Literature Review
Readmission rates of mental health patients have soared in the recent past. This trend is an inherent source of frustration to patients, families and the respective treatment teams. Indeed, the rapid deterioration of patients that culminates in readmission can be distressing to the patients as well as their supporters. The complex process of discharge and re hospitalization that happens within a very short period of time requires lengthy hours of multidisciplinary efforts and input that is always rendered redundant at the end of the process. In their nationwide study regarding the occupation of psychiatric wards,
Glazer and Ereshefsky (2006) ascertain that over 50 of the beds are occupied by re hospitalization cases. A notable pattern of patient illness in psychiatric wards is based along recurring of illnesses. Thus once the mental health patients leave the hospitals, the probability that they would return in future is seemingly high.
The differences in the readmission of psychiatric patients are based on different factors of the institution milieu. The severity of the illness, indulgence in risky behaviors, substance use and abuse, fragmented care pathways and other modifiable factors have increasingly being associated with patient return in mental health institutions. Of great importance are the economic factors that have been identified as the main contributory factors to rapid readmissions. Generally, current statistics are a major cause of concern for most mental heath institutions. Efforts have been mounted through consistent research to identify intrinsic gaps that contribute to this scenario. This literature review underscores the previous findings in this regard.
Trends in Mental Health Policy
National statistics indicate that close to forty four million Americans suffer from mental health illness. In his study, Prince (2009) ascertained that the mental health department in America is presently experiencing a shortage in human resources. As a result, the quality of services being provided by the sector greatly compromises the recovery and holistic wellbeing of mental health patients.
Nationally, mental health has been identified as a neglected realm of the public health sector according to Delaney and Fogg (2007) who analyze the National health report based on the survey carried out in 2007. The information regarding the mental policy is also fragmented as exemplified by the World Heath Organization report of 2008. Essentially, it seeks to address the underlying goals of mental health but only mentions the reduction of suicide.
A report presented by Prince (2009) draws particular attention on the increasing rates of mortality for schizophrenia. In addition, it cites vital surveys that highlight a significant 28 of the population believed to consult mental health services annually. Furthermore, he notes that social deprivation indicators like unemployment are elemental in psychiatric morbidity and highlights the urgent need for collaboration between different sectors. He concludes by stating that mental health services are critical for this segment of the national population whose incapacitation is likely to lead to increased poverty and marginalization.
As highlighted above, mental health is relegated and is not identified as one of the public health priorities in America. Notably, psychiatric patients comprise of the poor in this nation. It is therefore imperative to enhance equitable distribution of mental health services in order to ensure that the psychiatric patients benefit from the same. Giffords (2006) has proposed the matrix model to be the most ideal approach to addressing the emergent concerns regarding healthcare. This presents various interventions with regard to mental health treatment, prevention, promotion and sustainable rehabilitation of the affected population. He argues that in order to attain optimal results, an all inclusive approach that incorporates both public and individual concerns needs to be adopted.
Burns and Fim (2002) affirm this contention by indicating that effective treatment of psychotic disorders requires input from all segments of the society. In particular, they show that while pharmacological treatment controls severe symptoms, social interventions and psychological support are instrumental in enhancing the quality of life of the patients and preventing physical deterioration and malfunctioning. Further, a multivariate analysis revealed the inherent relationship between substance abuse and criminal victimization of the psychiatric patients.
Burns and Fim (2002) also indicate that the sector has in the recent past received particular attention from consumer organizations. Fundamentally, these play a critical role in evaluating the performance of the sector. In particular, they publicize the extent of the department in addressing its goals of providing sufficient services to the mental health population, addressing stigmatization, providing integrated and comprehensive health services, reducing costs associated with mental health and increasing the workforce. A recent study indicates that the department has dismally failed in all these areas. By bringing these concerns to the fore, consumer organizations have played a critical role in encouraging formulation of sustainable policies by the federal government.
Implications of Deinstitutionalization
Various controversies have emerged over the process of deinstitutionalization that was carried out in the last quarter of the previous century. Shadish, Lurigio and Lewis (1995) decry this process and argue that mental health patients need long-term institutionalization in order to recover fully. He highlights the ineffectiveness of rehabilitation programs in dealing with violent behavior, impulsive suicide and substance abuse that is exhibited by the patients. However, Easterbrook, Berlin, Gopalan and Mathews (1991) point out that community programs have made it possible for the economically weak within the society to access these vital services. In response, Shadish et al (1995) ascertain that effective community care is more expensive than institutionalization. Further, he shows that long term rehabilitation that greatly benefits the patient is also an added expense.
Also, Gopalan and Mathews (1991) indicate that deinstitutionalization provides an ideal environment for the mental health patients to recover easily. In this regard, they argue that community based care provides a more humane environment that enables the mental health patients to access outpatient care. In addition, Geller (2000) posits that deinstitutionalization has been effective in shortening the period of time that the mental health patients stay in hospitals. According to him, the hospital environment is restrictive and does not provide the patients with a chance to socialize with the entire public. In other words, the environment provided therein is not viable and psychologically, this undermines the recovery process. However, Shadish et al (1995) contests this by indicating that this can only be achieved if the community based facilities are equipped with sufficient infrastructure including human resources. Notably, this has not been achieved in the US and as a result, mental patients continue to suffer.
In his review, Dowdall (1999) describes deinstitutionalization a s an adjustment process that provides mental heath patients with a chance to recover without having to experience the effects of the life provided in institutions. This was based upon the realization that mental health patients that are institutionalized tend to become accustomed to the environment in the institutions and find it difficult to adjust to the conditions outside the institution. Dowdall (1999) asserts that deinstitutionalization allows that patients to be empowered and regain their freedom. This then enables them to assume responsibility for their action and therefore recover faster. Unlike in the mental institutions that have their distinct rules, the community environment allows the patients to adapt to the normal environment and co-exist with the rest of the population with ease.
In his study, Scull (1991) argues that deinstitutionalization gives hope to the mental patients. According to him, it provides a viable environment that enables the patients to be appreciated and be cared for by the entire community. This gives hope to the patients and hastens their recovery as they are perceived as normal individuals in a communal environment. Nonetheless, Shardish et al (1995) indicates that such an ideal scenario is yet to be achieved in the current US society as the patients face a high degree of stigmatization from the society. He further proposes that psycho education and other viable measures would be instrumental in altering the present demeaning perception that mental health is accorded by the public. According to him, only then would deinstitutionalization yield desirable outcomes.
Nonetheless, Shardish et al (1995) indicates that deinstitutionalization has resulted in incidences of homelessness. This is due to the fact that it results in to premature discharge of the mental health patients from the hospitals. However, the community based mental health institutions lack the vital infrastructure and resources to provide quality services to the discharged patients. In the long run, the patients lack vital care and fall victims of homelessness.
Burns and Fim (2002) pertaining to USA health services reviewed the transfer of mental health patients for hospitals to community care programs. Findings indicated that community based models were more effective in shortening the duration of the patients in hospitals, reducing incidences of readmission, and enhancing community integration. However, a parallel review undertaken by Foster (2002) indicated an increase in mortality rates, homelessness and frequent readmissions for patients whose conditions were severe. In order to counter the later scenario, Foster (2002) proposed that there is need to ensure that the community programs and given sufficient resources and are well planned for. In particular, he cites that that planning of community programs need to be attuned to the specific needs of the psychiatric patients.
Modifiable Risk Factors for Rapid Readmission in Mental Health Hospitals
Frequent Hospitalization
In their research, Weiden and Glazer (1997) found out that a history of consistent hospitalization in mental health hospitals is a predictor of rapid readmissions. According to this study, patients that had a pattern of seeking inpatient treatment tended to repeat the treatment-seeking behavior. In this regard, Carmel (2002) affirms that psychiatric patients that are accustomed to the mental health institutions or felt comfortable and relieved during their previous admissions often prefer readmissions as a viable mode of adjustment to their painful experiences during a relapse. He refers to this tendency as hospitalphilia. This is characterized by a short interval between admissions that lasts for a relatively shorter duration and often ends against the medical advice. Such patients according to him prefer short and frequent admissions to extended periods of admission.
Although previous studies indicated that such admissions are influenced by violence, this study found out that the admissions are self initiated and the characteristic aggression does not influence re hospitalization. Notably, the patients did not exhibit any form of violence after admission, perhaps a strategy aimed at restraining the hospital staff from interfering with the self initiated admission schedule. The limitation of this study was that it reviewed only documented and published information about the patients. At this point, it should be acknowledged that unpublished studies are likely to contain more factual information that would conflict with these findings. However, the study was very comprehensive and various documentaries from a diverse cultural background were reviewed. Therefore, it can be applicable to other countries outside USA.
In a bit to explain the relationship between system variables and rapid re hospitalizations, Carmel (2002) found out that the attitude that the mental health workers accorded patients also influenced rapid readmissions. The study employed a sample of sixty one mental patients with revolving door syndrome in a psychiatric unit in North Carolina. The results indicated that patients that were perceived regulars by the nurses were in some instances overlooked when admitted or handled superficially. As a result, the emergent issues in their medical status were not handled effectively because particular attention was given to major symptoms. Lack of timely interventions regarding emergent infections of these patients influenced their rapid readmission. In order to address this, the study recommended a change in the attitude towards frequently admitted mental health patents by the mental health providers.
Notably this study was restricted to one facility and one state. In this regard, it should be appreciated that the professional experiences of mental health individuals vary across the nation. These variations are influenced by the different economic resources that the states have. In addition, Huff (2000) notes that state policies also influence the quality of mental services offered in different states. It can therefore be argued that the findings do not have a nationwide application. However, the implications of these findings to policy formulators are desirable.
Non Compliance to Treatment and Medical Appointments
In his study, Green (1998) analyzed the causes and patterns of acute admissions in a psychiatric unit in New York for patients with revolving door syndrome. He employed 63 inpatients that were suffering from schizophrenia. This study was aimed at making efforts to improve treatment options and enhance sustainability upon discharge from the hospital. The leading cause was identified to be lack of compliance to medication.
Lack of response to the treatment was cited as the second most common cause of acute readmissions in the institution. The treatment that was currently available for use at the time of study was oral conventional antipsychotic, atypical antipsychotic and depot conventional antipsychotic. The decision to employ either atypical or depot treatment was based on the identification of whether the relapse was caused by non response or non compliance. This study recommended that medication for such patients need to be determined during acute admission.
Notably, the study relied solely on the data collected from in patient. In his review Easterbrook et al (1991) argues that inpatients tend to have different characteristics from outpatients. In particular, he ascertains that the attention and management that the two groups of patients are accorded differs significantly. This has various implications on the policies undertaken at various stages. At this juncture, it can be argued that the data employed for this study was not presentation of the psychiatric population. However, it can be contended that the first hand information got from the study is very instrumental in making viable decisions regarding treatment of inpatients suffering from mental disorders.
A previous study undertaken by Weiden and Glazer (1997) that employed a pharmaco-economic decision analysis model evaluated the implications of changing treatment from traditional oral neuroleptics to modern atypical oral treatments and depot neuroleptics for revolving door patients. The study employed one hundred and fifty patients that were randomly picked from various psychiatric state institutions across US. The rationale for this was to capture the inherent economic disparities and analyze how the same contributed to rapid readmission of mental health patients. Shifting of treatment was perceived as a viable means of management of schizophrenic out patients. This study found out that patients with limited resources were more likely to be rapidly readmitted than their counterparts. This was attributed to the low quality of previous medication that such patients were previously accorded. It was further compounded by lack of quality after care services at the community level. The study affirmed that these conditions worsened the symptoms after discharge and prompted rapid readmission.
In his study that sought to determine the relation between non compliance to outpatient admissions and rapid re hospitalization in psychiatric wards, Geller (2000) found out that patients who did not comply with outpatient appointments after being discharged from the hospitals were three times more likely to be readmitted. He employed a sample of 241 revolving door patients in three south eastern states. Findings indicated that out of the entire sample, almost sixty percent did not comply with the outpatient appointments regardless of the fact that they had been scheduled accordingly by respective institutions. These segment of the sample experienced more rapid readmission rates than their counterparts. The study recommended that patients utilizing outpatient services need to comply with the medical instructions in order to avoid rapid readmission. According to this study, lack of compliance complicated the recovery process and made it difficult for the health providers to monitor the status of the illness and intervene accordingly. The limitation of this study was that it was restricted to female patients only.
Notably, non compliance to medical appointments has been associated with non compliance to treatment. In his research regarding the relationship between non compliance and rapid readmission, Bech (2005) found out that psychiatric patients who personally discontinued their medication found it difficult to disclose this to the medical providers. As such, they preferred to discontinue with the appointments altogether. Conversely, the psychiatric patients that missed important appointments tended to make misinformed decisions regarding their after care. This led to complications that ultimately culminated in rapid readmission. Further, Bech (2005) shows that non compliance to appointments and treatment undermines the quality of services that the patients are given by the medical staff. In particular, this tendency compromises communication between the patients and health providers, decreases the degree of health provider empathy and increases the level of provider frustration. In order to avoid this, Bech (2005) proposed that the patients should be given sufficient information regarding medical schedules.
Severity of Illness
In his consultative review, Blader (2004) explored factors that determined rapid readmission in psychiatric institutions for adolescents and reported that severe early diagnosis especially that of affective psychoses and schizophrenia contributed significantly to rapid relapse that characterizes the revolving door syndrome. Despite the fact that this study entirely focused on adolescents, it can be argued that this applies to children as well as adults. Also, the deductions can be ascertained to have been based on credible data due to the fact that the study was conducted within a period of ten years. Conventional studies have cited severity of the illness to be a contributory factor to frequent readmission. These are represented by Lyons, Uziel-Miller and Reyes (2000) that employed psychometric screening procedures in identifying psychiatric patients that were at a high risk of rapid readmission.
In this, they ascertained that factors relating to frequent readmission in hospitals had been studied intensely in the recent past in a bit to curb the expenses involved as well as improve the outcomes of the disease. In this respect, they referred to the recent dramatic increases in readmissions in mental hospitals that involved revolving door patients. Notably, this led to an increase in deinstitutionalization. Their study employed 130 patients and lasted for a period of three months. They concluded that identification of the patients that were at a higher risk of readmission would be useful. In particular, it would give mental health personnel a chance to plan for their management in a timely manner and make viable interventions accordingly. Such measures according to them would include discharging patients to community based institutions.
The limitation of this study was that it was undertaken within a very short period of time. Considering the fact that it was using observation as an important tool of collecting data, this study should have taken more time in order to come up with viable conclusions. In this respect, Boardman, Hodgson, Lewis and Allen (1997) point out that severity of illness in mental patients is contributed to by various factors that are both environmental and economic in nature. It is therefore imperative to take sufficient time to identify deserving patients and take intervention measures accordingly. Nevertheless, the study was credible as it utilized factual first hand information from the mental health practitioners.
Substance Abuse
In his study in mental hospitals in the State of Mississippi Prince (2009) found out that coupled with treatment non compliance, substance abuse contributed significantly to rapid re hospitalization for revolving door patients. His study was based on a sample of seventy patients that were randomly picked from a psychiatric institution. He concluded that sustainable intervention measures such as patient education could be instrumental in reducing such incidences. Like wise, Haywood, Kravitz, Grossman and Lewis (2008) carried out a comparative evaluation of mental health inpatients without and with co morbid substance-related complications. They found out that instances of readmissions were more rapid for the psychiatric patients with co morbid substance-related complications. However, they indicated that this was only for a short period of time.
Further, Gastal, Andreoli and Quintama (2000) carried out a four year prospective review after relapse in schizophrenia for one hundred patients. Their findings indicated that non compliant patients that had been previously diagnosed of substance assumed a significant 64 of the institutional rapid readmissions. They also found out that the duration before re hospitalization was relatively shorter for non compliant patients that had dual diagnosis for substance use and abuse than for non compliant patients that had not been previously diagnosed for substance abuse. Further, they indicated that patients that were medication compliant had a relatively longer period before readmission than their counterparts that had been diagnosed of substance abuse. Basing on this analysis, they concluded that sustainable treatment programs in this respect need to address substance abuse and non compliance in order to attain optimal results.
A relative research was carried out by Levine (1998) who sought to identify factors that contributed to substance use and abuse by schizophrenic patients and the relationship of the same with rapid readmissions. This study was motivated by the recognition that substance abuse was one of the reasons behind rapid re hospitalization of mental health patients in the state of Arizona. The findings indicated that the relatives, family and community members of the patients contributed to their substance abuse by selling alcohol and drugs to them. In addition, this study revealed that use of alcohol and drugs by the patients was aimed at containing severe side effects that are related to the use of anti-psychotic drugs, avoiding drowsiness and suppressing hunger as a result of shortage of food. However, this led to severe side effects and undermined the effectiveness of the medication. As such, affected patients were readmitted in hospitals within a very short period f time.
The key areas of intervention in this regard were identified as enhancing psycho education amongst patients and the community at large, raising community awareness with regard to substance use and abuse, strengthening the abilities of law enforcers and care takers to curb substance use and abuse and initiating community based campaigns that target the protection and care of the mental health patients. The limitation of this study was that the data that was used was derived from clinical records. However, the implications can be applied to a large geographical area.
Violence
Violence and criminal behavior have also been implicated for contributing significantly to rapid readmission. A study conducted in North Carolina by Appleby, Desai and Luchins (2001) using a sample of 330 involuntary out patients suffering from psychotic and major mood disorders analyzed the specific characteristics and environments of violent mental patients. They found out that violent behavior was exhibited by half of the sample and contributed significantly to rapid readmission. The main limitation of this study was that the data employed was derived from a single facility.
Further, a study conducted by Casper and Regan (1996) in Canada indicated that violence was one of the main reasons that contributed to frequent and rapid readmissions. This viewpoint was brought forth by the care giving relatives who ascertained that severe relapse of mental health disorder in psychiatric patients culminated in a situation where the safety of the relatives was jeopardized, their property destroyed and in severe instances, their lives threatened as a result of violence. A study conducted by Gastal et al (2000) in Mexico indicated that such a situation became even more disheartening in cases where the law enforcement agencies failed to respond in a timely manner. Further, the fact that the patients were unlikely to be held criminally responsible for their activities made the relatives to request for rapid readmissions. In his study regarding the relationship between violence, substance abuse, criminal victimization and rapid readmission, Boardman et al (1997) found out multiple actors that discouraged the care giving relatives from taking up criminal proceedings in such instances.
To begin with, it was indicated that relatives feared that their patient was likely to lead a devastating life in prison while she is awaiting trial. Further, the fact that the patient was likely to receive long term hospitalization in instances where she was found mentally unfit to stand trial made the relatives reluctant to pursue criminal proceedings. Finally, Burns and Fim (2002) found out that the police were always reluctant to press criminal charges in such instances and therefore the efforts could be fruitless. In his study undertaken in New York about the reasons for frequent readmissions, Gifford (2006) found out that five of the 60 patients with revolving door syndrome had spend close to five months in the institution because of violence. Haywood et al (2008) explains this by indicating that the care giving relatives often take hasty measures in incidences where the patient has previously portrayed violent behavior. In particular, they arrange for readmission as soon as the patient goes in to a relapse.
In order to address this Casper and Regan (1996) suggest that the public and especially the relative care givers need to liaise with community mental health providers. This would ensure that they are well acquainted with vital information regarding violence and mental health. In particular, they would be informed of timely and effective measures to manage such relapse and avoid readmission. In addition, they note that the criminal justice system also needs to be well informed about the implications of violence in this regard. Policy changes with respect to long term stay in mental institutions are likely to have a positive impact on the perception of the public about violence and mental health.
This study was limited by the involuntary nature of the respondents. In this regard, Gifford (2006) indicates that seeking the consent of the patient is important as it ensures that the information is given out of free will. Notably, this enhances the credibility of such information. With regard to the above study, it can be argued that the data collected was subjective in nature. Nevertheless, the fact that a significant number of respondents were employed implies that such mishaps were screened accordingly.
Implications of High Risk Behavior
Rapid readmission in mental health hospitals is also occasioned by manifestation of high risk behavior. This is all inclusive and it includes drug use and abuse and inappropriate sexual behavior that expose individuals to infections such as HIV. This then makes the mental health patients susceptible to readmissions. In his study in New York, Casper and Donaldson (2000) ascertained that high risk behavior has far reaching implications on the mental health patients with the profound being probability of frequent readmission in mental hospitals. The limitations of this study were that it was not gender representative as the researcher placed undue emphasis on the female segment of the society. Nevertheless Gifford (2006) indicates that the implications are transgender and therefore are applicable to all segments of the society.
With regard to vulnerability and susceptibility, Green (1998) points out that the vulnerable segment of the society is usually comprised of the elderly, women and persons that are intellectually and physically fragile. It is posited that they are frequently admitted because they are considered to be at risk and therefore require a considerable degree of protection from the society that they belong to. According to Carmel (2002), their vulnerability loading undermines their ability to protect themselves against societal ills and violence. Thus in most cases, they are victimized and suffer dire consequences.
Suicide attempts as a result of high risk behavior have also been identified as a major contributory factor to rapid readmissions in mental hospitals. In this regard, Fontanella, Bridge and Campo (2009) indicate that suicidal thoughts stem from the understanding and experience of the grave implications that are associated with high risk behaviors. In particular they ascertain that use and abuse of drugs causes suicidal thoughts in mental heath patients. In their survey in thirty three mental institutions across US, Fontanella et al (2009) found out that fifty two percent of the mental health patients were readmitted rapidly because of suicidal attempts. While some were associated with economic vulnerability, a significant 63 were attributed to risky behavior after discharge from hospital.
These presumptions were also affirmed by Geller (2000) who undertook a similar study in UK. His findings indicated that while a great percentage of the population believed that suicidal attempts by mental health patients were associated with their vulnerable status and the stigmatization from the society, some of them (54) were caused by the implications of high risk behavior. In particular, he indicated that the implications of the female patients being sexually andor physically assaulted because of their unstable mental status made them feel dejected and resort to suicide. In addition, this study affirmed that use and abuse of drugs was responsible for triggering suicidal thoughts in mental health patients and therefore prompting readmissions.
In order to counter this, Geller (2000) asserted that the stakeholders in community mental health need to complement their efforts towards enhancing care and protection of the mental health patients in the community. To achieve this, he indicated that the community needs to be educated about mental health. In addition patients need to spend sufficient time in institutions so that they can be informed about their vulnerability and how to manage the same. This according to Geller (2000) can only be attained if patients recover well before being discharged to mental health institutions. Notably, complete recovery also enables them to understand their status and avoid resistance.
Social Deprivation
Numerous studies of whom Hawthorne, Green and Lohr (1999) are represented ascertain that social indicators of deprivation contribute to an increase in readmission in mental institutions. They demonstrate that composite measures of social deprivation such as unemployment rates, Jarman Underprivileged Area Score and various other complex statistical models have successfully and accurately been employed in the past to determine the rate of readmission in psychiatric hospitals. Of great importance is the fact that this study ascertains that social deprivation influences re hospitalization in psychiatric institutions. This contention is also affirmed by Roy (1996) who asserts that particular indicators such as lack of a car as well as unemployment are predictive of readmission. Further, social derivation also contributes to relative disorders such as personality disorders, psychotic disorders and substance use and abuse. Notably, these compromise treatment and compliance to medication.
In this regard, Roy (1996) indicates that lack of sufficient economic resources makes individuals susceptible to mental illness. However, mental illness also contributes to economic deprivation. This according to him is well exemplified by schizophrenia patients that have been proved to be liable to downward social rift phenomenon. This twin relationship makes it difficult to identify specific causal factors that are responsible for increased readmissions. He employed a sample size of sixty psychiatric patients that were drawn from three different mental institutions. His findings indicated that almost half of the patients were unemployed. Of the thirty two male patients, twenty six were not married. In addition, the study found out that eighteen of the patients were homeless and did not leave any address for follow up. However, this study failed to provide a clear differentiation between first admissions and readmissions.
Further, Walling and Bishop (1996) attribute rapid readmissions to multiple intricate and augmenting factors. They used clinical information and records to ascertain that the nature of diagnosis, occupational status, previous episodes, multiple agency use and the number of previous re hospitalizations can be used to analyze the frequency of readmissions. In order to attain optimal results, they asserted that they need to be prioritized in order of relevance to a patient and then employed in monitoring patients accordingly.
Care Pathways
In their review, Mahendran, Mythily and Chong (2005) ascertained that the rapid readmission of patients in psychiatric hospitals in the state of Georgia was attributed to poor coordination of vital services with regard to referral pathways between secondary specialists and primary healthcare. This study employed a sample population of three psychiatric institutions and was carried out over a period of two years. The results ascertained that in order to enhance quality services, the referral system between specialists and health care provides needs to be clarified. In particular, the study recommended that there is an urgent need to increase the specific referral systems to facilitate and increase the accessibility of psychiatric patients to an integrated and comprehensive system as well as to community- based healthcare provision.
This study was limited by its over reliance on informal reports provided by the patients and their relatives. Thus the accuracy of its conclusions can not be accredited. However, the fact that it employed more than one mental institution during its study shows that it captured the diversity required. In this regard, it is worth acknowledging that the contextual conditions of various mental institutions differ. As such, the quality of the services provided by such institutions also differs considerably. Notably, the study captured these differences and therefore, it can be ascertained that the conclusions are representative of the mental health institutions in Gorgia.
In his review, Kastrup (1997) contends that the mental health care givers as well as their clients are in most instances confused with regard to the correct and effective healthcare path way. In his partially qualitative review undertaken in rural Virginia, he indicated that most patients and care givers fail to understand the best approaches that can be used to treat the mental health disorder effectively. This according to this study is attributed to various factors that range from complexity of the disease to the equally complex mental health system in the country. The limitation of this study was that it employed a rural population. Thus its findings can not be applied in the urban context that comprises a host of mental health patients.
Further, a study conducted by Goodpastor and Hare (2002) in New York ascertains that the multicultural and relatively complex emergent economic factors make it difficult for the mental health care givers to figure out the specific cause of the disease and take timely and effective intervention measures. They employed a sample of fifty mental health patients that were drawn from a diverse background with respect to social, racial, cultural and economic wellbeing.
Apart from the economic and environmental factors, this study found out that cultural indifference and in particular language highly compromised the quality of mental heath services. In this regard, they showed that differences in language made it difficult for minority patients to follow the Doctors instructions and prescriptions accordingly. Thus they failed to adhere to the medication instructions which led to rapid readmission. This was further compounded by the complex nature of the mental health system in the country. To counter this they suggest that there is need to ensure that the health care pathways are well defined.
Lack of insight, knowledge and Acceptance of the Psychiatric Condition
Prince (2009) indicates that insight, knowledge and acceptance of the mental situation of the patient need to occur at a macro level. In particular, the patient, household and general neighborhood should understand and appreciate the situation. In their study that sought to underscore the implications of stigmatization to mental patients in Illinois and the relationship of the same with rapid readmission, Mueller, Carlos and Wulf (2005) found out that stigmatization contributed significantly to denial of the mental illness by the patient and resistance to medication. This was further compounded by the adverse effects of mental illness to the wellbeing of the patients. In this respect, it is indicated that the judgment of such patients is often impaired and this makes it difficult for them to understand and accept their status. This undermines the treatment and rehabilitation efforts.
Further, Mueller et al (2005) noted that stigmatization was more pronounced amongst the members of the public than amongst patients. This according to him made it difficult for the patients to cope with ease after being discharged from mental hospitals. Of great importance to this study is the indication that stigmatization contributes to social seclusion and compromises the process of recovery.
In a follow up study by Dalrymple and Fata (2003) in New York concerning the effectiveness of community based care, findings showed that most mental health patients cease taking their medication once they leave the hospital. Basically, they believe that they have recovered fully and the illness is unlikely to recur. This then culminates in noncompliance to medication and frequent readmission. This study was qualitative in nature and it employed ten revolving door patients in the psychiatric unit. The nurse of this institution contended that the period of hospitalization is short as the patient leaves as soon as she starts stabilizing.
At this point, the patient may not have recovered enough to participate actively in the treatment plan and she may be unreceptive of any knowledge or insight. Also, the relatively short period of hospitalization does not provide sufficient time to explain to the patients the implications and management of the mental illness. The limitation of this stud was that it focused on one mental facility.
Psychiatric Disorders
In their study about the predictors of readmission amongst children and youths, Lyons, Uziel-Miller and Reyes (2000) cited psychiatric disorders to be one of the strongest predictors of rapid readmission in mental health hospitals. He observed that children that are frequently readmitted suffer from depressive disorders. Notably, these findings complemented Bladers observations that indicated the youth with depressive disorders were more likely to be rapidly readmitted in mental hospitals than their counterparts (Blader, 2004). In addition, the study found out that mental health youths who exhibited oppositional deviant behavior were frequently admitted. This study was compromised by different factors. To begin with, it entirely focused on a Caucasian sample. Then, it also relied on informal information from the relatives of the children. Accuracy of such information was not assured. However, it presented useful insights regarding the contribution of psychiatric disorders to frequent re hospitalization. It recommended that in order to yield optimal results, mental treatment in children and adolescents needs to treat the related behavioral disorders too.
Another study conducted by Anderson and Estle (1999) regarding factors influencing rapid readmission in psychiatric hospitals amongst the elderly indicated that secondary medical conditions have limited influence on re hospitalization. It employed a sample population of one hundred and fifty elderly patients that had been identified to have revolving door syndrome. In particular, the study analyzed the influence of cardiac diseases and diabetes on rapid re hospitalization. This study had a limitation of primarily depending on clinical records for data. Thus the credibility was undermined by its employment of secondary, rather than primary data. However, the fact that the data captured differences in racial and economic status of the patients enhanced its applicability to a diverse population.
Challenges Facing Community Based Institutions
The ineffectiveness of community healthcare has been blamed by Foster (2002) for the increasing incidences of rapid readmissions. Usually, patients that do not find sustainable care in the community institutions tend to deteriorate with time. He shows that in order to provide sustainable services to the affected population, community mental health institutions need to be expanded. It is because the number of mental health patients being discharged from the hospitals has increased in the recent past. At this juncture, it is worth noting that deinstitutionalization sought to transfer the resources from a central point to community services. As such, they need to be utilized accordingly.
In his study that sought to determine the quality of resources in mental health institutions, Foster (2002), noted that insufficient bed capacity contributed to frequent re hospitalization of mental health patients. This study found out that this situation led to early discharge of mental patients before they attained stability. This was influenced by the increased number of mental health patients. In addition, he found out that lack of vital resources in community health institutions contributed to a large turnover in the same. This study ascertained that the quality of the infrastructure that is found in secondary healthcare institutions is far much better than that employed at primary level. It recommended that in order to enhance service delivery, there is need to provide sufficient resources in mental health institutions. The main limitation of this study was that it was conducted in a single state. Nationwide application was therefore undermined in this respect.
Lack of sufficient staff was also identified to be a contributory factor to frequent and rapid readmission. In this regard, Foster (2002) found out that limited hospital staff does not allow that patients to undergo effective treatment. In Particular, he noted that the level of counseling, community support to the families and relatives and quality of psycho education was very low. In this respect, Carmel (2002) indicates that according counseling and psycho education sufficient time was instrumental in avoiding readmissions. In order to counter this situation and provide quality mental services to the population, Foster (2002) suggested that there is need for the government to reconsider distribution of resources and ensure that all mental services are equipped with sufficient resources.
Diathesis-stress Model
This denotes that every individual has a certain level of vulnerability and susceptibility (diathesis) that makes the same liable to developing a mental disorder (Scher, Rick Zindel, 2005). Nevertheless, this model presumes that persons have their own individual points at which they develop the disorder. This is entirely influenced by the interaction between the level of stress being experienced by the individual and the degree of the risk factors.
In their review of related theories, Scott and Anne (1991) cite the model to be instrumental in determining the persons that are likely to develop disorders because it solely addresses the interaction between situational stressors and pre morbid risk factors. The risk factors that have been widely studied entail mental illness or family history of drug use and abuse, personal psychological factors like impulsivity or hostility, environmental characteristics like low socioeconomic status and biological factors. Stress in this regard refers to experiences and events that trigger psychological distress (Scher et al., 2005). It has negative implications on the vital body mechanisms that enhance the cognitive, physical and emotional stability of an individual.
As indicated earlier, this model implies that if a person is highly susceptible, a relatively low degree of stress is required for the person to fall ill and vice versa. It shows that determination of a persons stress and vulnerability is fundamental in ascertaining the probability of the person falling ill or the illness reoccurring. Thus the model is imperative for preventing the occurrence of illness. It is because timely intervention measures that target individuals that have the highest risk of developing negative health implications can be undertaken accordingly. A classic example in this regard would include psychological interventions that are taken to ensure that an individual at risk responds to stressful situations with ease.
The model is perceived important in explaining the occurrences of mental and behavioral disorders. In this respect, Scott and Anne (1991) indicate that previously, it has been employed in underscoring the relationship between environmental and hereditary factors that contribute to mental illnesses such as schizophrenia. Further, it has been beneficial in stimulating relevant research in mental health. In particular, it is indicated that it has enhanced research and treatment of mental disorders. Most importantly, it has been employed in mitigating stress and therefore preventing the pronunciation of diathesis through development of viable protective factors. The most common protective factors that have been put forth by Scott and Anne (1991) include skill building, rigorous psychopharmacology and development of effective support systems for the affected individuals.
The model has also been beneficial to the care takers and families of mental health patients. In this respect, Scott and Anne (1991) indicate that it enables the close associates of these individuals to determine periods when the patients are vulnerable, examine the stressors leading to such experiences and employ protective factors in helping the person cope with the experience effectively. Utilization of this profile has enhanced humane, efficient and effective treatment interventions.
Current Thinking on Modifiable Risk Factors
From the preceding analysis, it is certain that modifiable risk factors inhibit treatment and prevention of mental health illnesses. In deed, the implication of these factors to effective prevention, intervention and treatment of mental illness can not be overlooked. While Carmel (2002) points out that frequent readmission are effective in enhancing the treatment and ultimate recovery of mental heath patients, it is worth acknowledging that modifiable risk factors compromise the overall quality of mental health service.
In their review, Stanley, Kutcher and Magdalena (2005) indicate that not only do these factors undermine recovery, but they also lead to waste of resources that could have otherwise been employed for other purposes. This is even more important at this time when there is increased pressure on the mental health resources. For instance, it can not be disputed that preventing readmission of one patient in this respect would enable new patients to access the same. This according to Stanley et al (2005) is vital in enhancing early interventions and ensuring that appropriate measures are undertaken to prevent severity of the disease.
Further, Delaney and Fogg (2007), cite that addressing modifiable risk factors would be instrumental in reducing the risk of the persons suffering from mental health illness. This presumption is deduced from the Diathesis-stress model conception. Notably, modifiable risk factors are stressors. As such, they increase the vulnerability of persons at risk. Considering that this school of thought believes that biological factors can not be detrimental and are relatively manageable without the stress, it therefore follows that elimination of such stress would reduce the vulnerability of individuals of suffering from mental illness.
Further, Fontanella et al (2009) indicates that modifiable risk factors can not be effectively addressed without the intervention measures from the mental health providers. Generally, mental health practitioners are very resourceful and their knowledge is very instrumental in providing the right direction for the any action. In this regard, Foster (2002) argues that the information provided by these personnel is based upon factual analysis of the mental health status of the patients. As such, he recommends that they should not be eliminated from the cycle at all costs.
At this point in time, it should be acknowledged that the efforts of every stakeholder are imperative in addressing the modifiable risk factors. Major stakeholders in this respect entail the patients, mental health providers and the government (Nelson, Maruish Axler, 2000). Patients are charged with the responsibility of abstaining from activities that are likely to have adverse implications on their health and cooperating with the mental health providers by following medical instructions accordingly.
The mental health providers on the other hand provide technical support to the patients. In particular, they are responsible for providing vital information regarding the management of the disease to the patients. This is achieved through clear instructions and effective counseling. Further, they provide timely preventive and curative interventions to the patients. Of great importance is their role of making follow up to ensure strict adherence to medical instructions by the patients.
Finally, the government and relevant policy makers are expected to avail vital resources to the mental health department. These range from sufficient infrastructure in both primary and secondary mental health institutions to adequate human resource and facilities. In addition, Roy (1996) indicates that there is need to ensure that the mental health facilities are distributed equally across the nation. This would enable all segments of the population to have access to these vital services. Notably, failure of each one of the stakeholders to play his or her role is likely to compromise the quality of services and compromise the effort towards addressing modifiable risk factors.
In his viewpoint, Geller (2000) notes that the scientific effectiveness of the interventions that seek to address the modifiable risk factors is yet to be established. In this respect, he indicates that a great percentage of the research undertaken has been compounded by complexities that are related to the short duration of analysis, non randomization of interventions, use of inadequate sample sizes and employment of surrogate outcome measures. Thus to ascertain the effectiveness of the intervention measures, there is need to undertake consistent and credible research in this regard.
Furthermore, Kastrup (1997) shows that the ineffectiveness of the intervention measures is exemplified through the increase in the mental health patients in the recent past. This trend has continued irrespective of the fact that the intervention measures have been implemented in the past. To counter this, Geller (2000) recommends that prevention strategies need to be delivered based on available evidence of their effectiveness Otherwise, parents, educators, health providers and politicians are likely to continue investing in these programs that are either ineffective or harmful to the general public.
Conclusion
From the review, it is certain that the US mental health department has continuously failed to cater for the emergent needs of the mental health patients. This has been ascertained by the present trends that indicate that the sector is accorded minimal attention. Conventionally, deinstitutionalization was aimed at providing the mental health patients with a viable environment for recovery. Notably, this has not been achieved because of lack of sufficient resources and social stigmatization. Of great reference are the modifiable risk factors that undermine the effectiveness of the entire system.
At this juncture, it is important to acknowledge that modifiable risk factors remain a major setback in enhancing the provision of mental health to the US population. Severity of the illness, a history of hospitalization, substance use and abuse, fragmented pathways and lack of sufficient resources amongst others have been cited to undermine the quality of mental heath services in various ways. This is further compounded by the existence of a fragmented institutional framework and policies that are sectoral in nature. In addition, the complex nature of the mental health system makes it difficult for the minority patients to access quality care. Essentially, modifiable risk factors are a source of stress that increases the vulnerability of the population to mental illness. As such, sustainable measures need to ensure that preventive and effective intervention measures are used to prevent the occurrence of the mental illnesses.
In this regard, consistent, comprehensive and credible research needs to be undertaken. This is because of the fact that previous researches have had numerous inadequacies. This explains why previous intervention measures have been fruitless. Seemingly, the problem is not insurmountable. The challenge to attaining a sustainable solution is in mobilizing and marshalling the necessary will, political or otherwise to address the issues accordingly. As the current thinking about the modifiable risk factors ascertains, this can be achieved through partnerships and relevant collaborations between major stakeholders in the mental health sector. Efforts by individual stakeholders need to complement each other in order to come up with viable and lasting solutions to addressing modifiable risk actors and enhancing the quality of life of mental health patients.
Glazer and Ereshefsky (2006) ascertain that over 50 of the beds are occupied by re hospitalization cases. A notable pattern of patient illness in psychiatric wards is based along recurring of illnesses. Thus once the mental health patients leave the hospitals, the probability that they would return in future is seemingly high.
The differences in the readmission of psychiatric patients are based on different factors of the institution milieu. The severity of the illness, indulgence in risky behaviors, substance use and abuse, fragmented care pathways and other modifiable factors have increasingly being associated with patient return in mental health institutions. Of great importance are the economic factors that have been identified as the main contributory factors to rapid readmissions. Generally, current statistics are a major cause of concern for most mental heath institutions. Efforts have been mounted through consistent research to identify intrinsic gaps that contribute to this scenario. This literature review underscores the previous findings in this regard.
Trends in Mental Health Policy
National statistics indicate that close to forty four million Americans suffer from mental health illness. In his study, Prince (2009) ascertained that the mental health department in America is presently experiencing a shortage in human resources. As a result, the quality of services being provided by the sector greatly compromises the recovery and holistic wellbeing of mental health patients.
Nationally, mental health has been identified as a neglected realm of the public health sector according to Delaney and Fogg (2007) who analyze the National health report based on the survey carried out in 2007. The information regarding the mental policy is also fragmented as exemplified by the World Heath Organization report of 2008. Essentially, it seeks to address the underlying goals of mental health but only mentions the reduction of suicide.
A report presented by Prince (2009) draws particular attention on the increasing rates of mortality for schizophrenia. In addition, it cites vital surveys that highlight a significant 28 of the population believed to consult mental health services annually. Furthermore, he notes that social deprivation indicators like unemployment are elemental in psychiatric morbidity and highlights the urgent need for collaboration between different sectors. He concludes by stating that mental health services are critical for this segment of the national population whose incapacitation is likely to lead to increased poverty and marginalization.
As highlighted above, mental health is relegated and is not identified as one of the public health priorities in America. Notably, psychiatric patients comprise of the poor in this nation. It is therefore imperative to enhance equitable distribution of mental health services in order to ensure that the psychiatric patients benefit from the same. Giffords (2006) has proposed the matrix model to be the most ideal approach to addressing the emergent concerns regarding healthcare. This presents various interventions with regard to mental health treatment, prevention, promotion and sustainable rehabilitation of the affected population. He argues that in order to attain optimal results, an all inclusive approach that incorporates both public and individual concerns needs to be adopted.
Burns and Fim (2002) affirm this contention by indicating that effective treatment of psychotic disorders requires input from all segments of the society. In particular, they show that while pharmacological treatment controls severe symptoms, social interventions and psychological support are instrumental in enhancing the quality of life of the patients and preventing physical deterioration and malfunctioning. Further, a multivariate analysis revealed the inherent relationship between substance abuse and criminal victimization of the psychiatric patients.
Burns and Fim (2002) also indicate that the sector has in the recent past received particular attention from consumer organizations. Fundamentally, these play a critical role in evaluating the performance of the sector. In particular, they publicize the extent of the department in addressing its goals of providing sufficient services to the mental health population, addressing stigmatization, providing integrated and comprehensive health services, reducing costs associated with mental health and increasing the workforce. A recent study indicates that the department has dismally failed in all these areas. By bringing these concerns to the fore, consumer organizations have played a critical role in encouraging formulation of sustainable policies by the federal government.
Implications of Deinstitutionalization
Various controversies have emerged over the process of deinstitutionalization that was carried out in the last quarter of the previous century. Shadish, Lurigio and Lewis (1995) decry this process and argue that mental health patients need long-term institutionalization in order to recover fully. He highlights the ineffectiveness of rehabilitation programs in dealing with violent behavior, impulsive suicide and substance abuse that is exhibited by the patients. However, Easterbrook, Berlin, Gopalan and Mathews (1991) point out that community programs have made it possible for the economically weak within the society to access these vital services. In response, Shadish et al (1995) ascertain that effective community care is more expensive than institutionalization. Further, he shows that long term rehabilitation that greatly benefits the patient is also an added expense.
Also, Gopalan and Mathews (1991) indicate that deinstitutionalization provides an ideal environment for the mental health patients to recover easily. In this regard, they argue that community based care provides a more humane environment that enables the mental health patients to access outpatient care. In addition, Geller (2000) posits that deinstitutionalization has been effective in shortening the period of time that the mental health patients stay in hospitals. According to him, the hospital environment is restrictive and does not provide the patients with a chance to socialize with the entire public. In other words, the environment provided therein is not viable and psychologically, this undermines the recovery process. However, Shadish et al (1995) contests this by indicating that this can only be achieved if the community based facilities are equipped with sufficient infrastructure including human resources. Notably, this has not been achieved in the US and as a result, mental patients continue to suffer.
In his review, Dowdall (1999) describes deinstitutionalization a s an adjustment process that provides mental heath patients with a chance to recover without having to experience the effects of the life provided in institutions. This was based upon the realization that mental health patients that are institutionalized tend to become accustomed to the environment in the institutions and find it difficult to adjust to the conditions outside the institution. Dowdall (1999) asserts that deinstitutionalization allows that patients to be empowered and regain their freedom. This then enables them to assume responsibility for their action and therefore recover faster. Unlike in the mental institutions that have their distinct rules, the community environment allows the patients to adapt to the normal environment and co-exist with the rest of the population with ease.
In his study, Scull (1991) argues that deinstitutionalization gives hope to the mental patients. According to him, it provides a viable environment that enables the patients to be appreciated and be cared for by the entire community. This gives hope to the patients and hastens their recovery as they are perceived as normal individuals in a communal environment. Nonetheless, Shardish et al (1995) indicates that such an ideal scenario is yet to be achieved in the current US society as the patients face a high degree of stigmatization from the society. He further proposes that psycho education and other viable measures would be instrumental in altering the present demeaning perception that mental health is accorded by the public. According to him, only then would deinstitutionalization yield desirable outcomes.
Nonetheless, Shardish et al (1995) indicates that deinstitutionalization has resulted in incidences of homelessness. This is due to the fact that it results in to premature discharge of the mental health patients from the hospitals. However, the community based mental health institutions lack the vital infrastructure and resources to provide quality services to the discharged patients. In the long run, the patients lack vital care and fall victims of homelessness.
Burns and Fim (2002) pertaining to USA health services reviewed the transfer of mental health patients for hospitals to community care programs. Findings indicated that community based models were more effective in shortening the duration of the patients in hospitals, reducing incidences of readmission, and enhancing community integration. However, a parallel review undertaken by Foster (2002) indicated an increase in mortality rates, homelessness and frequent readmissions for patients whose conditions were severe. In order to counter the later scenario, Foster (2002) proposed that there is need to ensure that the community programs and given sufficient resources and are well planned for. In particular, he cites that that planning of community programs need to be attuned to the specific needs of the psychiatric patients.
Modifiable Risk Factors for Rapid Readmission in Mental Health Hospitals
Frequent Hospitalization
In their research, Weiden and Glazer (1997) found out that a history of consistent hospitalization in mental health hospitals is a predictor of rapid readmissions. According to this study, patients that had a pattern of seeking inpatient treatment tended to repeat the treatment-seeking behavior. In this regard, Carmel (2002) affirms that psychiatric patients that are accustomed to the mental health institutions or felt comfortable and relieved during their previous admissions often prefer readmissions as a viable mode of adjustment to their painful experiences during a relapse. He refers to this tendency as hospitalphilia. This is characterized by a short interval between admissions that lasts for a relatively shorter duration and often ends against the medical advice. Such patients according to him prefer short and frequent admissions to extended periods of admission.
Although previous studies indicated that such admissions are influenced by violence, this study found out that the admissions are self initiated and the characteristic aggression does not influence re hospitalization. Notably, the patients did not exhibit any form of violence after admission, perhaps a strategy aimed at restraining the hospital staff from interfering with the self initiated admission schedule. The limitation of this study was that it reviewed only documented and published information about the patients. At this point, it should be acknowledged that unpublished studies are likely to contain more factual information that would conflict with these findings. However, the study was very comprehensive and various documentaries from a diverse cultural background were reviewed. Therefore, it can be applicable to other countries outside USA.
In a bit to explain the relationship between system variables and rapid re hospitalizations, Carmel (2002) found out that the attitude that the mental health workers accorded patients also influenced rapid readmissions. The study employed a sample of sixty one mental patients with revolving door syndrome in a psychiatric unit in North Carolina. The results indicated that patients that were perceived regulars by the nurses were in some instances overlooked when admitted or handled superficially. As a result, the emergent issues in their medical status were not handled effectively because particular attention was given to major symptoms. Lack of timely interventions regarding emergent infections of these patients influenced their rapid readmission. In order to address this, the study recommended a change in the attitude towards frequently admitted mental health patents by the mental health providers.
Notably this study was restricted to one facility and one state. In this regard, it should be appreciated that the professional experiences of mental health individuals vary across the nation. These variations are influenced by the different economic resources that the states have. In addition, Huff (2000) notes that state policies also influence the quality of mental services offered in different states. It can therefore be argued that the findings do not have a nationwide application. However, the implications of these findings to policy formulators are desirable.
Non Compliance to Treatment and Medical Appointments
In his study, Green (1998) analyzed the causes and patterns of acute admissions in a psychiatric unit in New York for patients with revolving door syndrome. He employed 63 inpatients that were suffering from schizophrenia. This study was aimed at making efforts to improve treatment options and enhance sustainability upon discharge from the hospital. The leading cause was identified to be lack of compliance to medication.
Lack of response to the treatment was cited as the second most common cause of acute readmissions in the institution. The treatment that was currently available for use at the time of study was oral conventional antipsychotic, atypical antipsychotic and depot conventional antipsychotic. The decision to employ either atypical or depot treatment was based on the identification of whether the relapse was caused by non response or non compliance. This study recommended that medication for such patients need to be determined during acute admission.
Notably, the study relied solely on the data collected from in patient. In his review Easterbrook et al (1991) argues that inpatients tend to have different characteristics from outpatients. In particular, he ascertains that the attention and management that the two groups of patients are accorded differs significantly. This has various implications on the policies undertaken at various stages. At this juncture, it can be argued that the data employed for this study was not presentation of the psychiatric population. However, it can be contended that the first hand information got from the study is very instrumental in making viable decisions regarding treatment of inpatients suffering from mental disorders.
A previous study undertaken by Weiden and Glazer (1997) that employed a pharmaco-economic decision analysis model evaluated the implications of changing treatment from traditional oral neuroleptics to modern atypical oral treatments and depot neuroleptics for revolving door patients. The study employed one hundred and fifty patients that were randomly picked from various psychiatric state institutions across US. The rationale for this was to capture the inherent economic disparities and analyze how the same contributed to rapid readmission of mental health patients. Shifting of treatment was perceived as a viable means of management of schizophrenic out patients. This study found out that patients with limited resources were more likely to be rapidly readmitted than their counterparts. This was attributed to the low quality of previous medication that such patients were previously accorded. It was further compounded by lack of quality after care services at the community level. The study affirmed that these conditions worsened the symptoms after discharge and prompted rapid readmission.
In his study that sought to determine the relation between non compliance to outpatient admissions and rapid re hospitalization in psychiatric wards, Geller (2000) found out that patients who did not comply with outpatient appointments after being discharged from the hospitals were three times more likely to be readmitted. He employed a sample of 241 revolving door patients in three south eastern states. Findings indicated that out of the entire sample, almost sixty percent did not comply with the outpatient appointments regardless of the fact that they had been scheduled accordingly by respective institutions. These segment of the sample experienced more rapid readmission rates than their counterparts. The study recommended that patients utilizing outpatient services need to comply with the medical instructions in order to avoid rapid readmission. According to this study, lack of compliance complicated the recovery process and made it difficult for the health providers to monitor the status of the illness and intervene accordingly. The limitation of this study was that it was restricted to female patients only.
Notably, non compliance to medical appointments has been associated with non compliance to treatment. In his research regarding the relationship between non compliance and rapid readmission, Bech (2005) found out that psychiatric patients who personally discontinued their medication found it difficult to disclose this to the medical providers. As such, they preferred to discontinue with the appointments altogether. Conversely, the psychiatric patients that missed important appointments tended to make misinformed decisions regarding their after care. This led to complications that ultimately culminated in rapid readmission. Further, Bech (2005) shows that non compliance to appointments and treatment undermines the quality of services that the patients are given by the medical staff. In particular, this tendency compromises communication between the patients and health providers, decreases the degree of health provider empathy and increases the level of provider frustration. In order to avoid this, Bech (2005) proposed that the patients should be given sufficient information regarding medical schedules.
Severity of Illness
In his consultative review, Blader (2004) explored factors that determined rapid readmission in psychiatric institutions for adolescents and reported that severe early diagnosis especially that of affective psychoses and schizophrenia contributed significantly to rapid relapse that characterizes the revolving door syndrome. Despite the fact that this study entirely focused on adolescents, it can be argued that this applies to children as well as adults. Also, the deductions can be ascertained to have been based on credible data due to the fact that the study was conducted within a period of ten years. Conventional studies have cited severity of the illness to be a contributory factor to frequent readmission. These are represented by Lyons, Uziel-Miller and Reyes (2000) that employed psychometric screening procedures in identifying psychiatric patients that were at a high risk of rapid readmission.
In this, they ascertained that factors relating to frequent readmission in hospitals had been studied intensely in the recent past in a bit to curb the expenses involved as well as improve the outcomes of the disease. In this respect, they referred to the recent dramatic increases in readmissions in mental hospitals that involved revolving door patients. Notably, this led to an increase in deinstitutionalization. Their study employed 130 patients and lasted for a period of three months. They concluded that identification of the patients that were at a higher risk of readmission would be useful. In particular, it would give mental health personnel a chance to plan for their management in a timely manner and make viable interventions accordingly. Such measures according to them would include discharging patients to community based institutions.
The limitation of this study was that it was undertaken within a very short period of time. Considering the fact that it was using observation as an important tool of collecting data, this study should have taken more time in order to come up with viable conclusions. In this respect, Boardman, Hodgson, Lewis and Allen (1997) point out that severity of illness in mental patients is contributed to by various factors that are both environmental and economic in nature. It is therefore imperative to take sufficient time to identify deserving patients and take intervention measures accordingly. Nevertheless, the study was credible as it utilized factual first hand information from the mental health practitioners.
Substance Abuse
In his study in mental hospitals in the State of Mississippi Prince (2009) found out that coupled with treatment non compliance, substance abuse contributed significantly to rapid re hospitalization for revolving door patients. His study was based on a sample of seventy patients that were randomly picked from a psychiatric institution. He concluded that sustainable intervention measures such as patient education could be instrumental in reducing such incidences. Like wise, Haywood, Kravitz, Grossman and Lewis (2008) carried out a comparative evaluation of mental health inpatients without and with co morbid substance-related complications. They found out that instances of readmissions were more rapid for the psychiatric patients with co morbid substance-related complications. However, they indicated that this was only for a short period of time.
Further, Gastal, Andreoli and Quintama (2000) carried out a four year prospective review after relapse in schizophrenia for one hundred patients. Their findings indicated that non compliant patients that had been previously diagnosed of substance assumed a significant 64 of the institutional rapid readmissions. They also found out that the duration before re hospitalization was relatively shorter for non compliant patients that had dual diagnosis for substance use and abuse than for non compliant patients that had not been previously diagnosed for substance abuse. Further, they indicated that patients that were medication compliant had a relatively longer period before readmission than their counterparts that had been diagnosed of substance abuse. Basing on this analysis, they concluded that sustainable treatment programs in this respect need to address substance abuse and non compliance in order to attain optimal results.
A relative research was carried out by Levine (1998) who sought to identify factors that contributed to substance use and abuse by schizophrenic patients and the relationship of the same with rapid readmissions. This study was motivated by the recognition that substance abuse was one of the reasons behind rapid re hospitalization of mental health patients in the state of Arizona. The findings indicated that the relatives, family and community members of the patients contributed to their substance abuse by selling alcohol and drugs to them. In addition, this study revealed that use of alcohol and drugs by the patients was aimed at containing severe side effects that are related to the use of anti-psychotic drugs, avoiding drowsiness and suppressing hunger as a result of shortage of food. However, this led to severe side effects and undermined the effectiveness of the medication. As such, affected patients were readmitted in hospitals within a very short period f time.
The key areas of intervention in this regard were identified as enhancing psycho education amongst patients and the community at large, raising community awareness with regard to substance use and abuse, strengthening the abilities of law enforcers and care takers to curb substance use and abuse and initiating community based campaigns that target the protection and care of the mental health patients. The limitation of this study was that the data that was used was derived from clinical records. However, the implications can be applied to a large geographical area.
Violence
Violence and criminal behavior have also been implicated for contributing significantly to rapid readmission. A study conducted in North Carolina by Appleby, Desai and Luchins (2001) using a sample of 330 involuntary out patients suffering from psychotic and major mood disorders analyzed the specific characteristics and environments of violent mental patients. They found out that violent behavior was exhibited by half of the sample and contributed significantly to rapid readmission. The main limitation of this study was that the data employed was derived from a single facility.
Further, a study conducted by Casper and Regan (1996) in Canada indicated that violence was one of the main reasons that contributed to frequent and rapid readmissions. This viewpoint was brought forth by the care giving relatives who ascertained that severe relapse of mental health disorder in psychiatric patients culminated in a situation where the safety of the relatives was jeopardized, their property destroyed and in severe instances, their lives threatened as a result of violence. A study conducted by Gastal et al (2000) in Mexico indicated that such a situation became even more disheartening in cases where the law enforcement agencies failed to respond in a timely manner. Further, the fact that the patients were unlikely to be held criminally responsible for their activities made the relatives to request for rapid readmissions. In his study regarding the relationship between violence, substance abuse, criminal victimization and rapid readmission, Boardman et al (1997) found out multiple actors that discouraged the care giving relatives from taking up criminal proceedings in such instances.
To begin with, it was indicated that relatives feared that their patient was likely to lead a devastating life in prison while she is awaiting trial. Further, the fact that the patient was likely to receive long term hospitalization in instances where she was found mentally unfit to stand trial made the relatives reluctant to pursue criminal proceedings. Finally, Burns and Fim (2002) found out that the police were always reluctant to press criminal charges in such instances and therefore the efforts could be fruitless. In his study undertaken in New York about the reasons for frequent readmissions, Gifford (2006) found out that five of the 60 patients with revolving door syndrome had spend close to five months in the institution because of violence. Haywood et al (2008) explains this by indicating that the care giving relatives often take hasty measures in incidences where the patient has previously portrayed violent behavior. In particular, they arrange for readmission as soon as the patient goes in to a relapse.
In order to address this Casper and Regan (1996) suggest that the public and especially the relative care givers need to liaise with community mental health providers. This would ensure that they are well acquainted with vital information regarding violence and mental health. In particular, they would be informed of timely and effective measures to manage such relapse and avoid readmission. In addition, they note that the criminal justice system also needs to be well informed about the implications of violence in this regard. Policy changes with respect to long term stay in mental institutions are likely to have a positive impact on the perception of the public about violence and mental health.
This study was limited by the involuntary nature of the respondents. In this regard, Gifford (2006) indicates that seeking the consent of the patient is important as it ensures that the information is given out of free will. Notably, this enhances the credibility of such information. With regard to the above study, it can be argued that the data collected was subjective in nature. Nevertheless, the fact that a significant number of respondents were employed implies that such mishaps were screened accordingly.
Implications of High Risk Behavior
Rapid readmission in mental health hospitals is also occasioned by manifestation of high risk behavior. This is all inclusive and it includes drug use and abuse and inappropriate sexual behavior that expose individuals to infections such as HIV. This then makes the mental health patients susceptible to readmissions. In his study in New York, Casper and Donaldson (2000) ascertained that high risk behavior has far reaching implications on the mental health patients with the profound being probability of frequent readmission in mental hospitals. The limitations of this study were that it was not gender representative as the researcher placed undue emphasis on the female segment of the society. Nevertheless Gifford (2006) indicates that the implications are transgender and therefore are applicable to all segments of the society.
With regard to vulnerability and susceptibility, Green (1998) points out that the vulnerable segment of the society is usually comprised of the elderly, women and persons that are intellectually and physically fragile. It is posited that they are frequently admitted because they are considered to be at risk and therefore require a considerable degree of protection from the society that they belong to. According to Carmel (2002), their vulnerability loading undermines their ability to protect themselves against societal ills and violence. Thus in most cases, they are victimized and suffer dire consequences.
Suicide attempts as a result of high risk behavior have also been identified as a major contributory factor to rapid readmissions in mental hospitals. In this regard, Fontanella, Bridge and Campo (2009) indicate that suicidal thoughts stem from the understanding and experience of the grave implications that are associated with high risk behaviors. In particular they ascertain that use and abuse of drugs causes suicidal thoughts in mental heath patients. In their survey in thirty three mental institutions across US, Fontanella et al (2009) found out that fifty two percent of the mental health patients were readmitted rapidly because of suicidal attempts. While some were associated with economic vulnerability, a significant 63 were attributed to risky behavior after discharge from hospital.
These presumptions were also affirmed by Geller (2000) who undertook a similar study in UK. His findings indicated that while a great percentage of the population believed that suicidal attempts by mental health patients were associated with their vulnerable status and the stigmatization from the society, some of them (54) were caused by the implications of high risk behavior. In particular, he indicated that the implications of the female patients being sexually andor physically assaulted because of their unstable mental status made them feel dejected and resort to suicide. In addition, this study affirmed that use and abuse of drugs was responsible for triggering suicidal thoughts in mental health patients and therefore prompting readmissions.
In order to counter this, Geller (2000) asserted that the stakeholders in community mental health need to complement their efforts towards enhancing care and protection of the mental health patients in the community. To achieve this, he indicated that the community needs to be educated about mental health. In addition patients need to spend sufficient time in institutions so that they can be informed about their vulnerability and how to manage the same. This according to Geller (2000) can only be attained if patients recover well before being discharged to mental health institutions. Notably, complete recovery also enables them to understand their status and avoid resistance.
Social Deprivation
Numerous studies of whom Hawthorne, Green and Lohr (1999) are represented ascertain that social indicators of deprivation contribute to an increase in readmission in mental institutions. They demonstrate that composite measures of social deprivation such as unemployment rates, Jarman Underprivileged Area Score and various other complex statistical models have successfully and accurately been employed in the past to determine the rate of readmission in psychiatric hospitals. Of great importance is the fact that this study ascertains that social deprivation influences re hospitalization in psychiatric institutions. This contention is also affirmed by Roy (1996) who asserts that particular indicators such as lack of a car as well as unemployment are predictive of readmission. Further, social derivation also contributes to relative disorders such as personality disorders, psychotic disorders and substance use and abuse. Notably, these compromise treatment and compliance to medication.
In this regard, Roy (1996) indicates that lack of sufficient economic resources makes individuals susceptible to mental illness. However, mental illness also contributes to economic deprivation. This according to him is well exemplified by schizophrenia patients that have been proved to be liable to downward social rift phenomenon. This twin relationship makes it difficult to identify specific causal factors that are responsible for increased readmissions. He employed a sample size of sixty psychiatric patients that were drawn from three different mental institutions. His findings indicated that almost half of the patients were unemployed. Of the thirty two male patients, twenty six were not married. In addition, the study found out that eighteen of the patients were homeless and did not leave any address for follow up. However, this study failed to provide a clear differentiation between first admissions and readmissions.
Further, Walling and Bishop (1996) attribute rapid readmissions to multiple intricate and augmenting factors. They used clinical information and records to ascertain that the nature of diagnosis, occupational status, previous episodes, multiple agency use and the number of previous re hospitalizations can be used to analyze the frequency of readmissions. In order to attain optimal results, they asserted that they need to be prioritized in order of relevance to a patient and then employed in monitoring patients accordingly.
Care Pathways
In their review, Mahendran, Mythily and Chong (2005) ascertained that the rapid readmission of patients in psychiatric hospitals in the state of Georgia was attributed to poor coordination of vital services with regard to referral pathways between secondary specialists and primary healthcare. This study employed a sample population of three psychiatric institutions and was carried out over a period of two years. The results ascertained that in order to enhance quality services, the referral system between specialists and health care provides needs to be clarified. In particular, the study recommended that there is an urgent need to increase the specific referral systems to facilitate and increase the accessibility of psychiatric patients to an integrated and comprehensive system as well as to community- based healthcare provision.
This study was limited by its over reliance on informal reports provided by the patients and their relatives. Thus the accuracy of its conclusions can not be accredited. However, the fact that it employed more than one mental institution during its study shows that it captured the diversity required. In this regard, it is worth acknowledging that the contextual conditions of various mental institutions differ. As such, the quality of the services provided by such institutions also differs considerably. Notably, the study captured these differences and therefore, it can be ascertained that the conclusions are representative of the mental health institutions in Gorgia.
In his review, Kastrup (1997) contends that the mental health care givers as well as their clients are in most instances confused with regard to the correct and effective healthcare path way. In his partially qualitative review undertaken in rural Virginia, he indicated that most patients and care givers fail to understand the best approaches that can be used to treat the mental health disorder effectively. This according to this study is attributed to various factors that range from complexity of the disease to the equally complex mental health system in the country. The limitation of this study was that it employed a rural population. Thus its findings can not be applied in the urban context that comprises a host of mental health patients.
Further, a study conducted by Goodpastor and Hare (2002) in New York ascertains that the multicultural and relatively complex emergent economic factors make it difficult for the mental health care givers to figure out the specific cause of the disease and take timely and effective intervention measures. They employed a sample of fifty mental health patients that were drawn from a diverse background with respect to social, racial, cultural and economic wellbeing.
Apart from the economic and environmental factors, this study found out that cultural indifference and in particular language highly compromised the quality of mental heath services. In this regard, they showed that differences in language made it difficult for minority patients to follow the Doctors instructions and prescriptions accordingly. Thus they failed to adhere to the medication instructions which led to rapid readmission. This was further compounded by the complex nature of the mental health system in the country. To counter this they suggest that there is need to ensure that the health care pathways are well defined.
Lack of insight, knowledge and Acceptance of the Psychiatric Condition
Prince (2009) indicates that insight, knowledge and acceptance of the mental situation of the patient need to occur at a macro level. In particular, the patient, household and general neighborhood should understand and appreciate the situation. In their study that sought to underscore the implications of stigmatization to mental patients in Illinois and the relationship of the same with rapid readmission, Mueller, Carlos and Wulf (2005) found out that stigmatization contributed significantly to denial of the mental illness by the patient and resistance to medication. This was further compounded by the adverse effects of mental illness to the wellbeing of the patients. In this respect, it is indicated that the judgment of such patients is often impaired and this makes it difficult for them to understand and accept their status. This undermines the treatment and rehabilitation efforts.
Further, Mueller et al (2005) noted that stigmatization was more pronounced amongst the members of the public than amongst patients. This according to him made it difficult for the patients to cope with ease after being discharged from mental hospitals. Of great importance to this study is the indication that stigmatization contributes to social seclusion and compromises the process of recovery.
In a follow up study by Dalrymple and Fata (2003) in New York concerning the effectiveness of community based care, findings showed that most mental health patients cease taking their medication once they leave the hospital. Basically, they believe that they have recovered fully and the illness is unlikely to recur. This then culminates in noncompliance to medication and frequent readmission. This study was qualitative in nature and it employed ten revolving door patients in the psychiatric unit. The nurse of this institution contended that the period of hospitalization is short as the patient leaves as soon as she starts stabilizing.
At this point, the patient may not have recovered enough to participate actively in the treatment plan and she may be unreceptive of any knowledge or insight. Also, the relatively short period of hospitalization does not provide sufficient time to explain to the patients the implications and management of the mental illness. The limitation of this stud was that it focused on one mental facility.
Psychiatric Disorders
In their study about the predictors of readmission amongst children and youths, Lyons, Uziel-Miller and Reyes (2000) cited psychiatric disorders to be one of the strongest predictors of rapid readmission in mental health hospitals. He observed that children that are frequently readmitted suffer from depressive disorders. Notably, these findings complemented Bladers observations that indicated the youth with depressive disorders were more likely to be rapidly readmitted in mental hospitals than their counterparts (Blader, 2004). In addition, the study found out that mental health youths who exhibited oppositional deviant behavior were frequently admitted. This study was compromised by different factors. To begin with, it entirely focused on a Caucasian sample. Then, it also relied on informal information from the relatives of the children. Accuracy of such information was not assured. However, it presented useful insights regarding the contribution of psychiatric disorders to frequent re hospitalization. It recommended that in order to yield optimal results, mental treatment in children and adolescents needs to treat the related behavioral disorders too.
Another study conducted by Anderson and Estle (1999) regarding factors influencing rapid readmission in psychiatric hospitals amongst the elderly indicated that secondary medical conditions have limited influence on re hospitalization. It employed a sample population of one hundred and fifty elderly patients that had been identified to have revolving door syndrome. In particular, the study analyzed the influence of cardiac diseases and diabetes on rapid re hospitalization. This study had a limitation of primarily depending on clinical records for data. Thus the credibility was undermined by its employment of secondary, rather than primary data. However, the fact that the data captured differences in racial and economic status of the patients enhanced its applicability to a diverse population.
Challenges Facing Community Based Institutions
The ineffectiveness of community healthcare has been blamed by Foster (2002) for the increasing incidences of rapid readmissions. Usually, patients that do not find sustainable care in the community institutions tend to deteriorate with time. He shows that in order to provide sustainable services to the affected population, community mental health institutions need to be expanded. It is because the number of mental health patients being discharged from the hospitals has increased in the recent past. At this juncture, it is worth noting that deinstitutionalization sought to transfer the resources from a central point to community services. As such, they need to be utilized accordingly.
In his study that sought to determine the quality of resources in mental health institutions, Foster (2002), noted that insufficient bed capacity contributed to frequent re hospitalization of mental health patients. This study found out that this situation led to early discharge of mental patients before they attained stability. This was influenced by the increased number of mental health patients. In addition, he found out that lack of vital resources in community health institutions contributed to a large turnover in the same. This study ascertained that the quality of the infrastructure that is found in secondary healthcare institutions is far much better than that employed at primary level. It recommended that in order to enhance service delivery, there is need to provide sufficient resources in mental health institutions. The main limitation of this study was that it was conducted in a single state. Nationwide application was therefore undermined in this respect.
Lack of sufficient staff was also identified to be a contributory factor to frequent and rapid readmission. In this regard, Foster (2002) found out that limited hospital staff does not allow that patients to undergo effective treatment. In Particular, he noted that the level of counseling, community support to the families and relatives and quality of psycho education was very low. In this respect, Carmel (2002) indicates that according counseling and psycho education sufficient time was instrumental in avoiding readmissions. In order to counter this situation and provide quality mental services to the population, Foster (2002) suggested that there is need for the government to reconsider distribution of resources and ensure that all mental services are equipped with sufficient resources.
Diathesis-stress Model
This denotes that every individual has a certain level of vulnerability and susceptibility (diathesis) that makes the same liable to developing a mental disorder (Scher, Rick Zindel, 2005). Nevertheless, this model presumes that persons have their own individual points at which they develop the disorder. This is entirely influenced by the interaction between the level of stress being experienced by the individual and the degree of the risk factors.
In their review of related theories, Scott and Anne (1991) cite the model to be instrumental in determining the persons that are likely to develop disorders because it solely addresses the interaction between situational stressors and pre morbid risk factors. The risk factors that have been widely studied entail mental illness or family history of drug use and abuse, personal psychological factors like impulsivity or hostility, environmental characteristics like low socioeconomic status and biological factors. Stress in this regard refers to experiences and events that trigger psychological distress (Scher et al., 2005). It has negative implications on the vital body mechanisms that enhance the cognitive, physical and emotional stability of an individual.
As indicated earlier, this model implies that if a person is highly susceptible, a relatively low degree of stress is required for the person to fall ill and vice versa. It shows that determination of a persons stress and vulnerability is fundamental in ascertaining the probability of the person falling ill or the illness reoccurring. Thus the model is imperative for preventing the occurrence of illness. It is because timely intervention measures that target individuals that have the highest risk of developing negative health implications can be undertaken accordingly. A classic example in this regard would include psychological interventions that are taken to ensure that an individual at risk responds to stressful situations with ease.
The model is perceived important in explaining the occurrences of mental and behavioral disorders. In this respect, Scott and Anne (1991) indicate that previously, it has been employed in underscoring the relationship between environmental and hereditary factors that contribute to mental illnesses such as schizophrenia. Further, it has been beneficial in stimulating relevant research in mental health. In particular, it is indicated that it has enhanced research and treatment of mental disorders. Most importantly, it has been employed in mitigating stress and therefore preventing the pronunciation of diathesis through development of viable protective factors. The most common protective factors that have been put forth by Scott and Anne (1991) include skill building, rigorous psychopharmacology and development of effective support systems for the affected individuals.
The model has also been beneficial to the care takers and families of mental health patients. In this respect, Scott and Anne (1991) indicate that it enables the close associates of these individuals to determine periods when the patients are vulnerable, examine the stressors leading to such experiences and employ protective factors in helping the person cope with the experience effectively. Utilization of this profile has enhanced humane, efficient and effective treatment interventions.
Current Thinking on Modifiable Risk Factors
From the preceding analysis, it is certain that modifiable risk factors inhibit treatment and prevention of mental health illnesses. In deed, the implication of these factors to effective prevention, intervention and treatment of mental illness can not be overlooked. While Carmel (2002) points out that frequent readmission are effective in enhancing the treatment and ultimate recovery of mental heath patients, it is worth acknowledging that modifiable risk factors compromise the overall quality of mental health service.
In their review, Stanley, Kutcher and Magdalena (2005) indicate that not only do these factors undermine recovery, but they also lead to waste of resources that could have otherwise been employed for other purposes. This is even more important at this time when there is increased pressure on the mental health resources. For instance, it can not be disputed that preventing readmission of one patient in this respect would enable new patients to access the same. This according to Stanley et al (2005) is vital in enhancing early interventions and ensuring that appropriate measures are undertaken to prevent severity of the disease.
Further, Delaney and Fogg (2007), cite that addressing modifiable risk factors would be instrumental in reducing the risk of the persons suffering from mental health illness. This presumption is deduced from the Diathesis-stress model conception. Notably, modifiable risk factors are stressors. As such, they increase the vulnerability of persons at risk. Considering that this school of thought believes that biological factors can not be detrimental and are relatively manageable without the stress, it therefore follows that elimination of such stress would reduce the vulnerability of individuals of suffering from mental illness.
Further, Fontanella et al (2009) indicates that modifiable risk factors can not be effectively addressed without the intervention measures from the mental health providers. Generally, mental health practitioners are very resourceful and their knowledge is very instrumental in providing the right direction for the any action. In this regard, Foster (2002) argues that the information provided by these personnel is based upon factual analysis of the mental health status of the patients. As such, he recommends that they should not be eliminated from the cycle at all costs.
At this point in time, it should be acknowledged that the efforts of every stakeholder are imperative in addressing the modifiable risk factors. Major stakeholders in this respect entail the patients, mental health providers and the government (Nelson, Maruish Axler, 2000). Patients are charged with the responsibility of abstaining from activities that are likely to have adverse implications on their health and cooperating with the mental health providers by following medical instructions accordingly.
The mental health providers on the other hand provide technical support to the patients. In particular, they are responsible for providing vital information regarding the management of the disease to the patients. This is achieved through clear instructions and effective counseling. Further, they provide timely preventive and curative interventions to the patients. Of great importance is their role of making follow up to ensure strict adherence to medical instructions by the patients.
Finally, the government and relevant policy makers are expected to avail vital resources to the mental health department. These range from sufficient infrastructure in both primary and secondary mental health institutions to adequate human resource and facilities. In addition, Roy (1996) indicates that there is need to ensure that the mental health facilities are distributed equally across the nation. This would enable all segments of the population to have access to these vital services. Notably, failure of each one of the stakeholders to play his or her role is likely to compromise the quality of services and compromise the effort towards addressing modifiable risk factors.
In his viewpoint, Geller (2000) notes that the scientific effectiveness of the interventions that seek to address the modifiable risk factors is yet to be established. In this respect, he indicates that a great percentage of the research undertaken has been compounded by complexities that are related to the short duration of analysis, non randomization of interventions, use of inadequate sample sizes and employment of surrogate outcome measures. Thus to ascertain the effectiveness of the intervention measures, there is need to undertake consistent and credible research in this regard.
Furthermore, Kastrup (1997) shows that the ineffectiveness of the intervention measures is exemplified through the increase in the mental health patients in the recent past. This trend has continued irrespective of the fact that the intervention measures have been implemented in the past. To counter this, Geller (2000) recommends that prevention strategies need to be delivered based on available evidence of their effectiveness Otherwise, parents, educators, health providers and politicians are likely to continue investing in these programs that are either ineffective or harmful to the general public.
Conclusion
From the review, it is certain that the US mental health department has continuously failed to cater for the emergent needs of the mental health patients. This has been ascertained by the present trends that indicate that the sector is accorded minimal attention. Conventionally, deinstitutionalization was aimed at providing the mental health patients with a viable environment for recovery. Notably, this has not been achieved because of lack of sufficient resources and social stigmatization. Of great reference are the modifiable risk factors that undermine the effectiveness of the entire system.
At this juncture, it is important to acknowledge that modifiable risk factors remain a major setback in enhancing the provision of mental health to the US population. Severity of the illness, a history of hospitalization, substance use and abuse, fragmented pathways and lack of sufficient resources amongst others have been cited to undermine the quality of mental heath services in various ways. This is further compounded by the existence of a fragmented institutional framework and policies that are sectoral in nature. In addition, the complex nature of the mental health system makes it difficult for the minority patients to access quality care. Essentially, modifiable risk factors are a source of stress that increases the vulnerability of the population to mental illness. As such, sustainable measures need to ensure that preventive and effective intervention measures are used to prevent the occurrence of the mental illnesses.
In this regard, consistent, comprehensive and credible research needs to be undertaken. This is because of the fact that previous researches have had numerous inadequacies. This explains why previous intervention measures have been fruitless. Seemingly, the problem is not insurmountable. The challenge to attaining a sustainable solution is in mobilizing and marshalling the necessary will, political or otherwise to address the issues accordingly. As the current thinking about the modifiable risk factors ascertains, this can be achieved through partnerships and relevant collaborations between major stakeholders in the mental health sector. Efforts by individual stakeholders need to complement each other in order to come up with viable and lasting solutions to addressing modifiable risk actors and enhancing the quality of life of mental health patients.
