BRIEF REPORT

Decertification Outcomes for Bipolar Disorder in an InpatientCommunity Mental Health Treatment Center: Impacton Subsequent Service Use Over Two Years

Glen L. Xiong • Ana-Maria Iosiff • Michael Brooks •

Charles L. Scott • Donald M. Hilty

Received: 4 May 2011 / Accepted: 18 January 2012 / Published online: 24 January 2012

� Springer Science+Business Media, LLC 2012

Abstract This study investigated differences in usage of

inpatient and outpatient mental health services over a

2-year period following the index hospitalization between

50 decertified and 48 certified subjects with bipolar manic

or mixed episode from an inpatient mental health treatment

center. The decertified group had higher number of

rehospitalization over the 2-year period compared to cer-

tified group (mean = 2.26, SE = 0.41 vs. mean = 1.19,

SE = 0.24; Wald v2 = 5.50, p = 0.02). Median time to

first rehospitalization was 40 weeks in the certified and

17 weeks in the decertified group, but the difference in

time to rehospitalization failed to achieve statistical sig-

nificance (p = 0.18). History of prior hospitalization was

associated with higher numbers of rehospitalizations and

crisis room visits (both p \ 0.01) and with shorter time

before first rehospitalization (p \ 0.001).

Keywords Bipolar disorder � Involuntary treatment �Decertification � Discharge against medical advice

Introduction

Patients with bipolar disorder often do not recognize the

need for treatment, leading to neurocognitive impairment

and increased hospitalizations (Martinez-Aran et al. 2009;

Scott 2000). In California, after the initial 72-h involuntary

treatment, Section 5250 of the Welfare and Institutions

Code mandates a certification hearing where a patient may

be ‘‘decertified’’ and discharged against medical advice or

‘‘certified’’ for additional involuntary treatment (Quanbeck

et al. 2003). The present report examines differences in

bipolar patients’ utilization of inpatient and emergency

services during the 2 years following their index discharge

between the patients who are decertified (released from

psychiatric inpatient treatment based on a denial of the

involuntary hold application) and those whose involuntary

treatment applications are certified by the hearing officer.

In patients with acute bipolar disorder, the lack of

insight strongly correlates with a need for involuntary

treatment (Husten 1999; Ghaemi et al. 1995). However, no

study has investigated the specific outcomes of the decer-

tification process in patients hospitalized for bipolar mania.

We recently examined the socio-demographic and clinical

variables that predict decertification in civil commitment

hearings for bipolar disorder (Xiong et al. 2010). The

present study examined whether decertification may lead to

a higher inpatient and a lower usage of outpatient mental

health services over a 2-year follow-up period. Specifi-

cally, we hypothesized that patients decertified and who

leave against medical advice, when compared with the

certified ones, will have fewer days before their first

re-hospitalization and greater numbers of re-hospitaliza-

tions and crisis room visits. We also hypothesized that

decertified patients will have lower rates of attendance to

outpatient psychiatric follow-up.

G. L. Xiong (&) � D. M. Hilty

Department of Psychiatry and Behavioral Sciences,

University of California at Davis, Davis, CA, USA

e-mail: glen.xiong@ucdmc.ucdavis.edu

A.-M. Iosiff

Deparment of Public Health Sciences, University of California

at Davis, Davis, CA, USA

M. Brooks

Department of Psychology, Rosalind Franklin University

of Medicine and Science, North Chicagoo, IL, USA

C. L. Scott

Division of Psychiatry and Law, Department of Psychiatry

and Behavioral Sciences, University of California at Davis,

Davis, CA, USA

123

Community Ment Health J (2012) 48:761–764

DOI 10.1007/s10597-012-9481-6

Methods

Data Collection and Study Population

We conducted a retrospective chart review of existing

mental health records at the Sacramento County Mental

Health Treatment Center (SCMHTC) with index hospital-

ization between 1992 and 1997. The SCMHTC is an

inpatient community mental health facility serving Med-

icaid and the uninsured population of Sacramento County

(total population of 1.2 million) in California. Patients were

not contacted or interviewed. Records were selected for

patients age C 18 years, who had primary psychiatric

diagnosis of bipolar I disorder, most recent episode, mania

or mixed. Chart review data were collected and coded

using standardized coding forms by the senior author.

Patient records were selected sequentially until 100

records, with 50 certified and 50 decertified cases were

collected. Two cases were dropped from the certified group

after data collection due to incomplete data giving a final

data set of 50 decertified and 48 certified patients. Details

regarding study methodology and patient characteristics

have been previously published (Xiong et al. 2010).

Baseline and Outcome Variables

Each medical record was reviewed in detail for the baseline

index hospitalization data and outcome variables 2 years

after the index hospitalization. Baseline socio-demographic

data included age, gender, race, insurance status (uninsured

vs. insured), and education level. Baseline clinical data

included number of prior psychiatric hospitalizations

2 years before the index episode, bipolar I disorder subtype

(mania or mixed), presence of psychotic features, comorbid

personality disorder, and comorbid substance use disorder.

The outcomes collected included the number of rehospital-

izations, time to the first rehospitalization (in weeks), the

number of emergency psychiatric visits, and whether the

patient scheduled and attended follow-up outpatient

appointments, within 2 years of the index hospitalization.

The outpatient data was obtained from the county mental

health system’s electronic billing records, which contains

data on county-operated and contracted outpatient commu-

nity mental health clinics. The study protocol was approved

by the Institutional Review Board at University of California

at Davis and Sacramento County Department of Human

Services Research Committee.

Data Analysis

Statistical analyses were conducted using SAS Version 9.2

(SAS Institute, Inc 2008) and included descriptive statistics

for all categorical and continuous variables. Survival

analysis based on the Kaplan–Meier curves and Cox

regression models was used to estimate the pattern of the

time to the first rehospitalization. Patients who were not

rehospitalized during the 2 year follow-up period were

censored and their time to rehospitalization was set to

2 years. Differences in the count outcomes (the number

of rehospitalizations and emergency psychiatric visits)

between the two groups were assessed using negative

binomial regression models for count response data. Sim-

ilar logistic regression models were used to evaluate if the

rates of scheduling and adherence for initial follow-up

appointments differed between the two groups. For all

outcomes we started with univariate models, containing

only the decertification status as a predictor. Further mul-

tivariate models examined the potential effect of the socio-

demographic and clinical variables, by sequentially adding

terms to the univariate model containing decertification

status as a predictor and testing their association with the

outcome of interest. Covariates were retained in the model

only if they had p \ 0.1. The significance of the predictors

in all the Cox, count, and logistic regression models was

tested using Wald v2 statistics. All tests employed were

two-tailed with a = 0.05.

Results

The mean age of the patients was 41 ± 12 years, ranging

from 21 to 69; the average participant completed high

school. Overall, 66 (67%) of the patients were women and

the sample was mostly (73%) white. The two groups did

not differ significantly on baseline socio-demographic

characteristics except that the decertified patients were

more likely to be uninsured than the certified patients (48

vs. 27%, p = 0.04). During the 2-year follow-up, 29 (60%)

of the certified and 36 (72%) of decertified patients were

rehospitalized. The number of rehospitalizations ranged

from 0 to 13 (median = 1) for the decertified patients and

from 0 to 7 (median = 1) for the certified patients. Uni-

variate count regression analyses revealed a significant

difference in the number of inpatient rehospitalizations

between the two groups (Wald v2 = 5.50, p = 0.02), with

an expected log count difference between groups of 0.64

corresponding to approximately one more hospitalization

in the decertified group (mean = 2.26, SE = 0.41) com-

pared to the certified group (mean = 1.19, SE = 0.24).

The final multivariate model contained decertification sta-

tus, prior hospitalizations, and comorbid substance use

disorder. Having comorbid substance use disorder was

marginally associated with an increased numbers of

rehospitalization (p = 0.06), while the number of prior

hospitalizations was the most powerful predictor of the

762 Community Ment Health J (2012) 48:761–764

123

number of rehospitalizations (p \ 0.01). Adjusting for

these demographic and clinical variables only slightly

weakened the association between decertification and the

number of rehospitalizations (estimate = 0.54, SE = 0.25,

p = 0.04).

The median time to the first rehospitalization was

40 weeks in the certified group and 17 weeks in the decer-

tified group, but Cox proportional hazard analyses indicated

that the time to rehospitalization did not differ significantly

between the two groups (hazard ratio (HR) = 1.40, p =

0.18). Further Cox proportional hazard analyses showed that

history of prior hospitalization was again the strongest pre-

dictor: the hazard ratio for rehospitalization increased by

18% for each additional prior rehospitalization (HR = 1.18

95% CI 1.08–1.29; p \ 0.001). We next stratified the de-

certified and certified group according to history of prior

hospitalization. Nearly 80% of patients with prior hospital-

izations and who were decertified were readmitted within

the 2-year follow-up period. On the other hand, nearly half

(48%) of the certified patients without prior hospitalizations

were not rehospitalized over the same period. Wald v2 tests

revealed that decertified patients with prior hospitalizations

had a significantly higher risk of earlier rehospitalization

than certified patients without prior hospitalizations

(HR = 2.21, 95% CI: 1.09–4.8; p = 0.03).

The number of emergency psychiatric visits over the

follow-up period did not differ significantly between the

two groups (range 0–15 in the decertified group and 0–22

in the certified one, with the median number of visits

equal to 2 and 1, respectively). The number of prior

hospitalizations was the only covariate that significantly

predicted the number of emergency psychiatric visits

(p \ 0.01).

As for post-discharge outpatient follow-up, 67% of the

certified patients and 44% of the decertified patients

scheduled initial outpatient appointments. Multivariate

logistic regression analyses showed that after adjusting for

baseline characteristics, the certified group was signifi-

cantly more likely to schedule follow-up appointments than

the decertified group: odds ratio (OR) = 2.64, 95% CI

1.14–6.14, p = 0.02. Interestingly, non-White were more

likely to schedule initial outpatient appointments than

White patients (OR = 3.00, 95% CI 1.09–8.23, p = 0.03).

Overall only 37% of the patients who scheduled an initial

follow-up appointment attended it. Furthermore, among

those who scheduled a follow-up appointment, there was

no difference between the two groups in terms of the

proportion of people who attended the initial outpatient

appointment (8 out of 22 in the decertified group and 12 out

of 32 in the certified group). No other demographic or

clinical characteristic were associated with adherence to

the follow-up appointment.

Discussion

This is the first study we are aware of that specifically

examines inpatient and outpatient follow-up for bipolar

patients who are discharged from involuntary legal holds

via decertification in a community mental health setting.

Despite methodological and temporal differences, our

study contrasts with previous findings that patients who are

discharged against medical advice were rehospitalized

sooner (Haupt and Ehrlich 1980; Chandrasena and Miller

1988; Dixon et al. 1997; McGlashan and Heinssen 1988)

and more frequently (Dalrymple and Fata 1993), and had

higher emergency care utilization and lower outpatient

services use (Chandrasena and Miller 1988). It is important

to note that the present study examines outcomes from

‘‘decertification’’ discharges, which is a specific sub-cate-

gory of discharge again medical advice. Of these studies,

Haupt and colleagues used rehospitalization rates within

6 months as an outcome and found that 17 of 69 (25%)

patients discharged against medical advice returned for

inpatient treatment, compared to 54 of 309 (18%) patients

in the control group (Haupt and Ehrlich 1980). The present

study examines rehospitalization rates over 2 years and

finds that 36 (72%) and 29 (60%) patients were rehospi-

talized in the decertified and certified patients, respectively.

The study findings have several important clinical and

research implications. First, patients with a prior history of

psychiatric hospitalization were rehospitalized much ear-

lier compared to those without prior hospitalization history,

regardless of certification status. Those decertified and with

prior hospitalizations fared the worst. Among those without

prior hospitalization, the survival curves were similar in

pattern for both the decertified and certified groups for

most of the follow-up period. The fact that prior hospital-

ization history is the most powerful predictor of time to

rehospitalization is somewhat unexpected, though this is

consistent with clinical experience. Therefore, both clini-

cians and hearing officials may want to use previous psy-

chiatric hospitalization history as an important fact to help

predict future need for inpatient treatment. Second, while

attendance to post-discharge follow-up appointments was

the same between the two groups, the decertified group

scheduled fewer follow-up appointments. The data high-

lights the problem of bipolar patients not keeping post-

discharge appointments in general. However, among

patients who scheduled a follow-up appointment, their rate

of attendance to appointments is similar between those who

were certified and decertified. Therefore, attempts to make

referrals and schedule appointments prior to discharge for

patients should occur regardless of the outcomes of certi-

fication hearings. Historically, against medical advice

discharges were associated with various outpatient

Community Ment Health J (2012) 48:761–764 763

123

restrictions, including temporary suspension of outpatient

services and no dispensing of medication in some systems

of care (Louks et al. 1989). The current finding supports

continued provision of outpatient services, even if patients

are discharged against medical advice. Interactional com-

ponents between patients and care providers are key fea-

tures in effective outpatient treatments aimed to enhance

treatment adherence in bipolar disorder (Sajatovic et al.

2004).

While this study generated important results on the

impact of decertification on use of psychiatric services,

there are several limitations. We did see a statistically

significant difference in the number of hospitalizations and

the rates of scheduling the initial outpatient appointment,

but the observed differences in time to first rehospitaliza-

tion were not as large as anticipated. The number of par-

ticipants in this study, even if four times our current sample

(and assuming similar censoring patterns), would not have

provided adequate power to detect significant differences

for the observed effect sizes. Our results indicate that the

hazard ratio was 1.40, with a 95% confidence interval of

0.86–2.29. This CI is mostly at the right of 1, so it is more

likely that there is a difference in the risk for rehospitali-

zation between the two groups. Future studies can be

designed based on this data to be able to detect this dif-

ference. In addition, since the study involves an inpatient

mental health facility within a large county mental health

program serving a Medicaid and uninsured population and

in a setting where the involuntary treatment certification

process is highly structured, the results may not be gener-

alizable to non-community mental health settings. Both

post-discharge arrest rates and, functional outcomes (Glick

et al. 1981) such as return to social roles, independent

living, and achieve mental health recovery should also be

measured in future studies.

Acknowledgments The authors thank the Sacramento County

Department of Health Human Services and Sacramento County

Mental Health Treatment Center; the Department of Psychiatry and

Behavioral Sciences, University of California, Davis; and Robert E.

Hales, M.D., Sally Ozonoff, Ph.D., Mark Frye, M.D., and Rona Hu,

M.D.

Conflicts of interest We have no conflicts of interest to report.

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