Mental Health Counselors' Decision-Making Priorities Related to Inpatient Admissions for Anxiety Disordered Clients: A Pilot Study
Schwartz, Robert C., Zarski, John J., Hilscher, Randall L., Journal of Mental Health Counseling
Factors related to making decisions about whether or not a client should be admitted as an inpatient are poorly understood. Research focused on mental health counselors' decision-making priorities related to admission decisions for anxiety disordered clients is scant. This pilot study assessed which clinical factors most led mental health counselors to recommend an immediate inpatient admission among anxiety disordered clients presenting at a community mental health center. Results revealed that suicidality and inability to care for oneself strongly predicted the recommendations for an inpatient admission. Clinical and research implications are discussed.
Anxiety disorders is one of 16 major diagnostic classes used by the American Psychiatric Association (APA, 2000) to classify mental disorders. The prevalence of specific anxiety disorders varies: The APA has reported lifetime prevalence rates in adult American samples of 1% to 2% for panic disorder, 7.2% to 11.3% for phobias, 2.5% for obsessive-compulsive disorder, 8% for posttraumatic stress disorder, and 5% for generalized anxiety disorder. According to the National Institutes of Mental Health (NIMH, 2001), 19 million Americans are affected by anxiety disorders annually. Moreover, NIMH has stated that anxiety disorders cost the United States nearly $46.6 billion a year in direct and indirect costs, equaling nearly one third of all American mental health expenditures.
A variety of treatment options exist, including psychiatric hospitalization in severe cases. Mental health counselors (MHCs) must choose among available treatment options on the basis of the nature and severity of presenting symptoms and related risk factors. The decision about whether hospitalization is required is difficult to make and has significant consequences for the client. As Way and Banks (2001) noted, inappropriate decisions either to admit or release clients can have profound negative impacts, including (a) an increased risk of self-harm or violence to others if a client needing inpatient treatment is misdirected and (b) stigmatization or loss of important social resources (e.g., housing, employment, child custody, finances) if an inappropriate admission occurs.
In the literature on inpatient hospitalizations, most studies focus on physician decisions for patients presenting at psychiatric clinics or hospitals. Only one study found to date (Hendryx & Rohland, 1997) addressed factors influencing the hospitalization decisions of MHCs. These researchers report only modest reliability in staff agreement regarding a need for hospitalization. Because the decision to recommend hospitalization "is complicated and often difficult ... and involves the integration of factors that are both objective and subjective" (p. 72), Hendryx and Rohland concluded that further research is called for in this area.
Among the research in this area not specifically focused on American MHCs, Gutterman, Markowitz, Loconte, and Beier (1993) analyzed records of all children and adolescents screened at a mental health center during a 6-month period. Four factors predicted psychiatric hospitalizations: (a) the presence of both assaultive and suicidal behavior, (b) a substance use problem, (c) a parental or family member's substance use problem, and (d) a first/initial screening. Sederer and Summergrad (1993) reported that dangerousness, symptom severity, and inadequate client support systems predict the need for admissions. Hooten, Lyketsos, and Mollenhauer (1998) proposed a cutoff score of 39 on the Brief Psychiatric Rating Scale (Overall & Gorham, 1962) as an appropriate predictor for non-suicidal patients presenting at a psychiatric emergency department. Perhaps routine evaluations of clients' global functioning, coupled with a determination of how specific psychiatric symptoms have recently become more severe, can help MHCs predict the need for hospitalization admissions (Somoza & Somoza, 1993). …