Charles Broderick, Allen Azizian, and Katherine Warburton
State psychiatric hospitals face increasing referrals for the evaluation and restoration of individuals whose mental health symptoms render them incompetent to stand trial (IST).1 As referrals can overwhelm capacity for admission, state hospitals at times are unable to admit IST patients in a timely fashion. The resulting use of “waitlists” has the undesirable consequence of forcing symptomatic individuals to endure long waits (while jailed) for admission to a psychiatric hospital. These long wait times have been determined to be unconstitutional, resulting in litigation against the responsible state mental health authorities.2 Unfortunately, available options to expedite hospital admission of these IST patients can have significant clinical and economic consequences. Simply admitting patients without sufficient treatment resources risks overcrowding, while building increased hospital capacity is time-consuming, costly, and contrary to the drive for community treatment for mental illness.
Another solution is to examine patient factors leading to a longer length of stay, with the goal to increase treatment efficiency. This in turn would reduce length of stay and increase overall availability of state hospital beds without the need to build additional capacity. Our study examined patient variables impacting length of stay, with the goals of identifying factors related to patient length of stay as well as identifying targets of treatment that could result in more efficient treatment delivery for IST patients.
The topic of competency restoration has a large literature base, but few studies have directly focused on the specific topic of hospital length of stay for IST patients. Previous research into the topic of pre-trial competency has generally studied three broad areas: (i) factors regarding which arrestees are found incompetent,3 (ii) factors to identify who can and cannot be restored to competency,4–6 and (iii) length of hospitalization, or time to restoration after being found incompetent.7–13 However, most studies purporting to have investigated length of stay instead actually examined percentage of patients remaining hospitalized at predetermined time intervals (e.g. patients restored to competency within six months, those restored within one year, etc.) or differences in time hospitalized between those found restorable compared to those found not restorable7,8,12 rather than actual hospital length of stay.9–11,13
Research on the topic of length of stay has been marked by a lack of utilization of clinical variables. The studies mentioned above that investigated length of stay typically examined demographic variables (e.g. age, sex, ethnicity, marital status) and perhaps a single clinical variable, such as diagnosis. Clinical factors that could describe hospital course and response to treatment have not been investigated as thoroughly. Our study sought to extend current research by investigating additional clinical variables likely to impact length of stay in IST patients. Specifically, we were interested in what the variable “number of violent acts while hospitalized” could reveal about hospital length of stay in IST patients, as our hospital’s annual reports on patient violence have informally documented a relationship between violence and increased length of stay.14 We were also interested in how such a clinical variable compared (in terms of relative importance) to the other variables typically studied (such as the demographic variables) in a model used to describe length of stay in these patients. Our hypothesis was that individual patient clinical factors would be more important than demographic factors in a statistical model of patient length of stay.