Psychosomatics 41:114-120, April 2000
© 2000 The Academy of Psychosomatic Medicine
Psychiatric Symptom Severity and Length of Stay on an Intensive Rehabilitation Unit
Igor Galynker, M.D., Ph.D., ,
Lisa Cohen, Ph.D.,
Cory Salvit,
Christian Miner, Ph.D., ,
Edward Phillips, M.D.,
Marius Focseneanu, M.D., , and
Richard Rosenthal, M.D.
Received February 1, 1999; revised August 12, 1999; accepted August 24, 1999. From the Beth Israel Medical Center/Albert Einstein School of Medicine, New York, NY. Address reprint requests to Dr. Galynker, 6 Karpas, Department of Psychiatry, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003.
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ABSTRACT
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The purpose of this study was to evaluate the role of psychiatric symptoms in the medical and surgical rehabilitation of patients on an intensive rehabilitation unit and to examine whether psychiatric symptom severity contributes to length of hospital stay (LOS). Forty-four patients (21 men and 23 women) were assessed at admission and before discharge with the Functional Independence Measure (FIM). Subjects were evaluated with the Mini-Mental State Exam (MMSE), the Hamilton Rating Scale for Depression (Ham-D), Positive and Negative Symptom Scale, (PANSS), and Scale for the Assessment of Negative Symptoms (SANS). Thirty-six percent of subjects were cognitively impaired (MMSE<25), 14% had significant depressive symptoms (Ham-D>12), and 52% had significant negative symptomatology (PANSS-N>15). A regression analysis yielded a model of three predictive factors. Gender, the PANSS General subscale, and the SANS Attention subscale accounted for 42.4% of LOS variance. These results indicate that psychiatric symptoms are common in medical rehabilitation inpatients and, together with demographic factors, are associated with increased LOS.
Key Words: Symptoms/Dimensions • Rehabilitation • Length of Stay
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INTRODUCTION
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The prevalence of psychiatric symptoms in medical and surgical patients undergoing intensive rehabilitation is not known. Given the impact of comorbid psychiatric symptomatology in medical patients on a range of treatment variables, including length of stay (LOS),1,2 such information is of interest. Several studies have been published, however, on a specific subgroup of rehabilitation patients, poststroke patients. Stroke rehabilitation patients have been reported to manifest a variety of psychiatric symptoms, including depression and other mood disorders, dementia, and negative symptoms.3–9 Previous studies in acute stroke patients have demonstrated that both depressive and negative symptoms significantly contribute to LOS,6–8 a parameter that could serve as a measure of patients' recovery. In the United States and Europe, the average LOS for stroke patients admitted to an intensive rehabilitation unit is 33–38 days, incurring high costs in health care and management.10,11 Other factors contributing to LOS in stroke patients include demographic variables (age, sex, gender, and ethnicity),12,13 communication difficulties,14,15 and psychological and cognitive factors.16,17
Although the presence of psychiatric symptoms in stroke patients often hinders treatment goals and impedes patients' progress, appropriate psychiatric treatment is often overlooked on rehabilitation units.17,18 Likewise, the presence of psychiatric symptoms in rehabilitation patients with other medical diagnoses may impede recovery. Identifying psychiatric disabilities in rehabilitation patients and providing appropriate treatment would likely facilitate their recovery and minimize LOS and related hospital expenses.
The purpose of this study was to evaluate the presence and severity of psychiatric symptoms and their impact on LOS in general medical rehabilitation inpatients. Because we were interested in the real-life circumstances of an actual rehabilitation unit, our study focused on the unit and not on specific diagnoses per se. A similar approach has been used in the study of heterogeneous medical/surgical inpatients.1 Following previous research on psychiatric symptomatology and LOS in acute stroke patients,3–9 we assessed depressive symptoms, negative symptoms, cognitive impairment, and general psychiatric distress in a medically heterogeneous sample of rehabilitation patients. We were particularly interested in the role of negative symptoms (e.g., amotivation, anergia, affective flattening), which have been associated with multiple psychiatric diagnoses, such as schizophrenia, depression, and dementia. Negative symptoms (NS) may be particularly relevant to impairment in independent functioning7 (and Galynker et al, unpublished manuscript). We used dimensional measures of psychiatric symptomatology rather than psychodiagnostic tools because, in this nonpsychiatric setting, we assumed subthreshold psychiatric morbidity is likely both more prevalent and less treated than diagnosable psychiatric disorders.
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METHODS
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Subjects
Subjects included 44 inpatients (23 women and 21 men) admitted to the intensive rehabilitation unit at Beth Israel Medical Center from August 1995 to January 1996. Admissions to this unit included patients recovering from common surgical and medical illnesses, such as fractures, tumors, and strokes. A total of 55 patients were approached within 48 hours of their admission, and 44 of them agreed to participate. Recruitment took place over a 6-month period, and recruitment methods were consistent for all prospective study participants. On the basis of their chart review, none of the subjects had been previously diagnosed with a psychiatric disorder. Thirty-three of the subjects were European American, 9 were African American, and 2 were of other ethnicities. Mean age for the sample was 70.72±13.4 years. Two (5%) subjects had not completed high school, 6 (14%) had a high school education, and 36 (82%) had postsecondary education (see Table 1).
Procedure
All subjects signed an informed consent before entering the study. Demographic and clinical data were collected on each patient within 48 hours of admission, and the total LOS was determined after discharge. One assessment [the Functional Independence Measure (FIM)] was repeated before discharge.
Psychiatric Evaluation
A battery of standardized psychometric scales was administered to measure psychiatric symptoms (such as mood, anxiety, and psychotic and negative symptoms), cognitive functioning, and physical impairment. Because we did not expect a high level of threshold psychiatric diagnoses, we used dimensional measures of symptoms in specific domains to maximize sensitivity to subthreshold scores. To give a rough estimate of prevalence, however, we also were interested in the number of patients who exceeded scale cut-off points. Depressive symptoms were measured by the 17-item Hamilton Rating Scale for Depression (Ham-D),19 in which a score higher than 12 indicates mild depression. The Ham-D was chosen over the Geriatric Depression Scale20 because we felt the inclusion of neurovegetative symptoms in the Ham-D might increase sensitivity to common manifestations of depression in elderly patients. Moreover, the Ham-D is more easily compared to other patient populations. The Positive and Negative Symptom Scale (PANSS)21 was used to evaluate general nonpsychotic psychiatric symptoms (PANSS-G), positive psychotic symptoms (PANSS-P), and negative symptoms (PANSS-N). A score higher than 15 on the PANSS-N indicates impairment.22 The Scale for the Assessment of Negative Symptoms (SANS),23 specifically designed to measure negative symptoms, was also used. Although these measures were originally normalized on medically healthy subjects, they were selected for this study for their widespread use as psychiatric measures. Moreover the SANS and PANSS scales have been successfully applied to medically ill subjects.7,24 The Mini-Mental State Exam (MMSE),25 a cognitive measure used to screen for dementia, was also administered. A score lower than 25 indicates significant cognitive impairment. Age normalizing for the MMSE was not used in this study.
Functional Evaluation
The FIM measures the capacity to function independently in the practical tasks of daily living. Functional independence is measured across six domains, self-care, sphincter management, mobility, locomotion, communication, and social cognition. The FIM is rated independently by different disciplines, including physical and occupational therapists, psychologists/neuropsychologists, and nursing staff.26,27 The total score for the FIM is the sum of the separate evaluations. The FIM was administered on admission (FIM-1) and again before discharge (FIM-2). An increase in the total score across time points indicates improvement. Out of the 44 subjects entered into the study, 8 subjects did not receive FIM assessments.
Statistical Analysis
To determine which factors contribute to the total LOS variance, set-wise hierarchical regression analysis was performed on the 36 patients who had received complete assessments. The 8 subjects with missing FIM data did not differ from the other subjects with regard to age, sex, LOS, Ham-D, MMSE, SANS total, or PANSS-P, -N, or -G. The first set entered included demographic variables (age and gender) and FIM at admission. The second set included FIM at discharge. The third set included PANSS-G and Ham-D as general psychiatric measures. The fourth set included SANS and PANSS-P as specific psychiatric measures. Because MMSE and LOS were not correlated, MMSE was not entered into the regression analysis. A later ad hoc analysis included an exploratory regression analysis based on a step-wise removal of variables. Statistical analyses were performed using the SYSTAT 5.2.1 software package.
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RESULTS
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Psychometric Data
The average length of hospital stay on the rehabilitation unit was 22.45±9.2 days. The mean score for the MMSE was 24.8±4.5, with 36% of subjects demonstrating cognitive impairment (MMSE<25). Depression, as measured by the Ham-D, was less common with only 14% rated mildly depressed (Ham-D>12) (mean=11.4±4). The mean score for PANSS-P subscale was 9.8±3.0 (mild), while the mean PANSS-N subscale was 17.5±7.0 (moderate), and for PANSS-G was 25.0±5.3 (mild). Fifty-two percent were found to have significant negative symptomatology for PANSS-N (>15). Scores on the SANS scale averaged 10.3±4.3 (3–20) indicating moderate negative symptom severity, consistent with PANSS-N subscale scores (see Table 1).
Relationship of LOS to Demographic and Psychometric Data
Set-wise hierarchical techniques were used to determine the contributions of demographic factors and psychiatric symptom severity to LOS (see Table 2). LOS regressed on FIM at admission, age, and gender (Set I) and accounted for 29% of the overall LOS variance (2=0.29; F=4.33; df[3,32], P=0.01). By Fisher's protected t test, gender was the only significant individual factor, with females staying 8 days longer than males in this sample (ß=6.25, t=2.16, P<0.05). The addition of FIM at discharge (Set II) to this set of predictors was nonsignificant. When the measures of general symptom severity, Ham-D, and PANSS-G (Set III) were added to the model, total LOS variance accounted for increased to 40.3% (2 =0.403, F=4.05, df[5,32], P<0.01), with these two psychiatric measures contributing a unique (semi-partial) increment =0.110 (F=3.50, df[2,30], P<0.05). Only PANSS-G yielded a significant result by the protected t test (ß=0.68, t=2.02, P<0.05). In the fourth set, more specific measures, SANS and PANSS-P were added. However, together they did not significantly add to the prediction of LOS. Overall, the sets combined yielded an 2=0.41, F=2.73; df[7,28], P<0.05, with only gender and PANSS-G affording significant (P<0.05) contributions to the overall LOS variance outcome. In an exploratory procedure, a regression analysis based on step-wise removal of variables yielded a model consisting of these two predictors (Gender ß= -9.44, SE =2.75, t= -3.43,P=0.002; PANSS-G ß=0.78, SE=0.23, t=3.44, P=0.002) plus the attention subscale in SANS (ß=-2.22, SE=1.18, t= -1.87, P=0.07), contributing 42.4% of the LOS variance (2=0.424, F=0.784, df[3,32], P<0.001) (see Table 3).
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TABLE 2. Effect of functional independence and psychiatric symptom severity on LOS on a medical rehabilitation unit: set-wise hierarchical regression analysis
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DISCUSSION
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The results of this study show that a number of patients undergoing intensive rehabilitation displayed psychiatric symptoms; these symptoms were present in patients who did not have any record of psychiatric disorders before hospitalization for their rehabilitation. Psychiatric symptoms found in this patient sample ranged from cognitive impairment to depression, anxiety, and negative symptoms, the latter being the most prevalent (found in 52% of the patients). Of the demographic and psychometric parameters, gender, PANSS General subscale, and SANS Attention subscale (but not depressive symptoms), significantly contributed to LOS, accounting for 42.4% (P<0.05) of LOS variance. This is in contrast to the measure of the patient's functional impairment (FIM), which was not significantly related to LOS. Although there exists a voluminous literature addressing the relationship between psychiatric symptoms (specifically depression) and functional impairment, most of the literature addresses either stable family practice outpatients28,29 or medically ill inpatients.30–32 There has only been a handful of studies addressing psychiatric symptoms in rehabilitation inpatients.6,33
The results of our study show that although none of the subjects carried a diagnosis of major depressive disorder, 14% of the rehabilitation patients had at least mild depression (Ham-D>12). There are a number of reports on the prevalence of depressive symptoms in stroke patients in acute care or rehabilitation facilities,3–5,34 all of which report higher rates of depression than found in our study. In previous reports, prevalence rates of depression range from 20% to 63%, and in some cases, depression was shown to affect rehabilitation recovery.17,18 A number of studies also show that depression increases LOS.1,2 One possible explanation for higher prevalence of depressive symptoms reported in the literature is that in this study, there were fewer stroke patients (5/44), who are prone to poststroke depression. Nonetheless, our results are also lower than the 39.3% rate reported by Shubert et al.6 for his sample of 17 amputee and 14 stroke patients undergoing rehabilitation; the rate being similar for both diagnoses. To our knowledge, the study by Shubert et al.6 was the only report in the literature on patients with heterogeneous diagnoses commonly seen on intensive rehabilitation units. However, the authors of that study used the Geriatric Depression Scale (GDS), which might account for the difference in the frequency of depression between that study and the present one. Moreover, in contrast to previous reports in which this distinction was not made, we also separately evaluated negative and depressive symptoms. Interpretation of negative symptoms as depression might have led to overestimation of depressive symptomatology in stroke patients.7
This is the first study to evaluate negative symptoms in a general patient group undergoing rehabilitation. Fifty-two percent of the patients had significant negative symptoms (PANSS-N>15). The mean negative symptoms scores in this group (PANSS-N: 17.5±7.0 and SANS-N: 10.3±4.3) are similar to those reported in Alzheimer's patients (PANSS-N: 16.3±8.11).22 The mean SANS scores are significantly higher than those reported by Meeks et al.35 for nursing home residents (SANS=3.96±5.93). Of note, dementia was used as an exclusion criteria in the latter study. Because Galynker et al.22 and Reichman36 demonstrated a significant correlation between dementia and negative symptom severity, the presence of cognitive impairment in a significant number of our subjects may have contributed to the high negative symptom scores. The inclusion of several stroke patients in our patient group may have further elevated negative symptom scores. Patients with cerebral vascular lesions with or without vascular dementia have been reported to have significant negative symptomatology.7,37
The results of our study show that a considerable percentage (36.3%) of the rehabilitation patients were cognitively impaired (MMSE<25). Although our sample included patients with several diagnoses, unexpectedly, not only stroke patients but also cardiac and orthopedic patients exhibited cognitive impairment. These results are consistent with the findings of Galski et al.33 who reported cognitive impairment in both orthopedic and stroke patients undergoing rehabilitation. A disproportionate number of elderly patients on inpatient psychiatric units who fall and suffer limb fractures may carry diagnoses of dementia of Alzheimer's type and vascular dementia (Truscelli, Somerville, Teusinck, 1998, unpublished observations). Therefore, it appears that cognitive impairment in rehabilitation patients is not limited to those with structural lesions.
The most surprising result is that neither the patients' overall physical impairment on admission or discharge (FIM scores) nor the functional improvement, as measured by the increase in FIM score from admission to discharge, contributed to the total LOS variance outcome in a regression analysis. This is in contrast to a previous study,33 in which FIM predicted LOS in stroke patients. One factor that may explain this result is that in contrast to the latter study, the diagnoses of the patients in our sample were heterogeneous. Another possible reason for this discrepancy between the two reports could lie in the different methodology used to compile the FIM scores; in the present report the total FIM score was compiled from individual evaluations of several treating specialists, which did not allow for a subscale analysis. In contrast, Galski et al.33 analyzed only subscale OT, PT, and psychology subscale FIM scores.
In agreement with the literature, increased general psychiatric symptoms, as measured by PANSS-G, were predictive of LOS. PANSS-G measures anxiety, somatic concern, guilt, and other parameters that reflect nonpsychotic symptoms. In agreement with our findings, Galski et al.33 showed that admission FIM psychology score (global measure of psychopathology) was a significant LOS predictor. Shubert et al.6 also reported that psychiatric symptoms in stroke and amputee patients correlated with an increase in LOS on a rehabilitation unit. It seems likely that, especially in small heterogeneous samples, where psychiatric symptoms are likely to be heterogeneous and nonspecific, a general measure of psychopathology will be more sensitive than a measure of specific symptoms. Although, given that depressive symptoms, as measured by Ham-D, did not predict LOS, the items measuring anxiety-related symptoms in the PANSS-G may have accounted for the findings. Further research is needed to establish if anxiety alone contributes significantly to functional impairment of rehabilitation patients.
The results of our study show that gender was a significant predictor of LOS, based on a regression analysis in which women were reported to stay 8 days longer than men. Post hoc analyses revealed no significant gender differences in the other clinical or demographic variables. There is a large body of literature within the mental health field documenting different help-seeking patterns in women and men. Women are more likely to acknowledge pain and difficulty and to ask for help. Men, in contrast, tend to minimize impairment in their independent functioning.37 It is possible these gender differences extend to help-seeking behavior for medical conditions.
The results of this study should be considered preliminary in view of its limitations. The subject group was fairly small, and therefore statistical power is modest. Also, subjects were limited to patients on a single intensive rehabilitation unit. All ratings were done by a single rater, precluding calculations of interrater reliability. Subjects were not assessed for medical diagnoses, and thus findings were not compared across medical diagnoses. Therefore, one must use caution in generalizing these findings to other hospital settings.
Further research on larger test groups in diverse hospital settings may clarify to what extent, if at all, psychiatric symptoms in rehabilitation patients are related to the nature of the medical illness, contributed to LOS, and whether these results can be generalized to other hospital settings. Within its limitations, however, this study calls attention to the prevalence of psychiatric symptoms in rehabilitation patients and the role of psychiatric symptoms in patients' length of stay.
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ACKNOWLEDGMENTS
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This study was supported in part by Singer Grant 1–480–400 to Dr. Galynker.
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REFERENCES
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D. R. Hopko, D. Lachar, S. E. Bailley, and R. V. Varner
Assessing Predictive Factors for Extended Hospitalization at Acute Psychiatric Admission
Psychiatr Serv,
October 1, 2001;
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1367 - 1373.
[Abstract]
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ABSTRACT
INTRODUCTION
