Mental health services in transition: the United States and the United Kingdom

Hospitalisation and length of hospital stay following first-episode psychosis: systematic review and meta-analysis of longitudinal studies

BACKGROUND

Reducing hospitalisation and length of stay (LOS) in hospital following first episode psychosis (FEP) is important, yet reliable measures of these outcomes and their moderators are lacking. We conducted a systematic review and meta-analysis to investigate the proportion of FEP cases who were hospitalised after their first contact with services and the LOS in a hospital during follow-up.

METHODS

Studies were identified from a systematic search across major electronic databases from inception to October 2017. Random effects meta-analyses and meta-regression analyses were conducted.

RESULTS

81 longitudinal studies encompassing data for 23 280 FEP patients with an average follow-up length of 7 years were included. 55% (95% CI 50.3-60.5%) of FEP cases were hospitalised at least once during follow-up with the pooled average LOS of 116.7 days (95% CI 95.1-138.3). Older age of illness onset and being in a stable relationship were associated with a lower proportion of people who were hospitalised. While the proportion of hospitalised patients has not decreased over time, LOS has, with the sharpest reduction in the latest time period. The proportion of patients hospitalised during follow-up was highest in Australia and New Zealand (78.4%) compared to Europe (58.1%) and North America (48.0%); and lowest in Asia (32.5%). Black ethnicity and longer duration of untreated psychosis were associated with longer LOS; while less severe psychotic symptoms at baseline were associated with shorter LOS.

CONCLUSION

One in two FEP cases required hospitalisation at least once during a 7-year follow-up with an average length of hospitalisation of 4 months during this period. LOS has declined over time, particularly in those countries in which it was previously longest.

Work-Related Activity for People with Long-Term Schizophrenia: A Review of the Literature

The nature of the disability experienced by people with long-term schizophrenia is described and the literature concerning work-related activities for these clients is reviewed. The role and value of work-related activities in their lives is discussed. There is some evidence from the few relevant outcome studies that structured activity programmes with these clients can be beneficial in terms of reducing symptomatology and maintaining community tenure; the importance of optimal levels of stimulation is stressed. Investigations of clients' opinions and preferences lend some support for the provision of structured activity programmes. Suggestions are made for possible further lines of inquiry.

Clients' perceptions of client-nurse relationships in local authority psychiatric services: a qualitative study

The Mental Health Care reform in Sweden aimed, among other things, to improve the possibilities for persons with mental illnesses to experience companionship and participation in society. The aim of the study was to describe how persons suffering from mental illness perceive their relationships with nursing staff in local authority psychiatric services. Data were collected through semi-structured recorded interviews with 17 strategically chosen clients. A qualitative approach inspired by phenomenography was used to analyse the data. The analysis resulted in four main categories and 13 subcategories. The main categories were: security, companionship, confirmation and development.

Psychiatric units in Brazilian general hospitals: a growing philanthropic field

BACKGROUND

Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals.

OBJECTIVE

To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided.

METHOD

A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit.

RESULTS

Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services.

CONCLUSION

The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.

Changing patterns of mental health care in Greece (1984-1996)

Greece joined the European Community in 1981 and, three years later, the Commission of the European Communities provided financial and technical assistance under EEC Regulation 815/84 for the modernisation of the traditional psychiatric care system, with the emphasis on decentralisation of mental health services and the development of community-based services, as well as on deinstutionalization of long-stay patients and improvement of conditions in public mental hospitals. Over the last 11 years, the implementation of the EEC Reg. 815/84 programme contributed to a significant shift towards extramural care and rehabilitation. The role of the large mental hospitals has gradually been diminished and a large number of long-stay patients have been deinstitutionalised. It is commonly accepted that the EEC-funded psychiatric reform programme, despite inadequacies and constraints, had an impact on the changing mental health scene in Greece.

Developing community mental health services for children in South Africa

As a result of South Africa's Apartheid history, mental health care for black people, especially in rural areas, has been grossly inadequate and even non-existent in many areas. Children have been severely neglected in this regard. This paper describes an attempt by clinical psychologists to develop a community intervention programme for children with emotional problems. From their hospital base the authors set out, on a monthly basis, to outlying areas up to 250 km away to (1) train primary care nurses and other personnel in the basic techniques of identifying and dealing with uncomplicated psychological problems of childhood, and (2) render consultations to psychologically disturbed children. The paper argues the need to provide primary care workers with mental health skills and thus integrate childhood mental health care into the primary care structure. Such a move could make mental health care accessible to all inhabitants, thus deviating from the policies of the past.

Challenges, Complexities and Contradictions in Mental Health Services

This Overview article focuses on mental health services and, specifically, looks at some aspects of government policy that remain a challenge for managers and practitioners. In particular, new ways are considered of undertaking the assessment of need and a description is given of one initiative: benchmarking to help practitioners measure performance. Examples of new service models emerging as part of the primary care agenda are also highlighted.

Predictors of clinical and social outcomes after hospitalization in schizophrenia

A prospective cohort study of schizophrenia was carried out in Sao Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level.

Do we still need mental hospitals?

“The debate is over” claimed a heading in a newspaper on the 1991 Amsterdam WHO conference ‘Changing mental health care in the cities of Europe’: “After half a century of debate of the issue of deinstitutionalisation the question is not any more if we should close the large mental hospitals, but what follows the closure and how to develop adequate community mental health care which replaces the functions of the mental hospital” (Gersons & Burns, 1992).

These ‘functions’ have actually secured the long-lasting success of the mental hospital which has been in the past and, to a certain extent, still is in a number of countries, the cornerstone of psychiatric care. It incorporates all the functions of a psychiatric system in a single, usually isolated facility, including crisis intervention, evaluation, treatment, aftercare, long-term custodial care, rehabilitation, etc. In order to phase down the mental hospital these functions have to be supplemented by newly established, discrete services disseminated in the community. The process is clearly a complex one, since it implies a transition from a system of care provided only in mental hospitals under medical direction, to one that is comprehensive in scope, community-orientated, and staffed by multidisciplinary teams.

The public image of the mentally ill and community care

Transferring the care of mentally ill patients to the community is not a new initiative. The first comprehensive Hospital Plan by the Department of Health and Social Security (DHSS, 1962) recognized and recommended that areas of health care which did not need to take place in hospital should be carried out in the community. Some 30 years later, this transition is taking place. This transition has not been a smooth process and in certain cases it has failed. The public image of mental illness has played a significant role in delaying the transfer of care to the community, although this is not the sole hindering factor. Poor liaison between health and social services, closure of hospitals before development of community facilities, inadequate community support and resources, and sensationalized media coverage have all been cited. Community care of mentally ill patients is a reality and it has been demonstrated that it can be well planned and properly funded (Faugier, 1993). Rather than dwelling on the shortcomings surrounding the implementation of community care, the way forward is to learn from mistakes and to identify means of increasing public acceptance of people suffering from mental illness.

Mental health nurses working purposefully with people with serious and enduring mental illness--an international perspective

There has been a world-wide refocus on people with serious and enduring mental health problems. This has provided major challenges for all those involved in mental health care, as the last two decades have produced radical changes in service delivery and a range of new interventions. Mental health nurses are playing a central role as community based clinical case managers and are beginning to use a range of psychosocial interventions. They are also revitalizing skills in the more traditional areas of medication management and residential care. In addition, there are growing problems of substance abuse and violence which needs to be addressed. Mental health nursing is responding in this new era by various training initiatives. However, these programmes need rapid expansion as mental health nurses will continue to play a key role in the services of the future and therefore need these new skills.

A national audit of new long-stay psychiatric patients. II: Impact on services

BACKGROUND

This second report of a national audit of new long-stay (NLS) psychiatric patients describes the services caring for the patients and the reasons why patients were still in hospital.

METHOD

Data analyses addressed the prevalence of NLS patients, the residential resources available to services, the distributions of patients within services, clinicians' views as to the appropriateness of current placement and the reasons for any inappropriate placements.

RESULTS

The average point prevalence was 6.1 per 100,000 population; it was significantly lower in England and Wales (5.6, s.d. = 3.2) than in Scotland and Northern Ireland (10.7, s.d. = 6.4, ANOVA F ratio = 10.9, P < 0.01). The estimated rate of accumulation was 1.3 per 100,000 population per year. Many English services had very few non-acute psychiatric beds and 31% of English NLS patients, despite their protracted lengths of stay, were housed on acute wards. Assessors thought that 61% of patients would be better placed in a non-hospital setting; 47% were thought to require a community-based residential setting, and of these over one-half were still in hospital because no suitable community placement was available.

CONCLUSIONS

Many NLS patients remain in hospital because their residential needs are not met by existing community provision.

Who pays for community care? The same old question

Trends in mental health service funding over the past 40 years show that the programme of hospital closures has not resulted in a significant release of resources to fund community based services. Far from being excessive, the current provision of residential services (both NHS and non-NHS) for mentally ill people is now below levels recommended as sufficient by the government, the Royal College of Psychiatrists, and the National Schizophrenia Fellowship. What clinical research evidence there is suggests that more rather than fewer residential places are required. This situation is likely to be compounded by the recent transfer of responsibility for funding private and voluntary residential care from the Department of Social Security to local authority social services departments.