Acute mental health admissions in inner London: changes in patient characteristics and clinical admission thresholds between 1988 and 1998

Are long-term psychiatric patients causing more crisis consultations outside office hours in mental health care?

BACKGROUND

As well as an improvement in community services, the de-institutionalization of patients receiving long-term psychiatric care can lead to marginally staffed mental health services, more homelessness, rising admission rates and more people in prison cells. It is assumed that an imbalance between community and hospital care for chronic patients puts pressure on crisis services.

AIMS

In this study, the central question is whether patients receiving long-term psychiatric care in Amsterdam do indeed put pressure on the city's emergency mental health services. We compare the pressure exerted by this group with the pressure resulting from the use of these services by all registered patients.

METHODS

Data were taken from the client registration systems of three mental health organizations in Amsterdam in the period from 2000 to 2004. Inclusion criteria for long-term psychiatric patients were age above 19 years and uninterrupted receipt of mental health care for a minimum of two successive years.

RESULTS

Annually, 6%-8% of all non-long-term patients experienced a crisis outside office hours in the period under investigation; this was 4%-6% for long-term patients. The non-long-term patients accounted for 83% of crisis contacts outside office hours over the entire study period, with long-term patients accounting for 17%.

CONCLUSIONS

The assumption that crises are more prevalent in long-term patients in the community seems to be an example of stigmatization rather than an observation based on fact.

Acute inpatient psychiatry in England: an old problem and a new priority

With the development of community care, the number of National Health Service psychiatric beds in England has been reduced to between one-fifth and one-quarter of those provided in the mid-1950s. Psychiatric bed numbers are close to the irreducible minimum if they have not already reached it. The problems facing today's acute psychiatric admission wards include: poor design, maintenance and ambience; a lack of therapeutic and leisure activities for patients leading to inactivity and boredom; frequent incidents of aggression and low-level violence and problems with staffing. It is suggested that there are a number of underlying causes: First, there has been failure to plan inpatient services, or to define their role, as attention has focused on new developments in community care. Second, the reduction in bed numbers has led to a change in the casemix of inpatients with a concentration on admission wards of a more challenging group of patients. Third, admission ward environments are permeable to the adverse effects of local street life, including drug taking. After years of neglect, acute inpatient psychiatric services in England are now high on the UK Government agenda. The paper lists a number of national initiatives designed to improve their quality and safety. A recent review of qualitative research suggests that acute psychiatric wards in other countries face similar problems to those reported in England. It is suggested that there might be a need for joint action which might take the form either of international research about acute inpatient care or the development of international standards and a common quality improvement system.

Effects of legal and illegal use of benzodiazepines at acute admission to a psychiatric acute department

BACKGROUND

In the psychiatric acute and emergency services patients present in severe crisis often complicated by behavioral problems, substance use, and multiple axis 1 diagnoses. In these clinical settings both legal and illegal use of benzodiazepines are difficult to evaluate since benzodiazepines could in some patients be regarded as first line treatment and in other patients as the cause of the acute psychiatric condition. The aims of this study were to evaluate the frequency and clinical effects of both legal and illegal use of benzodiazepines at admittance to a psychiatric acute department.

METHODS

All patients acutely admitted to a Norwegian acute psychiatric university department serving a catchment area were asked about use of benzodiazepines, other medications and substances before admission. Patients were asked to give urine samples for analyses of benzodiazepines and substances.

RESULTS

In 227 consecutive admissions there was legal use of benzodiazepines before admission in 39%, illegal use in 13% and no use in 48%. Patients with legal use of benzodiazepines were older, used more often antidepressants and a higher number of prescribed psychotropic medications. Illegal users of benzodiazepines more often used other illegal substances, were evaluated as clinically affected by a substance at admittance and were diagnosed with a substance use disorder. Patients with psychoses or major affective disorders treated with adequate medication (antidepressants, antipsychotics or mood-stabilizers) before admission more often received benzodiazepines than patients without adequate medication.

CONCLUSIONS

The patients using benzodiazepines at admittance to psychiatric acute departments could be divided in illegal and legal users. The illegal users were young, used illegal substances and were more often regarded clinically affected by substances at admittance. The legal users were older, did not use other substances and were not regarded as clinically affected by substances at admittance. Benzodiazepines were used as adjuvant therapy to specific pharmacological treatment with antidepressants, antipsychotics or mood stabilizers for major psychiatric disorders.

TRIAL REGISTRATION

NCT 00184119/NCT 00184132.

The bed requirement inventory: a simple measure to estimate the need for a psychiatric bed

OBJECTIVE

To develop an assessment of bed need that was as little affected by personal bias as possible.

METHOD

The Bed Requirement Inventory (BRI) is an eight-point scale designed to identify the appropriate use of an acute psychiatric bed. This is completed by a member of the ward staff, usually a nurse, and takes 5 minutes to fill in. The reliability, validity and feasibility of using the scale in normal practice were tested in a one-year study, and variations in inappropriate bed use described.

RESULTS

The inter-rater reliability of the scale was good (intra-class correlation coefficient = 0.63) and a comparison of the need for a psychiatric bed (comparing the BRI score with the judgement of an independent multidisciplinary group of professionals) also showed good agreement (k = 0.69), suggesting reasonable validity (although when the assessment was made by the named nurse agreement was less good). Results from a year-long survey in two West London hospitals showed that 17% of admissions were inappropriate and 32% had delayed discharge, black Caribbean patients had a significantly higher proportion (25%) of inappropriate admission than others (11%) and those referred from housing charities and hostels had a higher proportion (50%) of inappropriate bed use at some time than other groups (33%).

CONCLUSIONS

The Bed Requirement Inventory is a quick and reliable method of determining the appropriate use of a psychiatric bed and could be of use in estimating local bed needs. Delayed discharge remains a serious reason for inappropriate bed use in London.

Acute psychiatric admissions from an out-of-hours Casualty Clinic; how do referring doctors and admitting specialists agree?

Background

Over the last decades there has been an increasing pressure on the acute psychiatric wards in Norway. The major contributor to psychiatric acute admissions at the University Hospital of North Norway in the city of Tromsø in 2001 was the GP-based Tromsø Casualty Clinic, only open out-of-hours. We explored all acute psychiatric referrals from Tromsø Casualty Clinic in 2001. The purpose of the study was to characterize the admissions and assess the agreement between the referring doctors and the hospital specialists according to the need for hospitalization, agreement on application of the law and the diagnostic evaluation to assess whether the admissions were appropriate.

Methods

Retrospective, record based, descriptive study comprising 101 psychiatric acute referrals from the Tromsø Casualty Clinic to the psychiatric acute wards at the University Hospital of North Norway.

Results

The specialists accepted all referrals except one, they mostly agreed upon the diagnoses suggested by the referring doctors and they mostly confirmed the application of the law.

Seventy-five percent of the admissions took place during weekends, public holidays or nighttimes. Diagnoses of psychoses or suicidal attempts accounted for 76 % of the total referrals. Substance abuse was noted for 43 %, and in 22 % of all admissions the patients had stopped taking their psychopharmacological medication. The police assisted the referring doctors in one third of all admissions, and was the legal representative in 52 out of 59 involuntary admissions. Thirty percent of the admissions were first- time admissions. Thirty-two percent of the hospital stays lasted for three days or less. Median length of stay was 6.5 days.

Conclusion

The casualty clinic physicians and the hospital specialists mostly agreed in their evaluation of patients indicating that most of the admissions were appropriate. The police was more often involved in the involuntary admissions than intended in the law. The proportion of patients with substance abuse was significant. Alternative treatment strategies should be developed for non-psychotic patients in need of short-term stays.

Patterns of hospital admission for adult psychiatric illness in England: analysis of Hospital Episode Statistics data

BACKGROUND

The assessment and reporting of national patterns of psychiatric hospital admissions is important for strategic service development and planning.

AIMS

To investigate patterns of psychiatric hospital admissions of patients aged 16-64 years in England.

METHOD

We used the Department of Health's national Hospital Episode Statistics data on admissions to National Health Service hospitals in England between April 1999 and March 2000, to investigate patterns by region, gender, age and diagnosis.

RESULTS

The annual admission rate for England was 3.2 per 1000 population. There were marked regional variations and rates were higher in males than in females. Depression and anxiety together were the most common (29.6%) reason for admission. Length of stay exceeded 90 days in 9.2% of admissions and 1 year in 0.9% (highest in London and for psychoses).

CONCLUSIONS

Depression and anxiety together were the most frequent diagnoses leading to hospitalisation. There has been a reversal of the previously reported predominance of female admissions. Regional variations in activity and the significant numbers of patients remaining for long periods in'acute' inpatient care have important policy implications.

Descriptive psychopathology in people with mental retardation

This article considers variables associated with the presence of a psychiatric diagnosis in those referred to a specialist mental health service for people with mental retardation (MR). Data were collected on 752 newly referred clients. The presence of a psychiatric diagnosis was assessed by two psychiatrists based on International Classification of Diseases, 10th Revision, criteria. A series of binary logistic regression analyses were conducted. Older age, mild MR, admission to an inpatient unit, referral from generic mental health services, and detention under current mental health legislation were associated with an increased presence of any psychopathology. Severe MR, the presence of epilepsy, and residence with the family were associated with a lower incidence of any psychopathology. Findings relating to specific psychiatric diagnoses on the whole supported previous research. Clear service arrangements are necessary for people with mild MR who have a high incidence of psychiatric disorders.