Clinical Instability and Severity May Be a Marker for Psychiatric Hospitalization

Risk for psychiatric hospitalization may be related to clinical instability and severity scores, according to results of a study published in The Lancet Psychiatry.

Patients may likely reconsider psychiatric admission for alternative mental health care services due to high associated costs, potential distrust in doctor-patient relationships, and social consequences. To reduce inpatient psychiatric care rates, risk factors should be identified.

Data for this study were sourced from the NeuroBlu Database, which comprised 20 years of longitudinal patient-level data from 25 mental health centers in the United States. Patients (N=36,914) with major depressive disorder (MDD), bipolar disorder (BD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), schizophrenia or schizoaffective disorder, attention-deficit/hyperactivity disorder (ADHD), or personality disorder were evaluated for clinical instability and severity over a period of 2 months using the Clinical Global Impression Severity (CGI-S) instrument. Investigators assessed whether those outcomes — CGI-S scores — predicted hospital admission in the 6 months following evaluation.

The mean (SD) age of the patients was 29.7 (17.5) years. A total of 57.3% were women, 55.7% were White, 13.1% were Black, and race was unknown in 27.8%, 42.8% had MDD, 29.7% had PTSD, 25.0% had ADHD, 23.4% had BD, 19.1% had GAD, 15.9% had personality disorder, and 9.7% had schizophrenia or schizoaffective disorder.

Overall, 25.2% of the cohort were hospitalized. In general, greater clinical severity (hazard ratio [HR], 1.11; 95% CI, 1.09-1.12 per 1-SD increase; P <.0001) and instability (HR, 1.09; 95% CI, 1.07-1.10 per 1-SD increase; P <.0001) increased the risk for hospitalization.

Trends were similar across diagnoses but were strongest in ADHD (HR, 1.11; P <.0001) and GAD (HR, 1.11; P <.0001) and weakest in schizophrenia (HR, 1.07; P =.038) and BD (HR, 1.05; P =.025).

Higher CGI-S scores predicted hospitalization risk among adults (HR, clinical instability: 1.10; clinical severity: 1.15; both P <.0001), children (HR, clinical instability: 1.05; clinical severity: 1.05; both P ≤.0003), men (HR, clinical instability: 1.08; clinical severity: 1.08; both P <.0001), and women (HR, clinical instability: 1.09; clinical severity: 1.13; both P <.0001).

Although the trends associated with clinical instability and severity were similar, they were independent. Among the overall study population, patients who scored in the upper half of clinical instability and lower half of severity (HR, 1.31; 95% CI, 1.25-1.37; P <.0001) and those who scored in the lower half of clinical instability and upper half of severity (HR, 1.29; 95% CI, 1.23-1.36; P <.0001) were at increased risk for hospitalization compared with those who scored in the lower half of both domains. The patients who were in the top 50% for both clinical severity and instability had the greatest risk for hospitalization (HR, 1.45; 95% CI, 1.39-1.52; P <.0001).

Limitations of this study include potential bias as voluntary and involuntary hospitalizations were not separately assessed. Other common diagnoses were also excluded.

The investigators concluded, “[C]linical severity and clinical instability early in a patient’s clinical journey are both robustly associated with a higher risk of future hospital admission.” They continued, “These findings can help develop prognostic models, which might be useful to identify patients most likely to benefit from intensive community interventions, plan service provision, recruit patients into studies, and gain insights into the dynamic nature of psychopathology.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

This article originally appeared on Psychiatry Advisor