

differences

between

countries

and

cultural

differences

Cross-national

comparative

studies

-LSB-

-RSB-

attempt

to

correct

for

socio-demographic

variability

yet

differences

persist

In

some

regions

of

the

world

such

as

prevalence

rates

in

Chinese

based

studies

-LSB-

-RSB-

the

rates

are

markedly

different

than

the

rest

of

the

world

This

either

suggests

true

differences

in

the

rates

of

pathology

or

lack

of

cultural

appropriateness

of

the

diagnostic

tools

and

the

Western

diagnostic

systems

utilized

-LSB-

-RSB-

Understanding

these

cross-national

differences

may

provide

clues

into

the

etiology

of

psychopathology

Regional

differences

also

exist

within

countries

as

evidenced

by

studies

where

the

methodology

is

similar

across

geographic

areas

-LSB-

-RSB-

Regional

differences

in

the

presence

of

serious

mental

illness

have

been

attributed

to

migration

of

the

mentally

ill

-LSB-

-RSB-

birth

in

urban

areas

-LSB-

-RSB-

and

genetic

pooling

-LSB-

-RSB-

The

most

studied

regional

differences

are

those

between

urban

and

rural

populations

where

urban

environmental

adversity

is

argued

to

contribute

to

pathology

-LSB-

-RSB-

An

understanding

of

regional

differences

in

countries

where

the

population

is

spread

across

large

distances

is

relevant

for

health

care

planning

Potentially

risk

factors

may

differ

across

a

country

resulting

in

the

need

to

address

mental

health

needs

on

a

regional

basis

rather

than

centrally

Furthermore

an

understanding

of

geographic

variability

permits

allocation

of

resources

to

be

distributed

in

a

proportional

basis

by

need

This

issue

is

of

particular

importance

to

developing

countries

such

as

in

Latin

America

where

frequently

services

are

only

provided

centrally

or

disproportionately

to

the

wealthier

regions

of

a

country

In

addition

epidemiological

studies

based

on

single

regions

of

the

country

-LSB-

-RSB-

are

extrapolated

to

larger

population

bases

for

which

they

may

or

may

not

be

representative

Population

studies

about

psychiatric

disorders

in

Latin

America

as

well

as

other

developing

regions

of

the

world

are

rare

They

are

important

however

for

understanding

variations

in

patterns

of

disorders

underlying

determinants

and

service

needs

Chile

given

its

rather

extraordinary

geography

provides

an

important

test

of

variations

in

disorder

rates

across

a

spatially

dispersed

population

and

offers

perhaps

the

best

case

example

of

a

country

where

national

rates

would

seemingly

have

low

value

for

estimating

the

need

for

mental

health

services

and

programs

The

Chile

Psychiatric

Prevalence

Study

-LRB-

CPPS

-RRB-

was

developed

to

address

issues

regarding

the

prevalence

and

risk

factors

for

mental

illness

based

on

a

nationally

representative

sample

and

service

utilization

Chile

has

a

population

of

approximately

millions

people

The

country

is

composed

of

provinces

grouped

in

regions

covering

an

area

spanning

million

-LRB-

including

Antarctica

and

Insular

Territories

-RRB-

over

a

length

of

km

The

large

distances

between

major

population

centers

resulted

in

the

CPPS

being

conducted

in

four

regions

of

the

country

Bio

Bio

the

south-central

region

containing

the

second

largest

city

Metropolitana

the

north-central

region

which

includes

the

capital

Santiago

Tarapaca

the

north

and

Araucania

the

south

of

the

country

in

order

to

obtain

a

representative

sampling

of

the

population

of

the

nation

This

report

focuses

on

whether

regional

differences

in

the

prevalence

of

psychiatric

disorders

and

service

utilization

if

present

are

due

to

factors

other

than

socio-demographic

differences

between

population

centers

Methods

Sample

selection

The

CPPS

was

based

on

a

household

stratified

sample

of

people

age

and

older

A

more

detailed

description

of

the

methods

used

in

the

CPPS

is

available

in

earlier

publications

-LSB-

-RSB-

The

sample

frame

was

developed

to

be

representative

of

the

nation

's

population

Four

regions

and

their

most

representative

province

and

comunas

were

selected

These

were

subsequently

subdivided

into

districts

and

then

randomly

selected

blocks

The

number

of

households

available

on

each

block

was

enumerated

The

census

of

each

region

was

used

to

determine

the

number

of

households

required

on

each

block

A

list

of

the

inhabitants

age

and

older

in

each

household

was

generated

Using

pre-assigned

Kish

tables

-LRB-

Kish

-RRB-

one

person

per

household

was

selected

from

the

list

to

be

interviewed

The

survey

was

conducted

by

the

University

of

Concepcion

Department

of

Psychiatry

and

Mental

Health

between

July

and

June

with

each

site

being

completed

in

the

following

order

based

on

funding

Bio

Bio

Metropolitana

Tarapaca

and

Araucania

A

total

of

individuals

participated

in

the

survey

Response

rate

did

differ

by

site

-LRB-

χ2

df

P

-RRB-

with

Metropolitana

having

the

highest

non-response

rate

and

Tarapaca

the

lowest

A

weight

was

used

to

account

for

the

probability

of

the

comuna

district

block

household

and

respondent

being

selected

The

data

was

adjusted

to

the

census

of

each

region

based

on

age

gender

and

marital

status

using

a

second

weight

Diagnostic

assessment

Composite

International

Diagnostic

Interview

-LRB-

CIDI

-RRB-

versions

and

-LSB-

-RSB-

were

used

to

generate

the

diagnoses

using

well-trained

lay

interviewers

DSM-III-R

-LSB-

-RSB-

diagnostic

criteria

were

employed

A

section

on

health

service

utilization

in

the

prior

to

the

interview

was

also

included

The

Spanish

translation

was

conducted

using

the

protocol

outlined

by

the

World

Health

Organization

-LRB-

WHO

-RRB-

-LSB-

-RSB-

A

validation

study

of

the

Chilean

CIDI

was

found

to

have

kappas

that

ranged

from

for

somatiform

disorders

up

to

for

affective

disorders

-LSB-

-RSB-

using

a

sample

of

patients

and

volunteers

for

each

CIDI

section

After

double

entry

of

data

and

verification

for

logical

inconsistencies

diagnoses

were

generated

using

the

CIDI

computer

programs

for

and

-LSB-

-RSB-

The

DSM-III-R

diagnoses

included

in

this

report

are

all

affective

disorders

all

anxiety

disorders

defined

as

panic

disorder

agoraphobia

and

generalized

anxiety

disorder

substance

use

disorder

which

does

not

include

nicotine

dependence

and

any

diagnosis

Lifetime

and

prevalence

rates

were

examined

Interviewers

and

training

Social

science

university

students

in

their

senior

year

underwent

training

following

the

WHO

protocol

at

the

University

of

Concepcion

a

WHO

CIDI

training

and

reference

center

The

interviewers

received

over

h

of

instruction

and

practice

sessions

Each

interviewer

had

to

conduct

practice

interviews

with

volunteer

adult

subjects

with

and

without

psychiatric

disorders

selected

from

local

clinics

as

well

as

a

pilot

interview

on

an

individual

in

a

non-selected

household

in

the

community

Approximately

of

the

interviews

were

audiotaped

following

the

subject

's

consent

and

randomly

reviewed

for

quality

control

Analysis

procedures

The

SUDAAN

statistical

package

-LSB-

-RSB-

Taylor

series

linearization

method

was

used

to

estimate

the

standard

errors

due

to

the

sample

design

and

the

need

for

weighting

The

analysis

was

conducted

using

procedures

without

replacement

for

non-respondents

The

comuna

and

district

selected

were

used

as

the

defined

strata

Chi-square

analyses

were

used

to

examine

the

association

of

disorders

and

service

utilization

between

regions

Logistic

regression

was

used

to

adjust

for

socio-demographic

differences

across

regions

accounting

for

differential

rates

or

service

utilization

Additional

analyses

were

conducted

to

examine

urban

rural

differences

The

logistic

regression

analyses

included

gender

marital

status

age

group

education

and

income

as

potential

confounders

All

results

are

presented

as

weighted

data

Results

The

distribution

of

income

and

marital

status

were

found

to

differ

across

the

four

regions

of

the

country

-LRB-

see

Table

-RRB-

The

population

of

Bio

Bio

had

significantly

lower

incomes

than

the

other

regions

-LRB-

χ2

df

P

-RRB-

In

addition

Bio

Bio

had

the

lowest

rate

of

individuals

who

were

separated

or

had

annulled

marriages

-LRB-

χ2

df

P

-RRB-

In

two

of

the

regions

the

rural

population

was

under-represented

relative

to

the

census

In

Bio

Bio

of

population

was

rural

the

sample

only

included

and

in

Araucania

of

the

population

was

rural

and

the

sample

only

included

Table

characteristics

by

regionDisordersBio

Bio

-LRB-

N

-RRB-

Metropolitana

-LRB-

N

-RRB-

Tarapaca

-LRB-

N

-RRB-

Araucania

-LRB-

N

-RRB-

SE

SE

SE

SEGender

Age

Education

No

Marital

status

Never

Common

Income

U$

U$

40070.57.154.53.912.24.847.715.467.9690.0001

U$

U$

U$

U$

U$

Urban/rural

Prior

to

adjusting

for

socio-demographic

differences

between

the

regions

a

number

of

differences

in

prevalence

rates

were

noted

-LRB-

see

Tables

-RRB-

Lifetime

rates

for

major

depressive

disorder

were

markedly

elevated

in

Tarapaca

and

lowest

in

Bio

Bio

-LRB-

χ2

df

P

-RRB-

Drug

abuse

but

not

dependence

also

had

the

highest

prevalence

rate

in

Tarapaca

-LRB-

χ2

df

P

-RRB-

Interestingly

in

Araucania

the

rate

of

non-affective

psychosis

was

the

lowest

-LRB-

χ2

df

P

-RRB-

When

females

were

examined

the

differential

rates

for

major

depressive

disorder

-LRB-

χ2

df

P

-RRB-

and

substance

use

disorders

were

noted

-LRB-

χ2

df

P

-RRB-

Among

males

the

only

lifetime

difference

in

prevalence

rates

was

for

elevated

alcohol

abuse

in

Tarapaca

-LRB-

χ2

df

P

-RRB-

For

prevalence

the

increased

risk

for

major

depression

in

Tarapaca

persisted

-LRB-

χ2

df

P

-RRB-

for

both

genders

combined

and

for

females

-LRB-

χ2

df

P

-RRB-

The

differences

noted

in

the

prevalence

of

substance

use

disorders

were

no

longer

evident

at

Table

prevalence

rates

of

DSM-III-R

disorders

by

regionBio

BioMetropolitanaTarapacaAraucaniaDisorders

SE

SE

SE

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Cognitive

Any

CPPS

FemaleAffective

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Any

CPPS

MaleAffective

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Any

CPPS

disorder28.55.326.42.351.24.035.05.04.460.23Non-affective

psychosis

includes

schizophrenia

schizophreniform

disorder

schizoaffective

disorder

delusional

disorder

and

atypical

psychosisAny

CPSS

disorder

does

not

include

nicotine

dependence

or

cognitive

disorder

χ2

df

prevalence

rates

of

DSM-III-R

disorders

by

regionBio

SE

SE

SE

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Any

CPPS

FemaleAffective

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Any

CPPS

MaleAffective

disorders

Major

depressive

Manic

Any

affective

Anxiety

disorders

Panic

Agoraphobia

without

Generalized

anxiety

Any

anxiety

Substance

use

disorders

Alcohol

Alcohol

Drug

Drug

Nicotine

Any

alcohol

or

drug

use

Any

substance

use

Other

disorders

Non-affective

Somatoform

Any

CPPS

disorder21.85.320.52.522.03.017.33.41.120.77Non-affective

psychosis

includes

schizophrenia

schizophreniform

disorder

schizoaffective

disorder

delusional

disorder

and

atypical

psychosisAny

CPSS

disorder

does

not

include

nicotine

dependence

or

cognitive

disorder

χ2

df

health

service

utilization

in

the

past

by

region

among

those

with

DSM-III-R

prevalent

disorderBio

SE

SE

SE

MH

service17.61.121.12.525.90.312.01.910.090.03Non-specialized

MH

Specialized

MH

Substance

χ2

df

MH

Mental

HealthNon-Specialized

MH

Services

primary

care

physicians

Specialized

Mental

Health

Services

inpatient

or

outpatient

services

provided

by

a

psychiatrist

or

a

psychologist

or

formal

substance

abuse

services

Substance

abuse

services

included

inpatient

and

outpatient

detoxification

or

Alcoholics

Anonymous

Using

logistic

regression

controlling

for

socio-demographic

variables

the

regional

differences

for

major

depression

were

maintained

for

both

lifetime

and

prevalence

as

well

as

among

females

in

both

prevalence

periods

Males

with

lifetime

prevalent

affective

disorders

were

also

at

increased

risk

in

Tarapaca

In

addition

regional

differences

in

lifetime

prevalence

for

alcohol

abuse

drug

abuse

and

nicotine

dependence

were

found

Among

females

regional

differences

in

lifetime

prevalence

were

noted

for

drug

abuse

drug

dependence

any

alcohol

or

drug

use

disorder

and

cognitive

disorders

and

among

men

alcohol

abuse

with

increased

risk

among

those

residing

in

Tarapaca

The

statistical

differences

in

regional

lifetime

prevalence

of

non-affective

psychosis

for

both

genders

combined

and

females

in

both

prevalence

periods

persisted

with

the

rates

for

Araucania

remaining

low

As

the

rates

for

not

only

major

depression

but

also

alcohol

and

drug

use

disorders

were

elevated

in

Tarapaca

additional

analyses

were

conducted

controlling

for

comorbidity

in

the

logistic

regressions

the

regional

differences

noted

were

not

altered

Differences

in

service

utilization

across

the

four

regions

were

also

found

Araucania

had

the

lowest

use

of

mental

health

services

utilization

-LRB-

χ2

df

P

-RRB-

in

particular

in

the

non-specialized

health

care

sector

-LRB-

χ2

df

P

-RRB-

The

rates

of

service

utilization

by

region

are

presented

in

Table

The

lower

use

of

services

persisted

after

controlling

for

socio-demographic

variables

in

a

logistic

regression

When

urban

versus

rural

was

examined

across

all

sites

no

statistical

differences

in

the

rates

of

disorders

were

noted

In

addition

there

were

no

socio-demographic

differences

The

sample

size

of

the

rural

population

was

small

Discussion

Regional

differences

that

persisted

after

adjusting

for

potential

confounders

persisted

in

the

CPPS

Major

depression

and

substance

use

disorders

were

highly

prevalent

in

Tarapaca

The

high

rates

of

substance

use

disorders

especially

drugs

and

were

not

surprising

as

the

region

bordering

Bolivia

and

Peru

is

heavily

involved

in

the

drug

trade

The

increased

rates

of

major

depression

however

could

not

be

accounted

for

by

substance

use

disorder

comorbidity

The

differences

in

rates

for

non-affective

psychosis

although

may

simply

be

due

to

a

type

error

are

nonetheless

surprising

as

the

Araucania

region

's

population

and

our

sample

has

a

sizable

proportion

of

Mapuche

indigenous

people

The

Mapuche

in

earlier

psychiatric

literature

were

thought

to

be

at

increased

risk

for

psychosis

-LSB-

-RSB-

The

small

sample

size

of

the

rural

population

precluded

finding

statistically

significant

differences

The

utilization

of

health

service

was

lowest

in

Araucania

and

Bio

Bio

This

may

be

consistent

with

the

inequities

in

availability

and

access

that

do

exist

in

health

and

mental

health

resources

across

different

regions

of

Chile

The

southern

half

of

the

country

is

the

poorest

and

has

the

least

resources

therefore

the

lower

rates

may

be

due

to

a

lack

of

access

rather

than

demand

For

example

across

the

regions

the

number

of

available

mental

health

beds

in

the

public

health

service

per

were

Araucania

Bio

Bio

Metropolitana

and

Tarapaca

The

number

of

primary

care

physicians

per

populations

also

was

lowest

in

Araucania

compared

to

Bio

Bio

with

Tarapaca

with

and

Metropolitana

with

It

could

be

argued

that

these

regional

differences

are

simply

artifact

due

to

sampling

differences

Clearly

the

population

investigated

in

Tarapaca

is

small

for

a

prevalence

study

and

may

have

resulted

in

rates

that

may

prove

unstable

Another

potential

limitation

is

that

the

four

regions

were

investigated

sequentially

with

the

potential

for

socio-cultural

influences

to

impact

on

the

rates

during

the

intervals

between

data

collection

The

high

proportion

of

low-income

individuals

in

the

Bio

Bio

sample

in

comparison

to

the

other

sites

and

in

particular

Aracucania

the

poorest

region

of

the

country

reflects

the

improved

economic

conditions

in

Chile

during

the

course

of

data

collection

and

supports

a

cohort

effect

A

cohort

effect

however

is

highly

unlikely

to

explain

the

rates

of

psychopathology

given

that

data

collection

was

obtained

from

Araucania

last

yet

it

has

the

highest

rate

of

major

depressive

disorder

Conclusion

Regional

differences

across

countries

may

exist

that

have

both

implications

for

prevalence

rates

and

service

utilization

Planning

mental

health

services

for

population

centers

that

span

wide

geographical

areas

based

on

studies

conducted

in

a

single

region

may

be

misleading

and

may

result

in

areas

with

high

need

being

underserved

Psychiatric

epidemiological

studies

that

are

nationally

representative

of

developing

nations

are

needed

that

have

a

sufficient

sampling

frame

to

examine

populations

believed

to

be

at

high

risk

and

regions

where

increased

inequities

may

exist

Even

the

most

recent

epidemiological

studies

representing

Latin

America

-LSB-

-RSB-

have

ignored

large

segments

of

the

population

such

as

those

countries

and

regions

of

countries

with

large

indigenous

populations

or

segments

of

the

population

that

are

very

poor

Fewer

studies

in

the

region

have

examined

service

needs

and

have

addressed

regional

differences

in

services

Data

that

is

more

representative

of

the

Latin

American

population

is

needed

in

order

to

improve

mental

health

services

planning

and

addresses

the

large

under-estimated

treatment

gap

B I O B I O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

psychiatric disorders
regional differences
chile


Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients Background The objective of this analysis was to determine the ways in which patients ' legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables . This study specifically investigated differences between patients who were voluntary during both admission and discharge , patients who were involuntary on admission but voluntary on discharge -LRB- having converted to voluntary status during hospitalization -RRB- , and patients who were involuntary during both admission and discharge . Introduction In the United States , criteria for involuntary psychiatric hospitalization generally require imminent dangerousness to oneself or others , or complete inability to care for oneself -LSB- 1 , 2 -RSB- , though specific criteria vary between states -LSB- 3 -RSB- . An important rationale for involuntary psychiatric hospitalization is that patients admitted for evaluation often have severe deficits in their capacities to make treatment decisions -LSB- 4 , 5 -RSB- . Patients often revise their beliefs about the need for treatment during or after hospitalization . A study conducted by Gardner et al. -LSB- 6 -RSB- found that slightly more than half of patients who initially stated -LRB- upon admission -RRB- that they did not need hospitalization later admitted they indeed had needed treatment when re-interviewed several weeks after discharge . It has been suggested that involuntary treatment may reduce the likelihood that patients will voluntarily seek care in the future -LSB- 7 , 8 -RSB- . Subsequent aversion to psychiatric services may be due to a distrust of clinicians arising from coercive tactics or a lack of procedural justice -LRB- e.g. , the patient is treated unfairly , disrespected , ignored , or excluded from the decision-making process -RRB- encountered during hospitalization -LSB- 1 , 8 , 9 -RSB- . On the other hand , involuntary hospitalization may provide patients with needed treatment , even if involuntarily , that results in improved outcomes and treatment adherence -LSB- 10 -RSB- . Some research indicates that the presence or absence of coercion is accurately reflected by the patient 's legal status , but other studies demonstrate that coercive pressures and perceived coercion do not necessarily correlate well with legal status in all settings -LSB- 8 , 11 -RSB- . Evidence associating legal status with sociodemographic and clinical variables is sparse and inconsistent . One study found that higher re-admission rates and more unstable discharge living arrangements were associated with involuntary legal status on hospital admission -LSB- 12 -RSB- . A meta-analytic review conducted using studies from the 1950s through the early 1980s found that the only significant outcome measure correlated with admission legal status was length of stay -LSB- 13 -RSB- . Studies have reached opposing conclusions regarding whether or not male gender is significantly associated with involuntary legal status , especially when controlling for severity of illness -LSB- 7 , 12 , 14 -RSB- . With regard to clinical characteristics , psychotic disorder diagnoses , greater illness severity , and more frequent preadmission assaultive behaviors may be associated with involuntary admission -LSB- 13 -RSB- . Even fewer studies have examined factors associated with converting from involuntary to voluntary legal status during hospitalization -LSB- 14 -- 16 -RSB- . Cuffel -LSB- 14 -RSB- identified greater clinical improvement , less severe diagnoses , and non-minority ethnicity as factors predictive of converting to voluntary status early in the hospitalization . Later during hospitalization , the only factor associated with legal status conversion was having discharge living arrangements involving family and friends . Studies that find significant associations between legal status and outcomes may influence policies relating to resource allocation during hospitalization , discharge planning , and outpatient follow-up -LSB- 12 , 15 -RSB- . For instance , research characterizing those at risk for very short involuntary hospitalization -LRB- i.e. , discharge upon expiration of short-term commitment -RRB- addresses the need for more thorough and engaged evaluation and treatment while hospitalized . One may be able to enhance treatment adherence with a more focused treatment and evaluation plan , in conjunction with closer follow-up after discharge -LSB- 12 -RSB- . Though legal status is often overlooked in studies in which it would be particularly relevant , it is clearly an important variable for further research . The purpose of the present study was to compare three groups of hospitalized psychiatric patients : -LRB- 1 -RRB- patients admitted and discharged voluntarily -LRB- VOL-VOL -RRB- , -LRB- 2 -RRB- patients admitted involuntarily who later signed-in voluntarily and were discharged voluntarily -LRB- INV-VOL -RRB- , and -LRB- 3 -RRB- patients admitted and discharged on an involuntary legal status -LRB- INV-INV -RRB- . As such , this trichotomous criterion variable addressed the change -LRB- or lack thereof -RRB- in patients ' legal status during hospitalization , allowing an examination of whether or not certain sociodemographic and clinical factors are associated with differences in admission-to-discharge legal status . Treating legal status as a trichotomous variable -LRB- rather than solely considering either admission or discharge legal status -RRB- may yield meaningful results that add to the current body of research on correlates of patients ' legal status . Methods Subjects and setting This analysis was part of a study aimed at determining predictors of non-adherence with the first scheduled community mental health outpatient appointment following hospitalization -LSB- 17 -RSB- . Inclusion in the study was restricted to consecutively discharged patients with a scheduled follow-up appointment at any of 12 participating community mental health settings in a single urban county . Patients re-hospitalized during the course of data collection were not included a second time , in order to maintain independence of observations . This analysis included data that were collected on 227 patients from December 2003 to July 2004 . All patients were admitted to the 22-bed inpatient unit or the 8-bed crisis stabilization unit of a large , public-sector hospital in the southeastern United States . Both the longer-stay inpatient unit and the crisis stabilization unit admit patients primarily for evaluation and treatment of first episodes of illness or exacerbations of severe and persistent mental illnesses -LRB- primarily schizophrenia and other psychotic disorders and severe affective disorders -RRB- . This county hospital serves a predominantly low-income , urban , African American population . In the state of Georgia , commitment for involuntary evaluation can be initiated by a licensed physician , psychologist , clinical social worker , or psychiatric clinical nurse specialist . Taking custody for transportation to an emergency evaluation facility also can be carried out by a law enforcement officer . In either case , this initial commitment allows for the individual to be taken to and held at a locked evaluation facility . Commitment criteria include the fact that the person appears to have a mental illness , and either -LRB- 1 -RRB- presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or threats of violence presenting a probability of physical injury , or -LRB- 2 -RRB- is so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis -LSB- 3 -RSB- . Within 48 h of admission , if the individual continues to meet commitment criteria , a physician may sign for commitment for further evaluation and treatment of up to five business days in duration . During this period of time , some patients will sign-in as voluntary patients . If the patient does not sign-in voluntarily , then he or she is typically discharged after the 5 days , unless commitment criteria clearly continue to be present . In that case , a court hearing is scheduled to determine whether or not the legal standard is met for longer-term involuntary hospitalization . However , in this setting extended commitment is used relatively rarely , and only in circumstances in which the threat to self or others is very apparent . Procedures The majority of data collected were abstracted from patients ' medical charts . Subjectively rated variables -LRB- e.g. , treatment plan adherence during hospitalization , the treatment team 's opinion of likelihood of follow-up -RRB- were obtained by consulting with the social worker , the psychiatry resident or psychology intern , and the attending psychiatrist caring for the patient during hospitalization . As described in two recently published reports , basic demographic , socioeconomic , psychosocial , and clinical data were recorded in a systematic fashion using a standardized data collection instrument -LSB- 17 , 18 -RSB- . The criterion variable of interest in this analysis was a three-level variable representing the patient 's legal status at admission and at discharge : VOL-VOL , INV-VOL , and INV-INV . The research was approved by the university 's institutional review board and the hospital 's research oversight committee . Analysis Bivariate analyses were performed using a variety of independent variables in relation to the criterion variable . Continuous variables were analyzed using one-way analysis of variance and categorical variables were analyzed using chi-square tests of association . These bivariate analyses were conducted to inform the selection of variables for inclusion in the subsequent multivariate regression analysis . Polytomous logistic regression modeling was required due to the trichotomous nature of the admission/discharge legal status criterion variable . Those patients admitted and discharged voluntarily -LRB- VOL-VOL -RRB- were designated as the referent group in the regression model . Entering variables into the logistic model was based on significant bivariate test results -LRB- P < 0.05 -RRB- . A thorough assessment of confounding was conducted , and relevant confounding variables were controlled for in the model . The backward elimination method was used to identify variables that were independently significantly associated -LRB- P < 0.05 -RRB- with legal status . Appropriate modeling diagnostics were conducted to ensure the fit of the model to the data . Adjusted odds ratios and 95 % confidence intervals were computed to determine effect estimates for independent variables that were significantly associated with legal status , controlling for all other covariates in the model . The SAS version 9.1 software -LRB- SAS Inc. , Cary , North Carolina , USA -RRB- was used for all statistical analyses . Results Basic sociodemographic and clinical descriptive statistics for the overall sample are shown in Table 1 . Slightly over half -LRB- 55.5 % -RRB- of patients were female . The racial composition of the sample is consistent with that of the population served by the two inpatient units , and by the hospital in general . Specifically , 84.9 % of patients were Black/African American . At the time of admission , 94.2 % of patients were unemployed , and 25.6 % reported being homeless . The majority of patients were single/never married -LRB- 67.8 % -RRB- . The majority of patients had been previously hospitalized for psychiatric treatment -LRB- 75.1 % -RRB- . An even greater percentage of patients were reported as having psychotic symptoms at the time of admission -LRB- 85.8 % -RRB- . The mean age was 38.7 ± 12.4 years , and the mean educational level was 12.1 ± 2.3 years . The mean Global Assessment of Functioning -LRB- GAF -RRB- scale score on admission was 30.3 ± 8.2 , ranging from 10 to 55 . Table 1Basic sociodemographic and clinical descriptive statistics for the overall sample -LRB- n = 227 -RRB- VariableFrequencyGender , female126 -LRB- 55.5 % -RRB- Race Black/African American191 -LRB- 84.9 % -RRB- Hispanic/Latino4 -LRB- 1.8 % -RRB- White/Caucasian/European American 28 -LRB- 12.4 % -RRB- Other2 -LRB- 0.9 % -RRB- Employment status , unemployed213 -LRB- 94.2 % -RRB- Homeless on admission 58 -LRB- 25.6 % -RRB- Marital status Single/never married154 -LRB- 67.8 % -RRB- Married/living as married 19 -LRB- 8.4 % -RRB- Separated/divorced/widowed 54 -LRB- 23.8 % -RRB- Prior psychiatric hospitalization169 -LRB- 75.1 % -RRB- Psychotic symptoms present on admission194 -LRB- 85.8 % -RRB- VariableMean ± SDMedianRangeAge 38.7 ± 12.44017 -- 76 Years of education 12.1 ± 2.312 4 -- 18GAF score on admission 30.3 ± 8.23010 -- 55 Among the 227 patients , 56 -LRB- 24.7 % -RRB- were in the VOL-VOL group , 81 -LRB- 35.7 % -RRB- were in the INV-VOL group , and 90 -LRB- 39.6 % -RRB- were in the INV-INV group . As shown in Table 2 , select demographic and social variables were examined across the three groups . The difference in percentage of patients documented as having Axis IV psychosocial problems in the area of housing was statistically significant -LRB- χ2 = 6.43 , df = 2 , P = 0.04 -RRB- , with patients admitted and discharged voluntarily most likely to have housing problems -LRB- 60.7 % -RRB- . The percentage of patients who were receiving disability payments -- Supplemental Security Income -LRB- SSI -RRB- or Social Security Disability Insurance -LRB- SSDI -RRB- -- over the past 3 months also differed significantly across the three legal status groups -LRB- χ2 = 6.82 , df = 2 , P = 0.03 -RRB- , with patients admitted and discharged involuntarily most likely to be receiving disability payments -LRB- 61.1 % -RRB- . Table 2Sociodemographic characteristics of 227 hospitalized patientsVariableLegal status on admission and dischargeaTest statistic -LRB- df -RRB- P-valueVOL-VOL -LRB- n = 56 -RRB- INV-VOL -LRB- n = 81 -RRB- INV-INV -LRB- n = 90 -RRB- Gender , female32 -LRB- 57.1 % -RRB- 48 -LRB- 59.3 % -RRB- 46 -LRB- 51.1 % -RRB- 1.23 -LRB- 2 -RRB- 0.54 Race , Black/African American45 -LRB- 81.8 % -RRB- 66 -LRB- 81.5 % -RRB- 80 -LRB- 89.9 % -RRB- 2.87 -LRB- 2 -RRB- 0.24 Employed part-time or full-time2 -LRB- 3.64 % -RRB- 7 -LRB- 8.64 % -RRB- 4 -LRB- 4.44 % -RRB- 1.99 -LRB- 2 -RRB- 0.37 Homeless on admission17 -LRB- 30.4 % -RRB- 23 -LRB- 28.4 % -RRB- 18 -LRB- 20.0 % -RRB- 2.48 -LRB- 2 -RRB- 0.29 Current marital Single/never married32 -LRB- 57.1 % -RRB- 56 -LRB- 69.1 % -RRB- 66 -LRB- 73.3 % -RRB- 4.32 -LRB- 4 -RRB- 0.36 Married/living as married6 -LRB- 10.7 % -RRB- 7 -LRB- 8.6 % -RRB- 6 -LRB- 6.7 % -RRB- Separated/divorced/widowed18 -LRB- 32.1 % -RRB- 18 -LRB- 22.2 % -RRB- 18 -LRB- 20.0 % -RRB- Age on admission -LRB- Mean ± SD -RRB- 41.0 ± 11.537.0 ± 13.238.8 ± 12.11.73 -LRB- 222 -RRB- 0.18 Axis IV housing problems34 -LRB- 60.7 % -RRB- 35 -LRB- 43.2 % -RRB- 36 -LRB- 40.0 % -RRB- 6.43 -LRB- 2 -RRB- 0.04 Axis IV economic problems32 -LRB- 57.1 % -RRB- 51 -LRB- 63.0 % -RRB- 41 -LRB- 45.6 % -RRB- 5.40 -LRB- 2 -RRB- 0.07 Receiving disability payments over past 3 months -LRB- SSI or SSDI -RRB- 22 -LRB- 39.3 % -RRB- 40 -LRB- 49.4 % -RRB- 55 -LRB- 61.1 % -RRB- 6.82 -LRB- 2 -RRB- 0.03 aLegal status on admission and discharge : VOL-VOL , Patients having voluntary legal status on both admission and discharge ; INV-VOL , Patients having involuntary status on admission and voluntary status on discharge ; INV-INV , Patients having involuntary legal status on both admission and discharge Table 3 shows select clinical and diagnostic characteristics . The three legal status groups differed significantly on 13 of these 20 variables . The INV-INV group was most likely to have had previous psychiatric hospitalizations -LRB- 84.3 % -RRB- , followed by 71.6 % among the INV-VOL group , and 65.5 % among the VOL-VOL group -LRB- χ2 = 7.27 , df = 2 , P = 0.03 -RRB- . Compared to the VOL-VOL group , patients who were admitted and discharged involuntarily were more likely to have a primary diagnosis of a psychotic disorder , to have a change in GAF score from admission to discharge of < 20 points , and to have psychotic symptoms on discharge . Patients admitted and discharged involuntarily were less likely to have documentation of medical problems requiring medications at discharge , to be taking > 2 psychiatric medications at discharge , and to have good treatment plan adherence during hospitalization compared to the VOL-VOL group . Not unexpectedly , length of stay in days -LRB- F = 20.45 , df = 224 , P < 0.0001 -RRB- and the inpatient unit to which patients were admitted -LRB- χ2 = 32.84 , df = 2 , P < 0.0001 -RRB- were highly significantly different across the groups . Table 3Clinical and diagnostic characteristics of 227 hospitalized patientsVariableLegal status on admission and dischargeaTest statistic -LRB- df -RRB- P-valueVOL-VOL -LRB- n = 56 -RRB- INV-VOL -LRB- n = 81 -RRB- INV-INV -LRB- n = 90 -RRB- Prior psychiatric hospitalization36 -LRB- 65.5 % -RRB- 58 -LRB- 71.6 % -RRB- 75 -LRB- 84.3 % -RRB- 7.27 -LRB- 2 -RRB- 0.03 Psychotic symptoms on admission43 -LRB- 76.8 % -RRB- 71 -LRB- 87.7 % -RRB- 80 -LRB- 89.9 % -RRB- 5.20 -LRB- 2 -RRB- 0.07 Primary diagnosis , schizophrenia or other psychotic disorder26 -LRB- 47.3 % -RRB- 56 -LRB- 69.1 % -RRB- 63 -LRB- 70.0 % -RRB- 9.03 -LRB- 2 -RRB- 0.01 Comorbid substance use disorder diagnosis26 -LRB- 46.4 % -RRB- 34 -LRB- 42.5 % -RRB- 40 -LRB- 44.4 % -RRB- 0.21 -LRB- 2 -RRB- 0.90 Comorbid personality disorder diagnosis10 -LRB- 17.9 % -RRB- 13 -LRB- 16.1 % -RRB- 12 -LRB- 13.3 % -RRB- 0.58 -LRB- 2 -RRB- 0.75 Change of < 20 in GAF score -LRB- Discharge -- Admission -RRB- 23 -LRB- 42.6 % -RRB- 26 -LRB- 32.9 % -RRB- 47 -LRB- 53.4 % -RRB- 7.14 -LRB- 2 -RRB- 0.03 Depressive symptoms at discharge23 -LRB- 41.1 % -RRB- 23 -LRB- 28.4 % -RRB- 22 -LRB- 24.4 % -RRB- 4.69 -LRB- 2 -RRB- 0.10 Anxious symptoms at discharge23 -LRB- 41.1 % -RRB- 43 -LRB- 51.1 % -RRB- 28 -LRB- 31.1 % -RRB- 8.49 -LRB- 2 -RRB- 0.01 Psychotic symptoms at discharge27 -LRB- 48.2 % -RRB- 51 -LRB- 63.0 % -RRB- 67 -LRB- 74.4 % -RRB- 10.34 -LRB- 2 -RRB- < 0.01 Documented medical problems requiring medication at discharge35 -LRB- 62.5 % -RRB- 41 -LRB- 50.6 % -RRB- 32 -LRB- 35.6 % -RRB- 10.52 -LRB- 2 -RRB- < 0.01 > 2 Psychiatric medications at discharge20 -LRB- 36.4 % -RRB- 13 -LRB- 16.1 % -RRB- 14 -LRB- 15.9 % -RRB- 10.40 -LRB- 2 -RRB- < 0.01 Experiencing side effects at discharge7 -LRB- 12.5 % -RRB- 23 -LRB- 28.4 % -RRB- 13 -LRB- 14.4 % -RRB- 7.41 -LRB- 2 -RRB- 0.02 Required seclusion5 -LRB- 8.9 % -RRB- 11 -LRB- 13.6 % -RRB- 18 -LRB- 20.0 % -RRB- 3.52 -LRB- 2 -RRB- 0.17 Required restraints4 -LRB- 7.1 % -RRB- 8 -LRB- 9.9 % -RRB- 8 -LRB- 8.9 % -RRB- 0.31 -LRB- 2 -RRB- 0.86 Required PRN medicine14 -LRB- 25.0 % -RRB- 30 -LRB- 37.0 % -RRB- 38 -LRB- 42.2 % -RRB- 4.48 -LRB- 2 -RRB- 0.11 Patient has an established outpatient clinician15 -LRB- 26.8 % -RRB- 20 -LRB- 25.0 % -RRB- 38 -LRB- 42.2 % -RRB- 6.78 -LRB- 2 -RRB- 0.03 Good treatment plan adherence during week prior to discharge41 -LRB- 73.2 % -RRB- 60 -LRB- 74.1 % -RRB- 50 -LRB- 55.6 % -RRB- 8.06 -LRB- 2 -RRB- 0.02 Treatment team 's opinion of likelihood of follow-up Poor15 -LRB- 26.8 % -RRB- 16 -LRB- 20.0 % -RRB- 35 -LRB- 38.9 % -RRB- 15.02 -LRB- 4 -RRB- < 0.01 Fair19 -LRB- 34.0 % -RRB- 29 -LRB- 36.3 % -RRB- 38 -LRB- 42.2 % -RRB- Good22 -LRB- 39.3 % -RRB- 35 -LRB- 43.8 % -RRB- 17 -LRB- 18.9 % -RRB- Length of stay in days -LRB- Mean ± SD -RRB- 11.3 ± 7.515.5 ± 8.48.4 ± 6.020.45 -LRB- 224 -RRB- < 0.0001 Unit , longer-stay inpatient unit36 -LRB- 64.3 % -RRB- 67 -LRB- 83.8 % -RRB- 37 -LRB- 41.1 % -RRB- 32.84 -LRB- 2 -RRB- < 0.0001 a Legal status on admission and discharge : VOL-VOL , Patients having voluntary legal status on both admission and discharge ; INV-VOL , Patients having involuntary status on admission and voluntary status on discharge ; INV-INV , Patients having involuntary legal status on both admission and discharge The average lengths of hospital stay -LRB- in days -RRB- across the three groups of patients are displayed in Fig. 1 . Patients in the INV-INV group had an average length of hospitalization of 8.4 days , whereas patients in the VOL-VOL group had an average length of stay of 11.3 days . Patients in the INV-VOL group had the longest average length of hospital stay , at 15.5 days . Based on post-hoc tests using the Tukey approach , the difference between mean lengths of stay was significant for the INV-VOL group compared to the VOL-VOL group and for the INV-VOL group compared to the INV-INV group . Fig. 1Average lengths of hospital stay -LRB- days -RRB- in the three groups of patients Figure 2 illustrates the differences among the three groups in terms of the percentage of patients adhering with the first scheduled community mental health appointment following hospitalization . The average time interval between hospital discharge and the first scheduled community mental health appointment was 14 days and ranged from 0 -LRB- i.e. , the appointment was scheduled to occur on same day as discharge -RRB- to 59 days . -LRB- Follow-up was assessed by a single phone call to the community mental health center where the discharged patient had been scheduled for the first outpatient appointment . The follow-up phone call was made a few days after the appointment , and further outpatient adherence was not tracked -LSB- 17 -RSB- . -RRB- Patients in the INV-VOL group were the most likely to adhere with the first follow-up appointment -LRB- 52.0 % -RRB- , whereas patients in the VOL-VOL group -LRB- 30.9 % -RRB- and the INV-INV group -LRB- 27.1 % -RRB- were far less likely to adhere -LRB- χ2 = 11.75 , df = 2 , P < 0.01 -RRB- . Fig. 2Percentage of patients adhering with the first scheduled community mental health appointment following hospitalization Based on the significant bivariate test results and a thorough consideration of relevant confounding variables , 18 factors were entered into the polytomous logistic regression model . In this model , three of these factors were independently associated with legal status : psychotic symptoms at discharge , documented medical problems requiring medication , and number of psychiatric medications . Psychiatric inpatient unit , length of hospital stay , prior psychiatric hospitalization , and receiving disability payments -LRB- SSI/SSDI -RRB- were deemed confounding variables and were , therefore , controlled for in the final model . Because of sparse missing values , modeling results were generated using data from 221 individuals . Table 4 shows model coefficients , standard errors , adjusted odds ratios , and 95 % confidence intervals for each of the three significant variables , by legal status category . Table 4Independent variables significantly associated with admission and discharge legal status among 221 hospitalized patientsVariableLegal status categoryaBSEaOR95 % CIPsychotic symptoms at dischargeINV-VOL − 0.020.440.980.42 , 2.32INV-INV1.490 .464.421.80 , 10.86 Documented medical problems requiring medication at dischargeINV-VOL − 0.480.400.620.28 , 1.35INV-INV − 1.510.430.220.10 , 0.51 Number of psychiatric medications at discharge -LRB- > 2 -RRB- INV-VOL − 1.800.520.170.06 , 0.46INV-INV − 0.880.510.410.15 , 1.12 The model controls for psychiatric hospital unit , length of hospital stay , prior psychiatric hospitalization , and receiving disability payments -LRB- SSI/SSDI -RRB- a VOL-VOL -LRB- voluntary legal status on both admission and discharge -RRB- is the referent group for all comparisons ; INV-VOL , involuntary legal status on admission , voluntary status on discharge ; INV-INV , involuntary legal status on both admission and dischargeB , Coefficient value from the final regression model ; SE , standard error ; aOR , adjusted odds ratio ; CI , confidence interval Patients who were involuntary on admission and discharge -LRB- INV-INV -RRB- were approximately 4.4 times more likely to have psychotic symptoms at discharge , relative to the VOL-VOL group . Patients in the INV-INV group were also about 4.5 times less likely -LRB- or equivalently , 0.22 times as likely -RRB- to have documented medical problems requiring medications at discharge , relative to those in the VOL-VOL group . Patients who were involuntary on admission and voluntary on discharge -LRB- INV-VOL -RRB- were approximately 6 times less likely -LRB- 0.17 times as likely -RRB- to be prescribed more than two psychiatric medications at discharge . Discussion Multivariate logistic regression modeling yielded three clinical variables that were independently significantly associated with admission/discharge legal status , even after controlling for psychiatric unit , length of hospital stay , prior psychiatric hospitalization , and whether or not the patient received disability payments . As described below , the associations between legal status and each of these three significant variables potentially may be explained by the lower overall treatment engagement common among involuntary patients . First , patients in the INV-INV group were much more likely to be experiencing psychotic symptoms at discharge , compared to the VOL-VOL group . The most plausible explanation for this finding relates to a difference in the level of acceptance of treatment between the two groups . Involuntary legal status is generally an indicator of a lack of treatment engagement , resistance to treatment , and/or impaired insight . Bivariate test results for `` treatment plan adherence during the week prior to discharge '' support the idea that involuntary patients generally had poorer overall treatment adherence . When patients refuse to sign-in voluntarily and no longer meet dangerousness criteria , they may have to leave the hospital before resolution of psychotic symptoms . The abbreviated hospitalization may not have allowed for sufficient time for stabilization and adjustments to psychiatric medications . Due to the laws governing involuntary inpatient commitment in this state , individuals who have been hospitalized for the duration of the short-term commitment and who have refused to convert to voluntary status , must be discharged unless they clearly meet further commitment criteria -LSB- 3 -RSB- . On the other hand , patients with voluntary legal status are generally discharged based on clinical , rather than legal , criteria -- they are released from the hospital when symptoms have sufficiently resolved and the patient is stable enough to return to the community . A significant difference in psychotic symptoms at discharge was not found between the INV-VOL group and the VOL-VOL group . This is not surprising given the fact that these two groups were virtually equally as likely to be rated as having good treatment adherence during the week prior to discharge . Furthermore , these patients were discharged after sufficient resolution of symptoms rather than legal expiration . From a clinical vantage point , it appears that INV-INV patients are being discharged `` too soon '' due to legal constraints . An alternate explanation for the difference in psychotic symptoms at discharge among the three groups is that INV-INV patients were more likely to have psychotic symptoms at the time of admission compared to the other two groups . However , the bivariate test revealed no statistically significant difference between the three groups in terms of psychotic symptoms present on admission . Second , patients admitted and discharged involuntarily -LRB- INV-INV -RRB- were much less likely to have documented medical problems requiring medications at the time of discharge , relative to the VOL-VOL group . Because length of stay was controlled for in the model , the most likely reason for the difference in medical problems at discharge is a generalized lack of treatment engagement among involuntary patients . That is , poor treatment engagement is associated with a decreased likelihood of medical problems being reported and diagnosed . Involuntary patients are more likely to refuse medical history taking , physical examination , vital sign checks , diagnostic blood work , and other diagnostic procedures during hospitalization . Thus , clinicians may not have sufficient opportunities or information to detect common medical problems , such as hypertension , diabetes mellitus , and anemia . It is notable that a significant difference in documented medical problems requiring medication was not found between the INV-VOL and VOL-VOL groups . As noted earlier , these two groups had similar treatment adherence during the week prior to discharge . These results support the idea that converting to voluntary status is associated with better treatment engagement , affording more opportunities for medical problems to be detected and medication to be prescribed . Future research is needed to determine whether a general lack of treatment engagement alone , or some additional factors in combination with poor treatment engagement , accounts for the difference in documented medical problems requiring medication . Some alternate explanations as to why the INV-INV patients had fewer medical problems requiring medication at discharge merit consideration . For example , it is conceivable that even when clinicians detect a medical problem , they may be biased toward not prescribing medication to involuntary patients who are highly unlikely to agree to take it . However , in this particular study setting , when medical problems are detected in involuntary patients , clinicians typically prescribe the indicated medication , regardless of the likelihood that the patient will comply with taking it . Another possible explanation is that patients in the INV-INV group are generally healthier than the other two groups . However , because the three legal status groups were very similar with respect to age , gender , and race , it is highly unlikely that one group of patients would have been healthier than the other two . Third , though the INV-VOL and VOL-VOL groups did not differ with respect to psychotic symptoms and medical problems requiring medication at discharge , these two groups did differ in the number of psychiatric medications at time of discharge . Those patients in the INV-VOL group were much less likely to have been prescribed more than two psychiatric medications at discharge , relative to the VOL-VOL group . The difference in number of psychiatric medications between the INV-INV and VOL-VOL groups was not significant , though the effect for the INV-INV group was in the same direction as with the INV-VOL group . The most plausible explanation for this finding may be related to both a lower overall treatment engagement among involuntary patients and differences in clinician prescribing behavior for involuntarily admitted patients compared to voluntary patients . That is , perhaps clinicians err on the side of caution with patients recently converting to voluntary status by limiting the number of psychiatric medications used to treat symptoms . Clinicians may limit the number of prescribed medications , especially if psychiatric symptoms are resolving , in order to simplify the medication regimen and sustain good treatment adherence . Interestingly , a much higher percentage of patients in the INV-VOL group adhered with the first community mental health appointment compared to the VOL-VOL group and the INV-INV group . It is conceivable that a simpler treatment regimen -LRB- one or two psychiatric medications -RRB- may contribute to higher rates of adherence with initial community mental health follow-up . Several methodological limitations of this study merit consideration . First , the fact that patients are admitted voluntarily or involuntarily is a legal distinction , which may not accurately reflect the patient 's level of treatment engagement -LSB- 11 , 12 , 19 , 20 -RSB- . Patients admitted voluntarily do not necessarily always have the motivation and adherence behaviors of individuals truly pursuing treatment for mental illness of their own accord -LSB- 11 -- 13 -RSB- . For example , a voluntary patient who is pressured or coerced by family members to seek inpatient treatment may have motivation , adherence , and insight more similar to patients admitted involuntarily than to those voluntarily seeking treatment -LSB- 11 , 12 -RSB- . Likewise , some involuntary patients may be more similar to voluntary patients than to other involuntary patients . This might occur when patients who would willingly have signed-in voluntarily are admitted involuntarily in order to overcome obstacles associated with voluntary admission procedures in certain mental health systems -LSB- 11 -RSB- . Because legal status may not be an appropriate surrogate for measuring perceived coercion or treatment engagement -LSB- 5 , 8 , 11 -RSB- , future research should consider utilizing MacArthur 's Perceived Coercion Scale -LSB- 21 -RSB- and a continuous scale to assess treatment engagement . A second methodological limitation is that commitment statutes `` censor '' the number of patients that convert to voluntary status , since non-converters must be discharged upon expiration of the commitment . Therefore , the true difference between the INV-VOL and INV-INV groups is somewhat obscured because of the limited timeframe in which patients have to convert to voluntary status . One can not assume that any given INV-INV patient would never have converted to voluntary status ; rather one can only infer that he or she had not done so by time of discharge . In other words , caution must be exercised in assigning ontological status to the INV-INV group . A third limitation is that patients re-admitted during the data collection period were excluded from the analysis . Future research might consider focusing on INV-INV patients with multiple hospitalizations . Another limitation with regard to data collection was that clinical and diagnostic variables -LRB- some of which were subjectively rated -RRB- were based on clinicians ' reports or information in the hospital chart , without using rating scales administered directly to patients . However , given the goals of this study , the researchers deemed patient assessments , beyond that done as part of routine evaluation and treatment , unnecessary . Also , involuntary patients would have been less likely to participate in formal research evaluations compared to voluntary patients , thus restricting the ability of the analyses to examine the issues of interest . Lastly , the findings from this study may have limited generalizability , given the specific sociodemographic and diagnostic characteristics of the sample . However , the population of interest to the researchers was that of minority individuals with severe psychiatric illnesses being treated in a large , urban , public-sector hospital . Despite the methodological limitations inherent in the study design , there were also several strengths in the methodology and data analysis process . First , an extremely thorough assessment of confounding was conducted . The final model controlled for four variables that were considered likely confounders . Second , alternate modeling techniques were conducted , all of which resulted in the same findings . Lastly , a concerted effort was made to minimize missing values during data collection , and to prevent biases , the few variables with significant missing values were excluded from the analysis . Conclusions Research on associations between patients ' legal status and sociodemographic and clinical variables can directly and indirectly affect psychiatric treatment during and after hospitalization . For instance , patients in the INV-INV group have the shortest average length of hospitalization , which is a direct result of the commitment law dictating that patients can not be involuntarily hospitalized for more than 5 days unless they continue to meet dangerousness criteria -LSB- 3 -RSB- , even if symptoms have not yet resolved . In addition to being more likely to have psychotic symptoms at discharge , patients in the INV-INV group are less likely to have documented medical problems requiring medication at discharge . Thus , involuntary patients frequently may be discharged from the hospital with unresolved psychotic symptoms and undetected , untreated medical problems . The poor outpatient treatment follow-up rate among INV-INV patients suggests that this is a particularly vulnerable group needing focused attention by the mental health system . During hospitalization , clinicians should be attentive to the manner in which involuntary patients are treated because this can greatly influence patients ' perceptions of coercion . It has been suggested that a concerted effort to reduce the level of coercive practices used during the admission process could mitigate some of the negative effects of coercion , such as future non-adherence with treatment and outpatient follow-up -LSB- 8 -RSB- . After discharge from the hospital , involuntary outpatient commitment can be employed to stabilize patients in the community , though this form of coercive treatment is also controversial . Recent research has suggested efficacy of involuntary outpatient commitment in enhancing treatment compliance and reducing re-admission rates among persons with severe psychiatric illnesses -LSB- 22 , 23 -RSB- . Increased resource allocation for involuntary patients during the admission process and throughout hospitalization , discharge planning , and outpatient follow-up may have the downstream effect of preventing future hospital admissions and worsening of medical comorbidity .

O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O B O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Perioperative outcome of laparoscopic left lateral liver resection is improved by using a bioabsorbable staple line reinforcement material in a porcine model Hypothesis Laparoscopic liver surgery is significantly limited by the technical difficulty encountered during transection of substantial liver parenchyma , with intraoperative bleeding and bile leaks . This study tested whether the use of a bioabsorble staple line reinforcement material would improve outcome during stapled laparoscopic left lateral liver resection in a porcine model . The success of laparoscopic cholecystectomy has driven the application of minimally invasive techniques to other disease processes , and led to the use of laparoscopy in solid organ surgery -LSB- 1 -- 9 -RSB- . Since the report of the first laparoscopic liver resection for a 6-cm focal nodular hyperplasia , laparoscopic surgery for the treatment of liver diseases has become more popular -LSB- 28 -- 30 -RSB- . In 1995 , excision of a segment 4 hepatic tumor was reported . The first successful laparoscopic left lateral hepatectomy -LRB- segments 2 and 3 -RRB- in a patient with a benign adenoma was performed in 1996 -LSB- 8 -RSB- . Technological advances and the development of new equipment have facilitated the growing trend of laparoscopic liver resections -LSB- 2 -RSB- . However , laparoscopic liver surgery remains technically challenging . Compared to open surgery , the laparoscopic surgeon is limited by the lack of an effective means to divide substantial liver parenchyma . Transection of the liver can be performed laparoscopically in several different ways , however bile leakage rates of 1 -- 16 % and bleeding complication rates of 6 -- 55 % have been reported -LSB- 9 , 30 -- 32 -RSB- . We hypothesized that the addition of a bioabsorbable membrane to reinforce standard laparoscopic stapling devices would reduce the bleeding and biliary complications of stapled laparoscopic liver resections . We tested this hypothesis in a prospective survival study of 20 pigs undergoing laparoscopic left lateral liver resections . Methods Study design A total of 20 female pigs each weighing approximately 40 kg were used for the study . All animals were maintained in accordance with the recommendations of the institutional animal care and use committee at the Mount Sinai School of Medicine . Animals were randomly assigned at the time of surgery to either group A -LRB- n = 10 -RRB- in which the stapling devices used for laparoscopic left lateral segmentectomy were reinforced with a bioabsorbable membrane or group B -LRB- n = 10 -RRB- , in which standard stapling devices were used . Animals were followed prospectively for a 6-week period after which they were sacrificed . Surgery All animals were premedicated with ketamine -LRB- 22 mg/kg -RRB- and atropine -LRB- 0.04 mg/kg -RRB- and anesthetized with thiopentothal -LRB- 15 mg/kg -RRB- prior to intubation . Animals were then mechanically ventilated with an initial tidal volume of 10 ml/kg and a respiratory rate of 15 breaths per minute . The tidal volume was adjusted to maintain arterial PaCO2 of 35 -- 40 mmHg during the experiment . Anesthesia was maintained with inhaled isofluorane -LRB- 1.5 % -RRB- . The pig was placed in a supine position . A standard open technique was used to gain access to the abdomen and a total of five trocars -LRB- Karl Storz Endoscopy America , Culver City , CA , USA -RRB- were used for the procedure -LRB- Fig. 1 -RRB- . Fig. 1Schematic illustration of trocars placement in the porcine model Pneumoperitoneum was established to a pressure of 15 mmHg . After inspection of the abdominal cavity with a 10-mm 30 ° laparoscope , the remaining trocars were placed under direct vision . Two 10-mm trocars were used in the left and right upper quadrants . One 12-mm trocar was positioned in the left anterior axillary line for liver retraction . The liver capsule and parenchyma were inspected superiorly and inferiorly and the line of transection was visualized between the liver hilum , along the surface of the entire left liver lobes towards the diaphragm . Subsequently , the left lateral segmentectomy was demarcated -LRB- segments 2 and 3 of the liver -RRB- within 1 cm along the falciform ligament . If necessary , the diaphragmatic and minor omental attachments to the liver were divided to mobilize the left lobe . Once mobilized , attention was turned to transection of the liver parenchyma . This was accomplished with sequential firings of a 3.5-mm endo GIA stapler -LRB- US Surgical , Norwalk , CT -RRB- . In group A , the stapler cartridges were buttressed with a bioabsorble reinforcement material -LRB- Seamguard ® , W.L. Gore , Flagstaff , Arizona -RRB- -LRB- Fig. 2 -RRB- . In group B the standard stapler cartridges were used . As the liver parenchyma was divided , no attempt was made to isolate the major feeding vessels -LRB- major branches of the left hepatic artery and vein -RRB- to segments 2 and 3 ; rather , they were divided en masse with the liver parenchyma . Upon completion of the transection , hemostasis was achieved with the ultrasonic scalpel -LRB- Ethicon Endo-Surgery , Cincinatti , Ohio , USA -RRB- , which works by means of a vibrating blade or scissors and can effectively seal small vessels and bile ducts , and/or electrocautery . The resected specimen was placed into an endobag and retrieved through the umbilical trocar site that was extended approximately 3.5 -- 5.0 cm to accommodate the specimen . The abdomen was irrigated and inspected prior to closure of the trocar sites . No intra-abdominal drains were used . Fig. 2An absorbable polymer membrane -LRB- Bioabsorbable Seamguard , W.L. Gore , Flagstaff , Arizona , USA -RRB- is constructed as a buttress mat integrated in the stapler systems Data collection Operative data recorded at the time of surgery included operative time , specimen size , and blood loss as estimated by amount of fluid collected in a suction container minus irrigation fluid used . Animals were prospectively followed with regard to clinical outcome for 6 weeks . Clinical status -LRB- temperature , blood pressure = BP , heart rate = HR -RRB- was examined routinely on a daily basis unless clinical condition mandated additional assessment . Routine blood tests -LRB- bilirubin , ALT , AST , alkaline phosphatase , GGT , and complete blood count -RRB- were obtained 2 days and 6 weeks postoperatively . Animals were sacrificed at 6 weeks and examined for intra-abdominal abnormalities such as abscess or bile leaks . Standard methylene blue was injected into the biliary tree to examine for active biliary leaks . A standardized pressure-controlled injector using a green sized syringe injected 5 -- 10 ml methylene blue into the ligated common bile duct . Subsequently , the cut edge of the liver was examined both macroscopically and microscopically for evidence of biliary leak . The cut edge of the liver was then sent for histopathological analysis . Statistical analysis To obtain a 50 % reduction rate in postoperative outcome after laparoscopic liver resection an 80 % power analysis showed a series of 20 consecutive animals to be operated . Moreover , a 95 % confidence interval was obtained to achieve statistical significance . Data were compared between groups with Student 's t-test and chi-square tests . Results All animals tolerated the procedure well and were healthy during the entire follow up . Clinical status -LRB- temperature , blood pressure , heart rate -RRB- examined routinely on a daily basis were not different . All animals resumed normal diet within 1 day and had their first bowel movement within 2 -- 3 days . Routine blood tests -LRB- bilirubin , ALT , AST , alkaline phosphatase , GGT , white blood cell , hemoglobin , hematocrit -RRB- obtained 2 days and 6 weeks postoperatively showed no abnormalities in either group . Mean operative time was not different between groups -LRB- group A 64 ± 11 min versus group B 68 ± 9 min , p = ns -RRB- . Intraoperative blood loss was significantly higher in group B -LRB- 25 ± 5 mL versus 185 ± 9 mL , p < 0.05 -RRB- -LRB- Fig. 3 -RRB- . An average of six 60-mm stapler cartridge firings per animal were used in each group to transect the left lateral liver lobe -LRB- p = ns -RRB- . Resected specimen size was similar in both groups -LRB- average size 10 × 8 × 4 cm ; average weight 0.41 kg -RRB- . There was no morbidity or mortality in either group . However , two animals in group B were found to have bile collections in the previous operating field at the time of necropsy . When the livers were subjected to methylene blue injection via the common bile duct -LRB- CBD -RRB- , two additional animals in group B were found to have evidence of biliary leak -LRB- a total of four of ten animals in group B versus zero of ten in group A , p < 0.05 -RRB- . Fig. 3Intraoperative blood loss in groups A and B Histopathological examination of the cut surface of the liver in group A revealed no evidence of the staple line reinforcement material , indicating that it had been totally reabsorbed . There was no bile duct damage seen and only mild mononuclear inflammation was seen in the portal areas . Subcapsular sinusoid dilation and congestion was seen with sharp demarcation between areas of dilation and absence of dilation in a pattern suggestive of fixation artifact although ischemic or anoxic damage can not be ruled out . In group B marked fibrotic changes and damaged vascular and biliary endothelium were seen -LRB- Fig. 4 and 5 -RRB- . Fig. 4Macroscopic illustration of bile duct damage at the liver 's transection site of group B in which conventional stapling technique was performedFig . 5Microscopic examination -LRB- 20 × -RRB- of resection line of group A -LRB- above -RRB- and group B -LRB- below -RRB- Discussion While new technology is rapidly expanding the realm of laparoscopic surgery to include major hepatic resections , the majority of laparoscopic hepatic operations currently performed are for diagnostic purposes -LSB- 3 -- 5 -RSB- . One of the major limitations to laparoscopic liver resections is the difficulty encountered in division of substantial liver parenchyma . Commonly employed devices for standard open liver resections including the Cavitron ultrasonic surgical aspirator -LRB- CUSA -RRB- -LRB- Valleylab , Boulder , CO -RRB- , and the Argon Beam coagulator -LRB- Valleylab , Boulder , CO -RRB- are available for use in laparoscopy -LSB- 34 -- 36 -RSB- . Transecting the liver can be performed in laparoscopically several ways -LRB- varying from gasless procedures to hand-assisted or strict laparoscopic liver resections -RRB- , each technique with its own risk of bleeding and bile leaks . In the past , the percentage of these complications has not changed considerably , remaining between 10 % and 50 % -LSB- 9 , 31 -RSB- . Commonly used laparoscopic devices such as the ultrasonic scalpel or the Ligasure -LRB- Valleylab , Boulder , CO -RRB- are limited in their ability to divide liver parenchyma because of the small size of the active heating area . The addition of various buttressing materials to stapling devices has been tried as a means to improve results and reduce complications rates in both pulmonary and gastrointestinal surgery -LSB- 17 -- 23 -RSB- . We hypothesized that the addition of a buttressing material to standard laparoscopic stapling devices wouldprovide a novel technique for liver transection . One buttressing material -LRB- Seamguard ® , W.L. Gore , Flagstaff , Arizona -RRB- is a porous fibrous structure composed solely of synthetic bioabsorbable poly -LRB- glycolide : trimethylene carbonate -RRB- copolymer . Degraded via a combination of hydrolytic and enzymatic pathways , the copolymer has been found to be both biocompatible and nonantigenic , with a history of use as bioabsorbable sutures , membranes , and other implantable devices . When used for staple line reinforcement , it can be expected to retain mechanical strength for 4 -- 5 weeks and be completely absorbed by the end of 6 months -LSB- 11 -RSB- . The fact that this material is completely bioabsorbable should reduce concerns over possible long-term complications such as migration , erosion , calcification , and infection . In addition , this synthetic copolymer does not carry the risk of animal source contamination . The histopathological examination of the resection line of both groups showed fibrotic changes in group B in contrast to group A . This may be caused by excess mechanical stress which was avoided in group A due to addition of a staple line reinforcement . Our results show that transaction using conventional stapling devices is inadequate but that the addition of a bioabsorbable staple line reinforcement material to standard laparoscopic stapling devices can reduce intraoperative blood loss during transection of liver parenchyma . In addition , there was a reduction in postoperative bile leaks , although in this study these leaks were not clinically significant . Bioabsorbable reinforcement improves on complications and is a viable addition to laparoscopic liver resection .

O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O

laparoscopic surgery
liver resections
staple line reinforcement
complications