The measurement of improvement during hospitalisation for acute psychiatric illness

Effect of coercive measures on treatment outcome in involuntarily admitted patients in Amsterdam

Objective

The prevalence of involuntary admissions rose the last forty years in European countries, including the Netherlands. Involuntary admissions result in seclusion, physical restraint and forced medication in approximately 40% of patients. We looked at whether treatment outcomes differ in patients with and without coercive measures.

Methods

Using The Health of the Nation Outcome Scales (HoNOS) to measure treatment outcomes, we studied the files of 786 patients admitted involuntarily to an Amsterdam clinic. We applied Generalised Linear Models to determine whether the use, or not, of coercive measures during treatment was associated with a difference in outcomes.

Results

19% of the cohort were secluded in a High Security Room (HSR); 24% were secluded in their own room and/or received forced medication. After adjustment for the influence of diagnosis, disorder severity (initial HoNOS score) and treatment duration, the HSR group had, on average, a HoNOS difference score that was 2.4 points lower than patients without coercive measures (CI -4.0 to -0.8.; p 0.003). In the seclusion in own room group, this score was 2.6 points lower (CI -4.0 to -1.1; p 0.001), corresponding to an effect size of 0.35 and 0.40, respectively.

Conclusion

Seclusion, whether or not in combination with forced medication, was applied to two-fifths of patients. The HoNOS scores of the group without coercion improved by nearly two and a half points more on average than those of the two groups with coercion. A causal relationship between coercion and treatment outcome could neither be confirmed nor excluded on the basis of our results.

Do patients improve after short psychiatric admission?: a cohort study in Italy

BACKGROUND

Information on outcomes of acute inpatient care in routine psychiatric practice is scant. In particular, it is uncertain to what extent short hospitalization can produce clinically meaningful changes.

AIM

Our aim was to estimate the symptomatic outcome in a representative sample of patients admitted for short treatment to general hospital psychiatric units in Italy.

METHODS

Patients were assessed at admission and discharge using 24-item Brief Psychiatric Rating Scale (BPRS). Reliable change index was calculated to estimate the proportion of change attributable to measurement error and a cut-off score of 38 was adopted to identify the patients who showed clinically significant change.

RESULTS

Average length of stay was 5.7 days. Mean BPRS score dropped from 53.2 on admission to 41.5 at discharge, showing statistically significant improvement with an effect size of 0.80. However, reliable change was achieved by 24.7% of patients and clinically meaningful change by 13.6%.

CONCLUSIONS

Reliance on statistical significance and effect size overestimates treatment effects, whereas reliable and clinically significant change index provides a conservative way to assess outcome. Few patients showed relevant improvement after a brief admission.

Outcome measurement in chronic mental illness

This review begins with an outline of outcome measurement in the country where it has been most thoroughly implemented, namely Australia. There follows a consideration of what constitutes an outcome in mental illness generally, and chronic mental illness in particular. Some instruments, such as the Health of the Nation Outcome Scales (HoNOS), focus primarily on illness severity, and examples of their use in the area of chronic mental illness are presented. Other instruments, such as the Life Skills Profile (LSP), assess personal functioning or disability, and that literature is reviewed. One major area of attention in the chronically mentally ill is quality of life. Another fruitful approach to assessing outcome is to look at needs, especially unmet needs, for which the leading instrument is the Camberwell Assessment of Need; relevant findings are reviewed. The most recent area of interest is recovery. While several scales have been developed, there are as yet relatively few reports of their application with patients with chronic mental illness. The concluding section considers the benefits and weaknesses of using the same standard instruments with all consumers within a service, and shows the utility of outcome results in groups and individuals with generally small overall changes.

Patterns of care in patients discharged from acute psychiatric inpatient facilities: a national survey in Italy

OBJECTIVE

To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care.

METHODS

Socio-demographic and clinical characteristics, and patterns of care of 1,330 patients discharged from public and private inpatient facilities in Italy were assessed with a standardized methodology during an index period in the year 2004.

RESULTS

About one half of the sample had schizophrenia or bipolar disorder. However, the case-mix differed between public and private facilities, where in-patients had more frequently mood and anxiety disorders. The use of two or more drugs was very common, involving more than 90% of patients and including typically benzodiazepines and antipsychotics. Structured psychosocial treatments were rarely initiated during the hospital stay. Increasing age, male gender, long stay in the facility (>60 days), personality disorder and type of facility were associated with a higher likelihood of being discharged to a community residential facility. Predictors of discharge to another psychiatric facility were increasing age, being single, schizophrenia, personality disorder and organic mental disorder. Families were not involved in decisions about patients' discharge in a significant proportion of cases. University psychiatric clinics and private facilities were less coordinated with the community system of care than General Hospital Psychiatric Units. Referral of patients with substance use disorder to drug addiction services occurred in just 30% of subjects.

CONCLUSIONS

This study provides information on the characteristics and the pattern of care of patients discharged from inpatient facilities in a country that has closed down all its mental hospitals. This information may be relevant for those countries that are affording now the downsizing of MHs, and the expansion of community-based models of care.

Outcome measurement in rural mental health care: a field trial of rooming-in models

The main objectives of this project, in rural Western Australia, were to collect information, compare and evaluate the functioning of novel types of psychiatric services, including rooming-in facilities, using outcome measurement tools, and to assess the attitude of mental health professionals towards routine outcome measurement. For the first time in rural health services, two outcome measurement tools were used for this purpose: the Health of the Nation Outcome Scales and the World Health Organization Short Disability Assessment Schedule. While staff at 11 rural sites were trained in the use of outcome measurements, only staff from three sites were able to participate in the data collection that spanned for a year and shed information on 39 patients. Two of these sites were rooming-in facilities with different models of care and patient characteristics. Shortage of staff, lack of adequate local information technology support on sites and technical difficulties limited participation. The assessment of staff attitudes towards routine outcome measurement revealed a need to provide staff with reasons and incentives for incorporating outcome measurement into routine practice, in addition to provision of a thorough and on-going training and support in time and resources from management.

Comparative efficiency ratings between public and private acute inpatient facilities

OBJECTIVES

The aims of this study are to compare clinical outcomes and efficiency ratings in an acute psychiatric inpatient facility with findings from other studies, and to examine relationships between symptom severity, admission medico-legal status and length of stay.

METHOD

The Health of the Nation Outcome Scales was administered at admission and discharge and analysed against admission medico-legal status and length of stay. Efficiency ratings were calculated and compared with those from other acute psychiatric inpatient settings.

RESULTS

Clinical outcomes and efficiency ratings were similar to those from other public acute inpatient facilities, with greater admission severities and higher efficiency ratings than those found in private facilities. Involuntary hospitalisation was found to be associated with higher admission severities and longer lengths of stay.

CONCLUSIONS

Outcome or effect size is enhanced by higher admission severities, however, mean outcome per 10 days of stay is decreased by involuntary admission legal status. Factors unrelated to admission legal status effect differences in efficiency ratings found between public and private acute psychiatric inpatient facilities.