Closure of an Asylum: The Friern Study of Older People

This article reports a naturalistic study following the closure of Friern Hospital and the movement of elderly long-stay patients, who in the main suffered from severe dementia, to psychiatric nursing homes and hospital beds. It describes changes in the environments and in the patients’ cognition, behaviour and use of medical services. The results suggest that psychiatric nursing homes seem able to care for the majority if patients with severe dementia. Future studies should consider whether long-stay hospital beds may, however, be necessary for those with both psychiatric and physical health needs, where increased contact with health service personnel is essential. Prospective examination of the reasons for breakdown of placements in nursing homes and the differences between those placed in various settings may help future planning of services. Relatives’ opinions of the long-stay settings also require study. © 1997 by John Wiley & Sons, Ltd.     

Trends in discharge disposition,mortality, and service use among long-stay psychiatric patients in the 1990s

OBJECTIVE: This study examined changes in discharge disposition, mortality, and service use among three cohorts of highly vulnerable long-stay psychiatric patients in the Department of Veterans Affairs (VA) mental health system during the 1990s, a period of extensive bed closures. METHODS: National VA administrative databases were used to identify and prospectively follow three long-stay cohorts: mental health inpatients who had been hospitalized for at least one year as of the end of fiscal year 1991 (N=2,343), 1994 (N=1,853), and 1997 (N=1,156). The cohorts were compared in baseline demographic and diagnostic characteristics as well as discharge disposition, mortality, and service use over a three-year follow-up period. RESULTS: Nationally, the number of occupied long-stay beds decreased by 50 percent between 1991 and 1997. Over time, significant changes were noted in long-stay patients' principal diagnoses and discharge dispositions. Compared with the 1991 cohort, the 1994 and 1997 cohorts had a higher proportion of patients with psychotic disorders (69 percent, 77 percent, and 75 percent, respectively) and were more likely to be discharged from the hospital during the three-year follow-up period (33 percent, 54 percent, and 53 percent, respectively). However, among patients who were discharged, no substantial differences were noted in either mortality or overall VA service use across the three cohorts. CONCLUSIONS: The delivery of inpatient VA mental health services changed dramatically during the 1990s. This study provided evidence that continuing efforts to close VA mental health beds have not resulted in substantially adverse changes in mortality rates or in the extent to which long-term inpatients remain connected with the VA system after discharge.     

A study of the inpatient service of a Nigerian psychiatric hospital

Psychiatric hospitals and psychiatric units of teaching hospitals are gradually replacing the “civil asylums” in prisons, for the care of mentally ill patients in Nigeria.According to Boroffka,¹ 15 of such asylums still exist in addition to eight psychiatric hospitals and four psychiatric units situated in teaching hospitals. The phasing out of these asylums is due partly to the availability of more effective treatment for mental disorders and increasing numbers of psychiatrists in the country.Apart from Anumonye² and Jegede and Adaranijo,³ who have described the pattern of psychiatric practice in a psychiatric unit of a teaching hospital with four beds, no comprehensive information exists on the types of psychiatric patients requiring admission, either for a long- or a short-term stay and the management pattern and the relationship of such management to the underlying psychiatric illness. The present study is a preliminary report of a long-term longitudinal study, which aims at investigating both of the above problems, using the inpatients of a large psychiatric hospital.     

Avoidable mortality in long-stay psychiatric patients of Northern Finland

The aim of the present study was to examine mortality due to avoidable and unavoidable causes, unnatural deaths, and mortality possibly related to the use of psychotropic drugs. Mortality of 253 long-stay psychiatric patients from Northern Finland were monitored over a 9-year period and characterized according to standardized mortality rates (SMRs). Deaths due to avoidable causes included about 30% of all deaths, SMRs being 1.9 times (males) and 3.2 times (females) higher than those of the general population. The risk of unnatural deaths was also elevated, with SMRs amounting to 3.9 in males and 8.5 in females. An increased mortality risk, possibly related to the use of psychotropic drugs, was noticed. The physical care of long-stay psychiatric patients seems not to reach the same level that the general population enjoys. Continuous attention to the physical health of psychiatric patients is important, but new strategies and specific intervention methods should not be neglected. The concept of “avoidable mortality” is a useful, but rarely used indicator of the quality of the medical care in psychiatric populations. However, the concept needs regular updates from the whole field of medicine. From the psychiatric point of view, it was suggested that suicides be regarded as avoidable deaths.     

Medicare Inpatient Treatment for Elderly Non-dementia Psychiatric Illnesses 1992–2002; Length of Stay and Expenditures by Facility Type

We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.     

Do we still need beds for psychiatric patients?

While the utilization of outpatient psychiatric care increased steeply in the last few decades, the number of beds in psychiatric hospitals declined continuously in most countries. The future need for psychiatric hospital beds is influenced by changes in psychiatric morbidity, the range of services offered by mental hospitals and the availability of alternative forms of care for the chronically ill. A prospective cohort study conducted in Mannheim showed that currently, at a favourable standard of complementary service provision, one quarter of the schizophrenic patients requiring institutional care for more than one year - schizophrenics are the largest group of mental patients in need of long-term residential care - still need to be treated in mental hospitals. Beyond this threshold value the costs of alternative care exceed those of a continuous inpatient treatment, and, concurrently with them, the burden upon the people involved grows. Estimates of the future need can be made on the basis of field surveys, utilization data of a population and an analysis of long-term trends by using case register data. Provided a well-functioning system of alternative and outpatient mental health services is available, psychiatric bed ratios covering the actual needs in developed countries seem to range from 0.5 to 0.8 per 1000 population over 15 for the short-stay group and from 0.3 to 0.6 per 1000 for long-stay patients. The uncertainty inherent in the estimates requires a sufficient degree of flexibility in service planning and a continuous monitoring to make adjustments to changed conditions possible.     

I. Psychiatric Rehospitalization Following Hospital Discharge

The purpose of this study was twofold: to examine the patient characteristics at discharge from an acute psychiatric unit that were associated with an increased likelihood of rehospitalization within the following six months, and to examine the relationship between rehospitalization and the nature of psychiatric aftercare in a well-integrated hospital and community based psychiatric service. The study reviewed the extent of psychiatric rehospitalization following the closure of large numbers of institutional psychiatric beds. At six months after discharge 38% of the patients had been readmitted to an institution, most commonly a hospital. Despite the provision of an integrated hospital and community health service with excellent welfare support, dissatisfaction with finances independently exerted an influence on the risk of readmission. Implications for future research and treatment planning are discussed focussing on the complex integration of health and welfare services.     

Planning for crisis on a psychiatric research ward: A task analysis

The organizational structure of a psychiatric research ward facilitates its major tasks of data collection and clinical care. However, this structure also reflects the value conflicts inherent in pursuing both tasks.^1–4 Previous work has suggested that a ward's values and their conflicts may be highlighted during a crisis.⁵ The research ward described in this article was planning for a crisis, a threatened “job action” by the nursing staff. This anticipated job action involved possibilities ranging from a nursing staff “sick out” to strike action.This article discusses the interaction of clinical care and research values in this planning process. On this psychiatric ward, where biological research is conducted with severely impaired patients, data collection cannot occur without good clinical care. However, the specific type of care offered is determined by many factors including task priority, available personnel, assumptions about the efficacy of various forms of treatment, degree of patient impairment, phase of hospitalization, research protocol involvement by the patient, and responsiveness of the patient to medication and psychotherapy.The major task of the ward is research, in which all patients voluntarily participate. Following completion of their research protocols, patients usually are ready for individualized rehabilitative treatment. A high staff to patient ratio permits staff to engage patients in group, milieu and family treatments. In the transition from research to rehabilitative treatment the patient's role evolves from a passive research subject to an active therapeutic collaborator.In planning for the anticipated job action, the patient role was limited to a passive one. The ward values and boundary decisions which led to the definition of a passive rather than active patient role are discussed in this article as a reflection of the ways in which the conflicts between research and clinical care may be resolved on a psychiatric research ward.     

Crisis intervention program: an alternative to inpatient psychiatric treatment for children

This study evaluated the impact of a Crisis Intervention program as an alternative to use of psychiatric treatment beds for young children. A multidisciplinary community-based intervention was utilized, including family therapy, psychiatric intervention, and school consultations. The impact of the service was evaluated in relation to the use of psychiatric treatment beds by the population of children eligible for Medicaid or uninsured. In comparison to an historical control group, the program resulted in a 23% reduction in the use of psychiatric treatment beds. A cost-minimization analysis indicated that in addition to the program reducing the use of psychiatric treatment beds, the cost of treatment was also slightly reduced.     

Predictions about new long-stay patients: were they valid?

During 1979-1989, the long-stay population in Massachusetts state psychiatric hospitals declined and then moderately increased, although to far below its initial 1979 level. The increase toward the end of the period was due to a growing number of patients admitted, an increase in the proportion of these new patients who were retained for 1 year or longer, and a decrease in discharges of long-stay patients, especially those hospitalized for 20 or more years. The last factor was particularly important and was due to the fact that the number of these very-long-stay patients had become so small by 1983 that the effect of their continued discharge on the total long-stay population was minimal. The authors point out that more community services, not more hospital beds, may be needed. They recommend that states assess the clinical needs of the long-stay population before determining how to allocate their resources to address this phenomenon.     

Teaching psychiatry to nonpsychiatrists: II. A model curriculum

It is becoming increasingly clear that psychiatric and psychosocial needs of medical patients are not being adequately met. This need has led to an increasing emphasis on the psychiatric education of nonpsychiatrists at varying levels of experience. Given the many problems involved in these educational efforts, as well as the paucity of evaluation studies and the uncertainty of results, the authors argue that the systematic application of empirically-validated educational principles may lead to greatly improved effectiveness. In the first section of a two-part series, the authors reviewed educational methodology as it relates to the development of objectives, the selection of teaching procedures, and the use of evaluation techniques. The present paper, part-two, describes in detail a “model” curriculum for primary care residents that was developed according to these principles of educational methodology.     

An oral examination of the psychiatric knowledge of medical housestaff: Assessment of needs and evaluation baseline

To assess the psychiatric knowledge of medical housestaff, the authors devised an oral examination based on two simulated clinical encounters and administered it to 26 medical residents. The case material embodied those psychiatric problems known to be common in medical populations, namely depression, delirium, dementia, and “psychogenic” pain. The stan-dardized simulations were punctuated by standardized “open” questions with followup probes. A panel of experienced clinicians developed rating criteria for each question such that responses could be categorized as “good,” “adequate,” “inadequate,” or “poor,” in terms of “what an internist needs to know,” Blind raters of the exam achieved an interrater reliability of 0.88. The results indicated major deficits in the knowledge needed for assessment and treatment of these common problems. Only 16% of answers were “good,” whereas 42% were “inadequate” or “poor.” For example, 88% of the doctors could not name three factors that help distinguish organic from “functional” psychosis, and 88% could not list three side-effects of tricyclic antidepressants. The doctors' level of experience was not correlated with test scores, either overall or question by question. These results, together with measures of attitude and skill, have been used to develop a needs-based liaison psychiatry curriculum and to evaluate the effectiveness of that curriculum.     

Histrionic Personality and Antisocial Personality: Caricatures of stereotypes?

The proposal that the diagnoses Histrionic personality and Antisocial Personality represent sex-role caricatures of the concepts “woman” and “man”, respectively, was examined utilizing the semantic differential technique for the assessment of connotative meanings. Twenty-eight psychiatric residents and 21 academic psychiatrists rated the concepts “woman”, “man”, “histrionic personality”, and “antisocial personality” on each of 15 bipolar adjectival scales. No important differences were found between the ratings made by male or female psychiatrists or by resident and faculty psychiatrists. The subjects clearly distinguished between the connotative meanings of “woman” and “histrionic personality” and between “man” and “antisocial personality”, though there was a greater resemblance between the first pair of concepts than between the second. The linkages in meaning between women and the diagnosis Histrinic Personality are discussed, and it is proposed that the concept of sex-role caricatures be abandoned since the political overtones of the term “caricature” tend to undermine the empirical work needed to validate or reject clinical diagnoses.     

Care of chronic mental patients in The Netherlands

Summary While the Dutch Government is actively planning to reduce the number of mental hospital beds, particularly those for long-stay patients, it takes little notice of the reality of mental health care in The Netherlands, cherishing various misconceptions regarding institutionalism and community care. On the basis of a case-register study the population of chronic mental patients is estimated, including their current discharge rate from mental hospital without any aftercare. The burden of the mentally disabled on the community is discussed.     

Behavioural symptoms in the institutionalized elderly—relationship to dementia

A proportion of patients in long-term care institutions have behavioural symptoms that increase the physical and psychiatric workload of those caring for them. We performed a cross-sectional study in order to assess the prevalence of behavioural symptoms in patients in various types of long-stay institutions. In addition, we studied behavioural patterns to find predictors for behavioural symptoms. Prevalence and pattern of behavioural symptoms were studied in 1350 patients in the long-stay institutions in the county of Umeå using Gottfries and Gottfries Psychogeriatric and Sandman-Adolfsson's Multi-Dimensional Dementia Assessment Scales. The patients were in a psychogeriatric unit, a somatic long-stay unit, eight nursing homes and 15 homes for the aged with a total number of 1403 beds. Behavioural symptoms were found in 65% of the patients and were classified into six syndromes: escape, aggression, restlessness, wandering, regression and verbally disruptive behaviour.     

Admission histories,patterns, and subgroups of the heavy users of a state psychiatric hospital

The present study addressed several questions regarding the admissions patterns of the “heavy” users of a state psychiatric center. What percentage of “heavy” user cohorts go on to have one or multiple post-index admissions? What are the yearly post-index admission patterns of “heavy” users? Do different indexed “heavy” user cohorts have similar yearly post-index admission patterns? Are there discernible differences among “heavy” users in the number of post-index and lifetime admissions? The results and their implications, both theoretical and practical, are discussed. Future research directions are detailed.     

Community psychiatric services in England and Finland

Summary The study deals with the development of community psychiatric services in England and Finland, and in two urban areas (Camberwell and Turku) of these countries. The comparison between England and Finland is based on the official statistics for the countries since 1950, and the comparison between Camberwell and Turku on the samples of patients in contact with psychiatric facilities in 1965, 1970, 1975 or 1980. In England, the in-patient rates decreased steadily from the peak of 344 per 100,000 in 1954 to 161 in 1980. In Finland, the rates increased from 235 in 1954 to 425 in 1972, but thereafter decreased to 362 in 1980. During the 1970s, the number of old long-stay patients decreased in England but slightly increased in Finland. There are more day-hospital places in England than in Finland. On the other hand out-patient care increased more rapidly in Finland than in England in the 1960s and 1970s. In Camberwell, where there are more facilities for psychiatric patients than in most English districts, the combined rate for in-patients and those attending day hospitals, day centres or workshops remained quite stable during the 1970s. In Turku, where the out-patient care is more extensive but where other extramural facilities are less available than in Camberwell, the rates for long-stay and elderly in-patients did not decrease in the 1970s as they did in Camberwell. The results of this study support the view that overall the number of psychiatric beds (in-patients) is determined by the policy of health authorities and the government. In the 1950s and 1960s local authorities in Finland, encouraged by the government, built new hospitals for chronic psychiatric patients, while the official policy of the British government since the beginning of the 1960s has been to reduce the number of beds in mental hospitals. In Finland the same policy was not adopted until the 1970s. In Finland, extramural care, which has been based on Community Mental Health Centres operating mainly as out-patient clinics without beds, has not prevented the continued accumulation of long-stay and elderly in-patients. In England, on the other hand, extramural care includes day hospitals, day centres, workshops, hostels and group homes, and thus offers more social support than out-patient care alone. This may partly account for the fact that the number of long-stay and elderly in-patients in English mental hospitals is decreasing.     

Growth and inflation in psychiatry

An outline is presented of the changes that have occurred in psychiatry in the past 20 yr. Developments in psychodynamic social and biological psychiatry are separately described. The growth of psychiatry during this period has been spectacular, and there are no indications that this growth spurt will be followed by a period of stagnation. Yet there is a danger of inflation. By practicing restraint in the production and use of psychiatric “currencies” and by developing methods to test their “buying power” this danger can be avoided.     

The “bathroom game”: A systematic program for the elimination of encopretic behavior

The present investigation utilized a unique, variable ratio schedule of reinforcement (the “bathroom game”) to treat a 10-year-old encopretic male. Dependent measures included confirmed incidents of (a) soiling and (b) appropriate bowel movements monitored across an ABAB design (Baseline 1, “Bathroom Game 1”, Baseline 2, “Bathroom Game 2”) with one-year follow-up. During “bathroom game” conditions, contingent monetary rewards were provided for non-instances of soiling and appropriate bowel movements. Such rewards were progressively and systematically leaned-out over the course of treatment on a pre-determined variable ratio schedule. Results indicated a clear demonstration of functional control and clinically significant treatment effects during both experimental periods. These findings are discussed with regard to the positive features of the “bathroom game” procedure and recommendations are made for future investigations in the area.