Mental health counselors' decision-making priorities related to inpatient admissions for anxiety disordered clients: a pilot study.

Factors related to making decisions about whether or not a client should be admitted as an inpatient are poorly understood. Research focused on mental health counselors' decision-making priorities related to admission decisions for anxiety disordered clients is scant. This pilot study assessed which clinical factors most led mental health counselors to recommend an immediate inpatient admission among anxiety disordered clients presenting at a community mental health center. Results revealed that suicidality and inability to care for oneself strongly predicted the recommendations for an inpatient admission. Clinical and research implications are discussed.

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Anxiety disorders is one of 16 major diagnostic classes used by the American Psychiatric Association (APA, 2000) to classify mental disorders. The prevalence of specific anxiety disorders varies: The APA has reported lifetime prevalence rates in adult American samples of 1% to 2% for panic disorder, 7.2% to 11.3% for phobias, 2.5% for obsessive-compulsive disorder, 8% for posttraumatic stress disorder, and 5% for generalized anxiety disorder. According to the National Institutes of Mental Health (NIMH, 2001), 19 million Americans are affected by anxiety disorders annually. Moreover, NIMH has stated that anxiety disorders cost the United States nearly $46.6 billion a year in direct and indirect costs, equaling nearly one third of all American mental health expenditures.

A variety of treatment options exist, including psychiatric hospitalization in severe cases. Mental health counselors (MHCs) must choose among available treatment options on the basis of the nature and severity of presenting symptoms and related risk factors. The decision about whether hospitalization is required is difficult to make and has significant consequences for the client. As Way and Banks (2001) noted, inappropriate decisions either to admit or release clients can have profound negative impacts, including (a) an increased risk of self-harm or violence to others if a client needing inpatient treatment is misdirected and (b) stigmatization or loss of important social resources (e.g., housing, employment, child custody, finances) if an inappropriate admission occurs.

In the literature on inpatient hospitalizations, most studies focus on physician decisions for patients presenting at psychiatric clinics or hospitals. Only one study found to date (Hendryx & Rohland, 1997) addressed factors influencing the hospitalization decisions of MHCs. These researchers report only modest reliability in staff agreement regarding a need for hospitalization. Because the decision to recommend hospitalization "is complicated and often difficult ... and involves the integration of factors that are both objective and subjective" (p. 72), Hendryx and Rohland concluded that further research is called for in this area.

Among the research in this area not specifically focused on American MHCs, Gutterman, Markowitz, Loconte, and Beier (1993) analyzed records of all children and adolescents screened at a mental health center during a 6-month period. Four factors predicted psychiatric hospitalizations: (a) the presence of both assaultive and suicidal behavior, (b) a substance use problem, (c) a parental or family member's substance use problem, and (d) a first/initial screening. Sederer and Summergrad (1993) reported that dangerousness, symptom severity, and inadequate client support systems predict the need for admissions. Hooten, Lyketsos, and Mollenhauer (1998) proposed a cutoff score of 39 on the Brief Psychiatric Rating Scale (Overall & Gorham, 1962) as an appropriate predictor for non-suicidal patients presenting at a psychiatric emergency department. Perhaps routine evaluations of clients' global functioning, coupled with a determination of how specific psychiatric symptoms have recently become more severe, can help MHCs predict the need for hospitalization admissions (Somoza & Somoza, 1993). Klinkenberg and Calsyn (1998) concluded in a retrospective study that only previous psychiatric admissions reliably predict hospitalization. A Scottish study reported that psychotic diagnoses, risk to self, and current contact with other psychiatric services are the most significant predictors of admission (Taylor, Lawrie & Geddes, 1996). A study by Schnyder, Klaghofer, Leuthold, and Buddeberg (1999) found that the most significant predictors of hospitalization were referral by police or health professionals, current psychotic disorder diagnosis, and previous hospitalization. These results are similar to those of described by Schnyder, Valach, Morgeli, and Heim (1999). However, a Canadian study found that neither age, sex, nor previous psychiatric hospitalizations predicted admission rates (Oyewumi, Odejide, & Kazarian, 1992). The study indicated that diagnosis may better predict the need for admissions, Similarly, Pokorny, Shull, and Nicholson (1999) concluded that the most critical factors related to admission decisions are measures of preadmission dangerousness and overall psychiatric disability.

Although some studies have addressed inpatient predictors among community mental health clients, to date no research has focused on factors leading to admission decisions for persons with anxiety disorders One prior study focused on anxiety disorders in clients presenting at an emergency service in Israel, but findings were unrelated to admission predictors or decisions (Klein et al., 1995).The scant empirical research in this area has occurred despite evidence that even among medical patients, anxiety is a significant predictor of hospital admissions (Villarreal, 1995). As demonstrated above, results of studies on predictors of inpatient admissions are contradictory. Given the dearth of research related specifically to mental health clients with anxiety disorders, it seems clear that further research is warranted. This pilot study was conducted to more concretely delineate which factors led MHCs to make inpatient recommendations for anxiety disordered clients.

METHODOLOGY

Participants

Participants for this study were 33 clients selected from a community mental health agency in a Southeastern state. Data on adult clients diagnosed with anxiety disorders over a continuous 3-month period were included in this study. Clients were included as participants regardless of income, age (if over 18 years), severity of symptoms, physical disabilities, current or prior treatment history, or living status (i.e., homeless, supported housing, or independent living environments). The only inclusion criterion for this study was a confirmed anxiety disorder diagnosis. Participants ranged in age from 21 to 57 years (M = 31, SD = 10.6). In terms of sex, 19 (58%) were male, and 14 (42%) were female. Regarding race, 22 (73%) were Caucasian, and 8 (27%) were Black. Participants' average monthly income was approximately $760 US (SD = $600), indicating that most were from a lower socioeconomic status. All participants were eventually admitted to an inpatient unit for treatment, some voluntarily and some involuntarily; and psychosocial symptoms related to these inpatient decisions were assessed by the researchers. Participants were part of a larger ongoing study of anxiety disorder clients (Schwartz & Del Prete-Brown, 2003).

Procedure

During the initial assessment, all clients participated in a comprehensive evaluation conducted by master's-level or doctoral-level licensed MHCs, including the collection of demographic information, a medical history, prior treatment history, a social history, and a family history. Then, the Structured Clinical Interview for the Functional Assessment Rating Scale (SCI-FARS; Ward et al., 1995) was completed. Next, the Structured Clinical Interview (First, Spitzer, Gibbon, & Williams, 1995), a semi-structured interview approach specifically designed to guide MHCs in accurately assessing, evaluating, and diagnosing Axis I DSM mental disorders was completed. The classification of participants' symptoms was then diagnosed based on criteria outlined by the Diagnostic and Statistical Manual of Mental Disorders, (4th ed. text rev.; APA, 2000), and all diagnoses were confirmed by a board-certified psychiatrist.. Total interview duration averaged approximately 60 minutes. Each client was then rated by a MHC using the Global Assessment of Functioning scale (APA) and Functional Assessment Rating Scale (FARS; Ward & Dow, 1994).

Instruments

The GAF scale (APA, 2000) is a 100-point instrument used to rate clients' current overall functioning based on a standard global mental health-illness continuum. Higher numbers indicate better psychological and social functioning. The GAF is a widely used instrument in mental health settings (Moos, McCoy, & Moos, 2000), and researchers have reported that the scale captures important multidimensional information about general psychosocial functioning (Jones, Thornicroft, Coffey, & Dunn, 1995; Patterson & Lee, 1995). These studies as well as those correlating GAF scores with clinical symptoms (Roy-Byrne, Dagadakis, Unutzer, & Ries, 1996) point to the construct validity of this instrument.

The FARS (Ward & Dow, 1994) is a 17-item instrument used to assess symptoms and psychosocial impairments. Each item on the FARS is scored independently by a MHC after a structured clinical interview takes place. A standardized 9-point rating system is used for all items (1 = absent, 3 = mild, 5 = moderate, 7 = severe, 9 = extreme). In this study, the FARS was used to assess the following psychosocial symptoms: need for an inpatient admission, anxiety, suicidality, homicidality, self-care deficits, and substance abuse. Ward and Dow report interrater agreement on FARS items, ranging from r = .76 to r = .89. Schwartz (1999) reported average interrater reliability correlations of r = .88 when two MHCs rated the same clients; mean stability reliability correlations of r = .86 after the same clients were rated again by MHCs 2 weeks after their initial assessment; mean concurrent reliability correlations of r = .89 when MHCs simultaneously rated clients on the FARS and Positive and Negative Syndrome Scale; and good construct validity as evidenced by average ratings of 1.3 on a 1 to 5 Likert-type scale evaluated by MHCs based on the perceived accuracy/usefulness of the FARS (1 = extremely accurate/useful, 2 = accurate/useful, 3 = somewhat accurate/useful, 4 = inaccurate/not useful, 5 = extremely inaccurate/not useful).

All variables were operationalized in behavioral terms, and all clinicians were trained to use the FARS before clinical evaluations began. Need for an inpatient admission was operationalized as the client's current need for inpatient treatment, including his or her need for to be placed in a secure clinical environment in order to prevent extreme future psychosocial risk/impairment. This rating was made by MHCs based on the client's verbalized symptoms, affect, and behavioral observations of imminent risk. Anxiety was characterized by symptoms such as physical tension, restlessness, feeling "on edge," signs of nervousness, and difficulty sitting still or sleeping through the night. Suicidality was defined as the severity of reported and observed dangerousness to self, as evidenced by suicidal ideation, intent to harm one's self, lethality of a current plan (if any), and opportunity or means of completing that plan. Homicidality was defined as the severity of reported and observed dangerousness to others due to current homicidal ideation, intent to harm another, lethality of a current plan (if any), and opportunity or means of completing that plan. Self-care deficits were defined as a reduced ability to independently perform basic adult daily living skills such as personal hygiene, cooking, cleaning, or money management. Substance abuse was measured by current excessive drinking, attempts but inability to cut down, legal or work-related problems linked to drinking habits, and physical signs of tolerance and withdrawal.

RESULTS

Frequency distributions revealed that, although the full range of need for inpatient treatment was represented (Range = 1-9), in general this need was "moderate" (M = 4.5, SD = 2.3). The range of MHCs perceptions about clients' immediate need for inpatient treatment was likely due to the fact that some clients presented for a voluntary mental health assessment (i.e., perhaps for non-acute symptoms). Therefore, some clients were admitted for inpatient treatment for preventive purposes, a clinical decision consistent with MHCs treatment philosophy. Participants demonstrated a moderate level of suicidality (M = 5.1, SD = 2.4), a moderate intensity of current anxiety (M = 4.6, SD = 2.2), a mild degree of substance abuse (M = 2.9, SD = 2.2), a mild severity of poor self-care skills (M = 2.8, SD = 2.5), and a mild degree of homicidality (M = 2.5, SD = 2.2).

Need for an inpatient admission served as the dependent variable in this study; the other five items--anxiety, suicidality, homicidality, self-care deficits, and substance abuse--were chosen as independent variables because these factors carry the potential for personal risk. A standard multiple regression analysis was used to evaluate the accuracy of the independent variables in predicting the criterion variable. An alpha level of p < .05 was used for all statistical tests. Regression results indicated that the overall multiple regression model significantly predicted MHCs ratings on clients' need for an inpatient admission, [R.sup.2] = .55, [R.sup.2.sub.adj] = .47, F(5, 27) = 6.23,p < .001).This model accounted for approximately 55% of the variance in ratings of need for an inpatient admissions. A summary of regression coefficients is presented (see Table). Only two of the tire variables, suicidality (t = 2.08, p = .048) and inability to care for one's self (t = 2.46,p = .021), significantly contributed to the prediction model. These results indicate that as anxiety disordered clients manifest more severe symptoms of suicidality of more extreme self-care deficits, MHCs are significantly more likely to recommend an inpatient admission. Overall level of current anxiety, homicidality, or substance abuse did not predict MHCs' inpatient decisions. It is interesting to note that overall level of current anxiety was not a significant predictor variable. Other studies have shown that suicidality is an important inpatient predictor (Gutterman et al., 1993; Somoza & Somoza, 1993), though MHCs should note that Gutterman et al. linked a co-occurrence of both suicidality and assaultive behavior to inpatient admissions. Although we did not assess assaultive behaviors per se, homicidal ideation and intent did not significantly impact MHCs' inpatient decision-making. Taylor et al. (1996) also found risk to self as the most significant reason for admission decisions at a rural hospital in Scotland. Thus, suicidal ideation and intent seem to indicate a reliable risk of physical danger, often precipitating an inpatient recommendation.

DISCUSSION

The results of this pilot study indicated that suicidality and inability to care for one's self significantly predicted MHCs' decisions to recommend inpatient admissions for anxiety disordered clients. Way and Banks (2001) state that both suicidality and an inability to care for oneself are two of five variables which should be part of a model developed for admission decisions. Our results support this assertion. Impairment in the ability to care for one's self was also identified by Pokorny et al. (1999) as the most frequent precipitating factor for both voluntary and involuntary admissions. Perhaps a loss of previous self-care skins might indicate a worsening of overall symptoms, leading to impaired global functioning and clear behavioral indicators that MHCs use to make hospitalization decisions.

Although our findings regarding homicidality and substance abuse contradict the results of some other investigations (Gutterman et al., 1993; Pokorny et al., 1999), it should be noted that none of the previous research specifically focused on anxiety disordered clients. Gutterman et al. found that both substance abuse problems on the part of children/adolescents and substance use disorders on the part of a parents of caregivers were significant factors which predicted admissions. But Rabinowitz et al. (1995), in a study of more than 2000 psychiatric emergency room admission decisions, found that, in the absence of other factors, neither anxiety nor substance abuse was found to predict admissions. Results reported by Way and Banks (2001) support these findings. Perhaps clients specifically manifesting anxiety disorders show heightened suicidality and self care deficits rather than severe homicidality of substance abuse. If this is the case, then the low level of dangerousness to others and substance use problems would limit the applicability of these factors in influencing inpatient decisions. That is, these variables may simply not be significant enough to warrant MHCs' attention.

Clinical Implications for MHCs

Inpatient hospitalizations can have major consequences for both the client in terms of a loss of important social freedom and for society due to the large financial commitment in subsidizing indirect and direct treatment costs. By better understanding factors that are predictors of hospitalization decisions, MHCs can improve their ability to preempt psychosocial crises. Given the serious consequences that may be incurred by a client when an inappropriate decision to admit or not admit is made, the results of this pilot study may provide MHCs with important clinical information. Based on this study's results, an important consideration is for MHCs to be thoroughly grounded in techniques for assessing suicidality, specifically, and self-care skills in general. Subsequently, supervisors and counselor educators may need to consider in-service training for MHCs who are responsible for conducting initial intake assessment with clients in order to refine assessment skills in these areas. In addition, it is important that these MHCs understand the complex dynamics associated with overall level, frequency, and intensity of suicidality and poor self care. It is likely that, as anxiety disordered clients become overly anxious and suicidal, their self-care skills diminish, thereby leading to a downward spiral of functional abilities.

We have several recommendations to address these issues. Morrison (1995),in his text on the DSM-IV, explains that MHCs should identify the history and evolution of symptoms leading to the immediate concern MHCs should assess possible diagnoses related to more common (rather than very rare) mental disorders; MHCs should diagnose the most severe mental disorders first; and MHCs should first rule out diagnoses that have a high lethality/risk potential (i.e., conditions that are associated with frequent inpatient admissions). In addition, we recommend that MHCs thoroughly familiarize themselves with the Structured Clinical Interview for DSM-IV Axis I disorders (First et al., 1995) and the Structured Clinical Interview for DSM-1V Axis II disorders (First, Spitzer, Gibbon, Williams, & Loma, 1994). It is important for MHCs to familiarize themselves with these diagnostic concepts and guidelines in order to effectively complete the diagnostic decision-making process.

Given the dearth of research related specifically to clients presenting with an anxiety disorder and the importance of accurate inpatient admission decisions, MHCs are advised to find and implement standardized evaluation instruments which may lead to reliable ratings about inpatient needs. MHCs should also routinely use instruments which validly assess correlates of suicidality because this variable seems to most strongly predict the need for inpatient treatment. In terms of suicide-specific questionnaires, we recommend employing the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) and the Beck Depression Inventory II (Beck, Steer, & Brown, 1996; see Westefeld et al., 2000 for reliability and validity estimates as well as clinical utility). Although results of this study found that MHCs do not base inpatient admission decisions on clients' degree of anxiety, it should be noted that for many individuals anxiety can exacerbate other psychosocial symptoms and lead to suicidality and an inability to care for one's self. Thus, we recommend that degree of anxiety be assessed and viewed as a global indicator of a client's mental health status. Assessment of anxiety is especially important if symptoms of anxiety have increased recently and are resulting in more impulsive behaviors. That is, anxiety may not serve as a reliable predictor of a client's need for inpatient treatment, but it may provide supplemental information about the overall effect that a crisis state has on that client.

Research Implications for MHCs

This pilot study had several limitations which influenced research findings and the generalization of results. One important limitation included a small sample size. The moderate statistical power achieved may have resulted in lower statistical significance than expected for those variables not found to be predictive of inpatient decisions. Therefore, a larger sample size would be preferable in future studies. In addition, the sample population was highly specific, focusing only on clients with DSM anxiety disorder diagnoses. Although a review of the research literature strongly suggested a focus on anxiety disorders, future research should compare the results presented above with evaluations of other diagnostic groups (e.g., depressive disorders) and whether suicidality and the self care deficits are significantly related to the inpatient admissions. For example, this study did not include depressive symptoms as an independent variable, and this factor may well be a mediating variable between suicidality and inpatient decisions. It is possible that depressive symptoms may account for some of the variance in suicidality ratings and, therefore, might have a direct effect on MHCs' admission decisions. We recommend that future investigators include this variable in their research design. Finally, extension of these results with a larger sample of patients using clientele from more diverse treatment settings is needed to substantiate the present findings. For example, MHCs may have different perceptions about one's need for inpatient treatment depending on the client's ethnicity or sex. In this study, ethnicity and sex were not included as independent variables in the prediction model. Perhaps if an investigation included clients from outpatient as well as inpatient settings, these two client populations could be compared, and those admitted for inpatient treatment could be profiled more effectively (e.g., using discriminant analysis as a statistical technique). The present study was a first step to identify predictors of inpatient admissions among clients with anxiety disorders. However, further research and increasing sophistication in both training and clinical decision making are crucial in order to address this important mental health concern.

Summary of Standard Multiple Regression Analysis for Variables
Predicting Need for Inpatient Admissions (N = 31)

Variable         B   [??]    t     p     Bivariate r  Partial r

Inability to
  Care for
  Self          .36   .40  2.46  .02 *        .56        .33
Suicidality     .35   .36  2.01  .048 *       .65        .38
Homicidality    .28   .27  1.56  .13          .38        .30
Substance
  Abuse        -.12  -.11  -.79  .44         -.12       -.15
Anxiety         .01   .01   .06  .96          .28        .01

* p<.05

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Robert C. Schwartz, Ph.D. is an associate professor and director of the Clinic for Individual and Family Counseling. E-mail: [e-mail]. John J. Zarski, Ph.D., is a professor, and Randall L. Hilscher, D.Min., is a doctoral student. All are with the Department of Counseling, The University of Akron, OH.