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BRIEF REPORT
Decertification Outcomes for Bipolar Disorder in an InpatientCommunity Mental Health Treatment Center: Impacton Subsequent Service Use Over Two Years
Glen L. Xiong • Ana-Maria Iosiff • Michael Brooks •
Charles L. Scott • Donald M. Hilty
Received: 4 May 2011 / Accepted: 18 January 2012 / Published online: 24 January 2012
� Springer Science+Business Media, LLC 2012
Abstract This study investigated differences in usage of
inpatient and outpatient mental health services over a
2-year period following the index hospitalization between
50 decertified and 48 certified subjects with bipolar manic
or mixed episode from an inpatient mental health treatment
center. The decertified group had higher number of
rehospitalization over the 2-year period compared to cer-
tified group (mean = 2.26, SE = 0.41 vs. mean = 1.19,
SE = 0.24; Wald v2 = 5.50, p = 0.02). Median time to
first rehospitalization was 40 weeks in the certified and
17 weeks in the decertified group, but the difference in
time to rehospitalization failed to achieve statistical sig-
nificance (p = 0.18). History of prior hospitalization was
associated with higher numbers of rehospitalizations and
crisis room visits (both p \ 0.01) and with shorter time
before first rehospitalization (p \ 0.001).
Keywords Bipolar disorder � Involuntary treatment �Decertification � Discharge against medical advice
Introduction
Patients with bipolar disorder often do not recognize the
need for treatment, leading to neurocognitive impairment
and increased hospitalizations (Martinez-Aran et al. 2009;
Scott 2000). In California, after the initial 72-h involuntary
treatment, Section 5250 of the Welfare and Institutions
Code mandates a certification hearing where a patient may
be ‘‘decertified’’ and discharged against medical advice or
‘‘certified’’ for additional involuntary treatment (Quanbeck
et al. 2003). The present report examines differences in
bipolar patients’ utilization of inpatient and emergency
services during the 2 years following their index discharge
between the patients who are decertified (released from
psychiatric inpatient treatment based on a denial of the
involuntary hold application) and those whose involuntary
treatment applications are certified by the hearing officer.
In patients with acute bipolar disorder, the lack of
insight strongly correlates with a need for involuntary
treatment (Husten 1999; Ghaemi et al. 1995). However, no
study has investigated the specific outcomes of the decer-
tification process in patients hospitalized for bipolar mania.
We recently examined the socio-demographic and clinical
variables that predict decertification in civil commitment
hearings for bipolar disorder (Xiong et al. 2010). The
present study examined whether decertification may lead to
a higher inpatient and a lower usage of outpatient mental
health services over a 2-year follow-up period. Specifi-
cally, we hypothesized that patients decertified and who
leave against medical advice, when compared with the
certified ones, will have fewer days before their first
re-hospitalization and greater numbers of re-hospitaliza-
tions and crisis room visits. We also hypothesized that
decertified patients will have lower rates of attendance to
outpatient psychiatric follow-up.
G. L. Xiong (&) � D. M. Hilty
Department of Psychiatry and Behavioral Sciences,
University of California at Davis, Davis, CA, USA
e-mail: [email protected]
A.-M. Iosiff
Deparment of Public Health Sciences, University of California
at Davis, Davis, CA, USA
M. Brooks
Department of Psychology, Rosalind Franklin University
of Medicine and Science, North Chicagoo, IL, USA
C. L. Scott
Division of Psychiatry and Law, Department of Psychiatry
and Behavioral Sciences, University of California at Davis,
Davis, CA, USA
123
Community Ment Health J (2012) 48:761–764
DOI 10.1007/s10597-012-9481-6
Methods
Data Collection and Study Population
We conducted a retrospective chart review of existing
mental health records at the Sacramento County Mental
Health Treatment Center (SCMHTC) with index hospital-
ization between 1992 and 1997. The SCMHTC is an
inpatient community mental health facility serving Med-
icaid and the uninsured population of Sacramento County
(total population of 1.2 million) in California. Patients were
not contacted or interviewed. Records were selected for
patients age C 18 years, who had primary psychiatric
diagnosis of bipolar I disorder, most recent episode, mania
or mixed. Chart review data were collected and coded
using standardized coding forms by the senior author.
Patient records were selected sequentially until 100
records, with 50 certified and 50 decertified cases were
collected. Two cases were dropped from the certified group
after data collection due to incomplete data giving a final
data set of 50 decertified and 48 certified patients. Details
regarding study methodology and patient characteristics
have been previously published (Xiong et al. 2010).
Baseline and Outcome Variables
Each medical record was reviewed in detail for the baseline
index hospitalization data and outcome variables 2 years
after the index hospitalization. Baseline socio-demographic
data included age, gender, race, insurance status (uninsured
vs. insured), and education level. Baseline clinical data
included number of prior psychiatric hospitalizations
2 years before the index episode, bipolar I disorder subtype
(mania or mixed), presence of psychotic features, comorbid
personality disorder, and comorbid substance use disorder.
The outcomes collected included the number of rehospital-
izations, time to the first rehospitalization (in weeks), the
number of emergency psychiatric visits, and whether the
patient scheduled and attended follow-up outpatient
appointments, within 2 years of the index hospitalization.
The outpatient data was obtained from the county mental
health system’s electronic billing records, which contains
data on county-operated and contracted outpatient commu-
nity mental health clinics. The study protocol was approved
by the Institutional Review Board at University of California
at Davis and Sacramento County Department of Human
Services Research Committee.
Data Analysis
Statistical analyses were conducted using SAS Version 9.2
(SAS Institute, Inc 2008) and included descriptive statistics
for all categorical and continuous variables. Survival
analysis based on the Kaplan–Meier curves and Cox
regression models was used to estimate the pattern of the
time to the first rehospitalization. Patients who were not
rehospitalized during the 2 year follow-up period were
censored and their time to rehospitalization was set to
2 years. Differences in the count outcomes (the number
of rehospitalizations and emergency psychiatric visits)
between the two groups were assessed using negative
binomial regression models for count response data. Sim-
ilar logistic regression models were used to evaluate if the
rates of scheduling and adherence for initial follow-up
appointments differed between the two groups. For all
outcomes we started with univariate models, containing
only the decertification status as a predictor. Further mul-
tivariate models examined the potential effect of the socio-
demographic and clinical variables, by sequentially adding
terms to the univariate model containing decertification
status as a predictor and testing their association with the
outcome of interest. Covariates were retained in the model
only if they had p \ 0.1. The significance of the predictors
in all the Cox, count, and logistic regression models was
tested using Wald v2 statistics. All tests employed were
two-tailed with a = 0.05.
Results
The mean age of the patients was 41 ± 12 years, ranging
from 21 to 69; the average participant completed high
school. Overall, 66 (67%) of the patients were women and
the sample was mostly (73%) white. The two groups did
not differ significantly on baseline socio-demographic
characteristics except that the decertified patients were
more likely to be uninsured than the certified patients (48
vs. 27%, p = 0.04). During the 2-year follow-up, 29 (60%)
of the certified and 36 (72%) of decertified patients were
rehospitalized. The number of rehospitalizations ranged
from 0 to 13 (median = 1) for the decertified patients and
from 0 to 7 (median = 1) for the certified patients. Uni-
variate count regression analyses revealed a significant
difference in the number of inpatient rehospitalizations
between the two groups (Wald v2 = 5.50, p = 0.02), with
an expected log count difference between groups of 0.64
corresponding to approximately one more hospitalization
in the decertified group (mean = 2.26, SE = 0.41) com-
pared to the certified group (mean = 1.19, SE = 0.24).
The final multivariate model contained decertification sta-
tus, prior hospitalizations, and comorbid substance use
disorder. Having comorbid substance use disorder was
marginally associated with an increased numbers of
rehospitalization (p = 0.06), while the number of prior
hospitalizations was the most powerful predictor of the
762 Community Ment Health J (2012) 48:761–764
123
number of rehospitalizations (p \ 0.01). Adjusting for
these demographic and clinical variables only slightly
weakened the association between decertification and the
number of rehospitalizations (estimate = 0.54, SE = 0.25,
p = 0.04).
The median time to the first rehospitalization was
40 weeks in the certified group and 17 weeks in the decer-
tified group, but Cox proportional hazard analyses indicated
that the time to rehospitalization did not differ significantly
between the two groups (hazard ratio (HR) = 1.40, p =
0.18). Further Cox proportional hazard analyses showed that
history of prior hospitalization was again the strongest pre-
dictor: the hazard ratio for rehospitalization increased by
18% for each additional prior rehospitalization (HR = 1.18
95% CI 1.08–1.29; p \ 0.001). We next stratified the de-
certified and certified group according to history of prior
hospitalization. Nearly 80% of patients with prior hospital-
izations and who were decertified were readmitted within
the 2-year follow-up period. On the other hand, nearly half
(48%) of the certified patients without prior hospitalizations
were not rehospitalized over the same period. Wald v2 tests
revealed that decertified patients with prior hospitalizations
had a significantly higher risk of earlier rehospitalization
than certified patients without prior hospitalizations
(HR = 2.21, 95% CI: 1.09–4.8; p = 0.03).
The number of emergency psychiatric visits over the
follow-up period did not differ significantly between the
two groups (range 0–15 in the decertified group and 0–22
in the certified one, with the median number of visits
equal to 2 and 1, respectively). The number of prior
hospitalizations was the only covariate that significantly
predicted the number of emergency psychiatric visits
(p \ 0.01).
As for post-discharge outpatient follow-up, 67% of the
certified patients and 44% of the decertified patients
scheduled initial outpatient appointments. Multivariate
logistic regression analyses showed that after adjusting for
baseline characteristics, the certified group was signifi-
cantly more likely to schedule follow-up appointments than
the decertified group: odds ratio (OR) = 2.64, 95% CI
1.14–6.14, p = 0.02. Interestingly, non-White were more
likely to schedule initial outpatient appointments than
White patients (OR = 3.00, 95% CI 1.09–8.23, p = 0.03).
Overall only 37% of the patients who scheduled an initial
follow-up appointment attended it. Furthermore, among
those who scheduled a follow-up appointment, there was
no difference between the two groups in terms of the
proportion of people who attended the initial outpatient
appointment (8 out of 22 in the decertified group and 12 out
of 32 in the certified group). No other demographic or
clinical characteristic were associated with adherence to
the follow-up appointment.
Discussion
This is the first study we are aware of that specifically
examines inpatient and outpatient follow-up for bipolar
patients who are discharged from involuntary legal holds
via decertification in a community mental health setting.
Despite methodological and temporal differences, our
study contrasts with previous findings that patients who are
discharged against medical advice were rehospitalized
sooner (Haupt and Ehrlich 1980; Chandrasena and Miller
1988; Dixon et al. 1997; McGlashan and Heinssen 1988)
and more frequently (Dalrymple and Fata 1993), and had
higher emergency care utilization and lower outpatient
services use (Chandrasena and Miller 1988). It is important
to note that the present study examines outcomes from
‘‘decertification’’ discharges, which is a specific sub-cate-
gory of discharge again medical advice. Of these studies,
Haupt and colleagues used rehospitalization rates within
6 months as an outcome and found that 17 of 69 (25%)
patients discharged against medical advice returned for
inpatient treatment, compared to 54 of 309 (18%) patients
in the control group (Haupt and Ehrlich 1980). The present
study examines rehospitalization rates over 2 years and
finds that 36 (72%) and 29 (60%) patients were rehospi-
talized in the decertified and certified patients, respectively.
The study findings have several important clinical and
research implications. First, patients with a prior history of
psychiatric hospitalization were rehospitalized much ear-
lier compared to those without prior hospitalization history,
regardless of certification status. Those decertified and with
prior hospitalizations fared the worst. Among those without
prior hospitalization, the survival curves were similar in
pattern for both the decertified and certified groups for
most of the follow-up period. The fact that prior hospital-
ization history is the most powerful predictor of time to
rehospitalization is somewhat unexpected, though this is
consistent with clinical experience. Therefore, both clini-
cians and hearing officials may want to use previous psy-
chiatric hospitalization history as an important fact to help
predict future need for inpatient treatment. Second, while
attendance to post-discharge follow-up appointments was
the same between the two groups, the decertified group
scheduled fewer follow-up appointments. The data high-
lights the problem of bipolar patients not keeping post-
discharge appointments in general. However, among
patients who scheduled a follow-up appointment, their rate
of attendance to appointments is similar between those who
were certified and decertified. Therefore, attempts to make
referrals and schedule appointments prior to discharge for
patients should occur regardless of the outcomes of certi-
fication hearings. Historically, against medical advice
discharges were associated with various outpatient
Community Ment Health J (2012) 48:761–764 763
123
restrictions, including temporary suspension of outpatient
services and no dispensing of medication in some systems
of care (Louks et al. 1989). The current finding supports
continued provision of outpatient services, even if patients
are discharged against medical advice. Interactional com-
ponents between patients and care providers are key fea-
tures in effective outpatient treatments aimed to enhance
treatment adherence in bipolar disorder (Sajatovic et al.
2004).
While this study generated important results on the
impact of decertification on use of psychiatric services,
there are several limitations. We did see a statistically
significant difference in the number of hospitalizations and
the rates of scheduling the initial outpatient appointment,
but the observed differences in time to first rehospitaliza-
tion were not as large as anticipated. The number of par-
ticipants in this study, even if four times our current sample
(and assuming similar censoring patterns), would not have
provided adequate power to detect significant differences
for the observed effect sizes. Our results indicate that the
hazard ratio was 1.40, with a 95% confidence interval of
0.86–2.29. This CI is mostly at the right of 1, so it is more
likely that there is a difference in the risk for rehospitali-
zation between the two groups. Future studies can be
designed based on this data to be able to detect this dif-
ference. In addition, since the study involves an inpatient
mental health facility within a large county mental health
program serving a Medicaid and uninsured population and
in a setting where the involuntary treatment certification
process is highly structured, the results may not be gener-
alizable to non-community mental health settings. Both
post-discharge arrest rates and, functional outcomes (Glick
et al. 1981) such as return to social roles, independent
living, and achieve mental health recovery should also be
measured in future studies.
Acknowledgments The authors thank the Sacramento County
Department of Health Human Services and Sacramento County
Mental Health Treatment Center; the Department of Psychiatry and
Behavioral Sciences, University of California, Davis; and Robert E.
Hales, M.D., Sally Ozonoff, Ph.D., Mark Frye, M.D., and Rona Hu,
M.D.
Conflicts of interest We have no conflicts of interest to report.
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