Crisis Visits and Psychiatric Hospitalizations Among Patients Attending a Community Clinic in Rural Southern California

To our knowledge, this is the first study examining psychosocial stressors and factors that are associated with psychiatric hospitalization in an underserved and predominantly Hispanic rural community in southern California. Our data showed two main cultural issues that have an impact on psychiatric hospitalizations.

First, being African American, having a psychotic diagnosis and being gravely disabled are significantly associated with increased hospitalization in a predominant Hispanic county; which supports previous studies where African-Americans tend to have a higher rate of psychiatric emergency visits and a higher odds of being hospitalized compared to other ethnic groups (Snowden et al. 2008, 2009). Ethnic tensions and mutual perceptions of dangerousness exist between African Americans and Hispanics in predominantly low SES neighborhoods (Kyriacou et al. 1999). According to a public health study done in Chicago, the odds of violent behavior was 85% higher for African Americans compared with Whites, whereas Latino-perpetrated violence was 10% lower compared to these ethnic groups; the gaps were explained primarily by protective factors such as the marital status of parents, immigrant generation, and dimensions of neighborhood social context (Sampson et al. 2005). These socio-cultural factors need to be further operationalized to determine if there is a need to increase community cohesiveness towards African Americans, especially in border rural counties to reduce contextual stresses that may impact hospitalizations.

These findings may also support a potential for clinician bias in diagnostic assessments and treatment recommendations for hospitalization (Sohler et al. 2004). It has been reported that African Americans may express psychotic behavior in a manner that could be seen as increased hostility towards others and be misinterpreted as a deficit in their ability to function, hence increasing the clinician’s inclination for hospitalization (Compton et al. 2008). With our results, this model needs to be further explored in our Hispanic rural community to evaluate if there are any perceived differences in hospitalization practice among clinicians based on the patient’s presenting psychiatric symptomatology and ethnic background. To further support this theory, a recent report showed that African Americans tend to receive less psychosocial interventions after being discharged from the hospital after a psychotic episode (Goulding et al. 2010). Without appropriate culturally sensitive services for African Americans, this could perpetuate the ongoing observed cycle of increased grave disability, psychosis and repetitive hospitalizations (Way and Banks 2001). Future interventions need to explore other factors that may be associated with ethnicity and decompensation of psychiatric symptoms in rural border communities. Once these factors are identified, culturally sensitive preventive measures could be instituted to prevent recurrent hospitalizations. Assessment of primary support groups for future disposition from our crisis unit will also help determine culturally sensitive interventions that may differ among different ethnic groups. The disposition and prevention of future hospitalization might vary in this area, where Hispanics are the ethnic majority. Future program evaluations should look at the need to implement different psychosocial interventions among the remaining ethnic groups in this rural area, such as African Americans and Caucasians.

The second important finding of our study is the inverse association between psychiatric hospitalization and partner/family conflict in our predominantly Hispanic sample residing in Imperial County. Our preliminary data are consistent with a previous study from San Diego County in which Spanish-speaking Latinos were less likely to access care through emergency services compared to Caucasians (Folsom et al. 2007). These data may underscore the potential protective effects of interpersonal relationships (i.e., familism/family support), even when there is conflict, to avoid psychiatric hospitalizations. These preliminary findings lend support to efforts to elaborate prevention/intervention models that enhance the empowerment of families to reduce psychiatric hospitalizations.

An important cultural factor that needs further study is the degree of acculturation among Hispanics attending our crisis unit. It would be interesting to evaluate the association between psychosocial stressors, psychiatric diagnosis and need for immigration-related assistance in this community. The literature has reported that less acculturated individuals respond better to basic case management interventions that target their basic needs such as food, clothing and shelter which could potentially reduce costly psychiatric hospitalizations (Telles et al. 1995). Acculturation factors need to be further evaluated in our community since this could have an influence on the moderating influence of family support on psychiatric hospitalizations.

To our knowledge, few studies have looked at psychosocial stressors associated with psychiatric hospitalization in border and/or rural regions where Hispanics are often the predominant population. Since this community has been described as one of the poorest regions in California (California Food Policy Advocates 2002), the influence of socioeconomic status should be considered. Gallo and colleagues have described how the Reserve Capacity Model (Gallo et al. 2005, 2009) is an important theoretical framework for understanding how low SES can contribute to health outcomes. Our cross-sectional data shows an inverse association between family stressors and psychiatric hospitalization, which could be supported by the theory of enhanced resilience (e.g., social resources, familism, religiousness) in the face of adverse circumstances, such as increased psychosocial stressors resulting in emergency psychiatric visits (Gallo et al. 2009). Research around this theory is needed to measure short term and long term outcomes (i.e., exacerbation of psychiatric symptoms after the crisis visit, suicidal behavior, and increased stressors) in those patients who were not hospitalized and were released back home to their families. Zayas and Pilat (2008) have shown that suicidal behavior in young Hispanic women has been associated with poor family bonding. In our sample, we need to further measure and validate the influence of family support as a sustainable protective factor against hospitalizations, since we do not have information about every day family dynamics and bonding among residents in rural areas such as Imperial County. In order to further corroborate our hypothesis, future studies should look at the long term effectiveness of social programs such as case management with family oriented in-home supportive services geared towards reduction of crisis visits and hospitalizations.

As a pilot study, there are some limitations. First, this study is a retrospective review of crisis visits with a relatively small sample that was collected during a 1-year period. Secondly, patients were not evaluated with a research diagnostic tool like the SCID or MINI; although the diagnoses were based on DSM-IV multiaxial approach by trained Master’s level clinicians and psychiatrists with extensive experience in rural mental health. Third, we did not included a formal measurement of psychosocial stressors. Fourth, given the small sample size and the absence of randomization, these findings may not be generalizable to other rural and/or border communities.