FACTORS INFLUENCING ADMINISTRATIVE DISPOSITION O F PSYCHIATRIC PATIENTS 59

REFERENCES 1. DAHLSTROM, W. G. and WELSH, G. S. An MMPI Handbook: A Guide to Use in Clinical Practice

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HOSPITALIZATION T I M E AND PSYCHIATRISTS’ PERCEPTIONS OF MENTAL PATIENTS*

IRWIN KOPPEL AND AMERIGO FARINA

University of Connecticut

PROBLEM Individuals described as schizophrenic or psychotic tend to remain hospitalized

for longer periods than other mental 3 , *). Since the more severe forms of mental disturbance imply long-term hospitalization, the informational value of hospital age could aid in, or confirm, certain clinical judgments. While the implicit use of length of hospitalization seems likely, e.g., in providing a “feel of the case”@), there is no strong evidence for a relationship between hospitalization time and psychiatrists’ perceptions of mental disturbance. If such an association does exist, then specific treatment recommendations may also be influenced by hospitalization time. Therefore, length of hospitalization was systematically varied to assess its effects while holding other material constant. Separately, ambiguity of background and mental status information were varied in the expectation that hospital time would be more influential when other diagnostic indicators were obscure.

METHOD Nine case descriptions were constructed from modified state hospital case

histories and published abstracts(5). These were rated by 32 randomly selected Board-certified psychiatrists, who judged three of the nine descriptions to be representative of patients encountered in a state hospital setting. The selected reports met criteria for typicality, amount of information, and clinical value. In addition, the reports varied along the dimension of ambiguity: Case I was described as generally clear, Case I1 as intermediate in ambiguity, and Case I11 as ambiguous.

Each description then was given one of three different hospitalization periods. The times of approximately two weeks, two months, and two years were chosen because they seem to represent significant stages of institutionalization. Two weeks are usually assigned for orientation, about two months is the period usually required for an official diagnosis, and after about two years of hospitalization the patient’s condition is viewed as chronic(2, 3 ) . These hospital ages were given in much the same way as the rest of the data in the case descriptions, but slightly different wording was used in the three cases to conceal the manipulation.

A listing of 440 psychiatrists was randomly selected from state hospital staff members in the American Psychiatric Association’s ( l ) 1965 membership directory. Each judge received a copy of the standard APA nomenclature, and the three case

*Based on part of a dissertation by the first author submitted to the De artment of Psychology, University of Connecticut, Storrs, Connecticut, in partial fulfillment of t i e requirements for the degree of Master of Arts.

This study was supported by research grants from the National Institute of Mental Health, United States Public Health Service (M-6167) and from the National Science Foundation (GS-2646).

60 IRWIN KOPPEL AND AMERIGO FARINA

descriptions with attached questionaires. Hospitalization time was systematically varied in such a way that each time period appeared equally as often as every other time period. The questionnaire required a diagnosis and asked the psychiatrist to specify three factors that influenced his decision. The judges were also requested to indicate the patients’ severity of disturbance and their own diagnostic confi- dence along nine-point rating scales, and they were asked to suggest recommen- dations for treatment, discharge or other disposition. Responses were obtained from 91 psychiatrists, but only the first two judgments received for each combi- nation of hospitalization times were retained in acquiring the 54 responses needed for a balanced design. These 54 judgments were made by psychiatrists from 46 cities in 26 states.

RESULTS AND DISCUSSION Psychiatric Diagnosis. As expected, the different cases were assigned different

diagnostic categories, and the more ambiguous cases received a greater diversity of diagnoses. However, chi-square analyses provided no evidence of significant diagnostic differences attributable to length of hospitalization. Of the 54 partici- pating psychiatrists, four noted hospitalization time as one of the three important factors used in determining the diagnosis.

Severity of Mental Disturbance. The means and standard deviations for severity of disturbance ratings are shown in Table 1. Hospitalization time appears to have a different effect for each of the three cases. The relationship between length of hospitalization and severity of disturbance was examined by an analysis of variance. The specific influence of hospitalization time failed to reach a statistically significant level, but the interaction of this variable with the specific case was highly significant (F = 5.26, df = 4,72, p < .01). It was also found that the three cases were de- scribed as differing in severity of disturbance irrespective of length of hospitaliza- tion (F = 52.15, df = 2,72, p < .01). These judgments are consistent with the range and types of diagnoses that psychiatrists ascribed to the cases.

TABLE 1. SEVERITY OF I)ISTUHBANCE RATINGS, NUMBER OF MEDIC.4TIONS AND COMBINED PSYCHIATRIC TREATMENT RECOMMENDATIONS FOR THE THREE CASES (N 5 18 FOR ALL CELLS)

Designated Mean Severity Combined Psychi-

Time Rating* ltecommendatioils Recommendations Hospitalization of Disturbance Medication atric Treatment

Case I 2 weeks 6.64 16 40 2 Months 2 Years

7.94 6.94

13 8

37 -

31 21

92 -

Case I1 2 Weeks 3.75 2 18 2 Months 2 Years

Case I11

3.67 5.33

3 8 -

16 24 -

13 .58

2 weeks 5.92 > 11 2 Months 5.83 8 14 2 Years 5.31 3 17

18 42 - -

*Higher ratings indicate greater severity of disturbance.

HOSPITALIZATION TIME AND PSYCHIATRISTS’ PERCEPTIONS OF MENTAL PATIENTS 61

Diagnostic Confidence. An analysis of variance showed that only the case descriptions were significantly different with respect to confidence ratings ( F = 80.06, df = 2,72, p < .01). There was no evidence that length of hospitalization influences diagnostic confidence either directly or by interaction. Since less confi- dence was expressed as the level of ambiguity increased, the significant F for con- fidence ratings may be regarded as an indication that ambiguity was successfully varied as desired.

Psychiatric Treatment and Discharge. Chi-square tests were performed on each case to determine whether psychiatric treatment plans were influenced by the patient’s hospital age. These recommendations included psychotherapy, electro- shock therapy, medication, outpatient care and discharge. Psychotherapy and electroshock therapy recommendations were independent of length of hospitaliza- tion. Table 1 shows the number of psychiatrists who advised medication for each case. Drug recommendations for Case I (most severely disturbed, least ambiguous) decreased as length of hospitalization increased (xz = 8.41, p < .02). I n Case I1 (least severely disturbed, intermediate ambiguity), these recommendations in- creased directly with hospitalization time ( x2 = 6.28, p < .05). Drug recommen- dations for Case I11 (intermediate severity, most ambiguous) were independent of length of hospitalization. Hence, length of hospitalization influenced recom- mendations for drug treatment, but the nature of the influence was a function of the specific case.

Outpatient care and discharge recommendations for Case I (most severely disturbed) and Case I1 (least severely disturbed) differed markedly. Case I re- ceived eight discharge recommendations, compared with 20 for Case I1 and 10 for Case 111. However, a chi-square analysis of these results led to the conclusion that length of hospitalization does not appear to play a significant role in determining outpatient care and discharge recommendations.

The number of recommendations for all psychiatric therapies combined, excluding outpatient care and discharge, is shown in Table 1. The influence of hospitalization time for Case I was highly significant, with treatment recommen- dations decreasing as hospitalization time increased (x2 = 13.71, p < .01). In the remaining cases, the number of total therapies advised was independent of length of hospitalization. Interestingly, the nonsignificant trend of Case I11 is inverse to that seen in Case I. Taken together, the results suggest that length of hospital stay may serve as an implicit cue that can affect psychiatrists’ perceptions of certain mental patients as well as influence treatment decisions.

SUMMARY This study examined the influence of length of hospitalization on perceptions

of mental disturbance and treatment recommendations. Fifty-four psychiatrists rated three typical case descriptions, in which only hospital age was systematically varied. Hospitalization time had a significant effect on how severely disturbed the patient was perceived to be, but the effect varied with the characteristics of the particular case. For some cases, length of hospital stay appeared to influence recommendations for medication and the total number of psychiatric treatments.

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