The Nordic comparative study on sectorised psychiatry: repeated emergency admissions to inpatient care during a 1-year follow-up

The emergency admissions to hospital care in six psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorised psychiatry. One year treated incidence cohorts were used, with the total cohort comprising 2,454 patients. Of the 803 patients who were admitted to inpatient care during a 1-year follow-up, 82% had at least one emergency admission and 23% repeated emergency admissions. The definition for the repeated emergency admissions was at least two admissions during the follow-up. The mean length of stay in emergency inpatient care per treatment episode for this patient subgroup was 28 days. Their emergency inpatient episodes constituted 30% of all inpatient days during the follow-up. However, the variations between the services and diagnostic subgroups were large. The results of a logistic regression analysis indicated that the following variables predicted repeated emergency admissions: inpatient care at index contact, emergency outpatient contacts or no planned hospital admissions during the follow-up, psychiatric service, age under 45 years, and a diagnosis of psychosis, personality disorder or dependency. The repeated emergency admissions were related to the existence of a special service unit for abusers but not to the rates of outpatient staff or acute beds in the services, to geographical distances, referral practice or existence of emergency services.     

Use of coercion in psychiatric care as narrated by patients,nurses and physicians

The patterns of use of outpatient services during a 1-year follow-up in seven psychiatric services in four Nordic countries were explored as a part of a Nordic comparative study on sectorized psychiatry. One-year treated incidence cohorts were used. Three main patterns of outpatient care emerged at the service system level. First, in two of the services the outpatient care was dominated by emergency contacts. In four of the services the outpatient care was dominated by scheduled contacts, and most of the patients had no emergency outpatient contacts at all. In one of the services a remarkably large number of (38%) the patients had no outpatient contact at all. In addition to the characteristics of the psychiatric services, the following variables predicted the use of emergency outpatient services: self-referral, no inpatient care and no planned outpatient contacts during the follow-up, diagnosis of adjustment disorder or functional psychosis, and being on sick leave. The following variables predicted several scheduled outpatient contacts during the follow-up: no inpatient care and two or more emergency outpatient contacts during the follow-up, female gender, age less than 65 years, no previous inpatient care, and diagnosis of non-organic psychosis, neurosis, or personality disorder.     

The Nordic comparative study on sectorized psychiatry I. Treated point prevalence and characteristics of the psychiatric services

Comparative studies relating characteristics of psychiatric services to rates of treated prevalence are scarce. As part of a Nordic comparative study on sectorized psychiatry, a point-prevalence study was performed in 5 sectorized psychiatric services with comprehensive service facilities for a defined population under responsibility. The rates of treated prevalence on a census day were related to a number of characteristics of the respective services and to accessibility of care. The results showed a great variation in one-day point prevalence in the 5 services, with almost fourfold differences. There were also marked differences in the diagnostic distribution of the cohorts. A positive correlation was found between number of beds and point prevalence, measured both as total point prevalence and impatient prevalence. The rates of beds and psychiatrists were most strongly related to the prevalence of patients with organic disorders and functional psychoses. A closed referral system was associated with a lower level of treated prevalence.     

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.     

Assessing methods of predicting the need for psychiatric beds

Actual psychiatric bed utilization in 16 metropolitan areas was compared with projected bed needs in those areas derived from seven common methods of assessing the need for inpatient psychiatric services. Six methods significantly underpredicted actual use, and one significantly overpredicted actual use. Methods that relied on multiple sources, including expert opinion, historical use, epidemiologic data, and social indicators, predicted need more accurately than those that relied exclusively on expert opinion or historical use. The author also found that utilization rates of acute beds in general and specialty hospitals kept pace with licensed bed rates at or below 45 to 50 beds per 100,000 population but remained steady if the number of licensed beds went higher. The author recommends reliance on local indicators to plan inpatient services.     

Health care utilization by older patients with coexisting dementia and depression

OBJECTIVE: Few studies have examined the course of coexisting dementia and depression. The purpose of this study was to compare elderly patients who had coexisting dementia and depression with elderly patients who had either disorder alone in terms of their utilization of inpatient and outpatient services. METHOD: The study group included 7,115 veterans aged 60 years or older who had been discharged from Department of Veterans Affairs inpatient units in 1992 with diagnoses of major depression, dementia, or both. Outcome measures were analyzed for a 2-year period following the index hospitalization for each diagnostic study group. RESULTS: Patients with coexisting dementia and depression had significantly more psychiatric inpatient days than the other two study groups and more medical inpatient days and nursing home readmissions than patients with depression alone. Patients with coexisting dementia and depression had significantly more total inpatient days than the other two groups. Notably, patients with coexisting dementia and depression did not utilize more outpatient resources than the other study groups; in fact, they had significantly fewer medical, psychiatric, and total visits than patients with depression alone. CONCLUSIONS: The findings suggest that patients with coexisting dementia and depression are high utilizers of inpatient services, with a course of illness that may resemble dementia in terms of nursing home and inpatient medical care utilization and depression in terms of inpatient psychiatric care utilization; however, these patients utilized significantly fewer outpatient resources than the group with depression alone. Aggressive outpatient treatment approaches might reduce utilization of inpatient care for patients with coexisting depression and dementia.     

The Nordic Comparative Study on Sectorized Psychiatry: patients who use only psychiatric in-patient care in comprehensive community-based services — a 1-year follow-up study

In the present paper a sample of patients using psychiatric in-patient care only is characterized and analysed with regard to characteristics of the psychiatric services. This paper forms part of the Nordic Comparative Study on Sectorized Psychiatry, designed to investigate contact rates and use of psychiatric care by new patients in 7 catchment areas in 4 Nordic countries during a 1-year follow-up. One-year treated incidence cohorts were used. The logistic regression analysis revealed that the variable ‘psychiatric service’ was one of the statistically significant determinants of using only in-patient care during the follow-up. The diagnostic groups with the highest probability of using only in-patient care were dependencies and functional psychoses. The following factors were associated with a high risk of using only in-patient care: older age, being referred by another psychiatrist, having received previous psychiatric in-patient care, male sex, being retired, and not living with one's parents or a partner. Patients who used only inpatient care had fewer admissions and days in in-patient care than others during the 1-year follow-up period. Lack of 24-hour emergency services in out-patient care correlated positively with the use of only in-patient care.     

Mental health services in Asia: International perspective and challenge for the coming years

In contrast to European countries and the United States of America, there has been a steady increase in the psychiatric inpatient population in Japan between 1960 and 1993. Japan has the biggest number of psychiatric beds in the world, both in absolute and relative numbers per population. However, Japan now focuses on community based services and the human rights of patients. In other Asian countries, the number of psychiatric beds is relatively small; however, the numbers are increasing each year in China, the Republic of Korea, Philippines, Indonesia and in many other countries in Asia. These countries are still facing the challenge of increasing psychiatric services and to improve the quality of care with scarce mental health resources. Should Asian countries take the similar path to European countries and develop mental health services? This review provides an overview of Asian mental health services and discussing the following issues: how many psychiatric beds do we need in Asia?; public vs private psychiatric services?; financing scheme to promote community based care in Asia; mental health services in primary health care; family education and user involvement in Asia; and the challenge for psychiatrists in Asia.     

The Nordic Comparative Study on Sectorized Psychiatry

As part of a Nordic comparative study on sectorized psychiatry in seven Nordic catchment areas, a prospective investigation of contact rates of new patients and pathways to the psychiatric services was performed. The results showed that there was more than a twofold difference between the services in the total contact rates. Regarding diagnostic groups, contact rates for neurosis were predominant in three of the services, while adjustment disorders, dependencies and personality disorders were predominant in other the services. The contact rate of functional psychosis, as well as the ratio of psychotic patients to the total contact rate were highest in two catchment areas serving inner parts of big cities. The most common way of getting into contact with the services was by self-referral, 39.4% of total referrals, followed by primary care referrals, although there were large differences between the services. Psychotic patients made contact with the services to a significantly less extent by self-referral. The majority of patients were treated in outpatient care at entry to the services, with a large variation between the services. It was also found that inpatient care at index contact was predicted by clinical characteristics—a diagnosis of psychosis and a history of former inpatient care-as well as by social characteristics—male, widowed or divorced, sick pension/old age pension.     

Development of a screening instrument for heavy users of psychiatric inpatient services

Patients who show an above-average utilization of medical care are described as "heavy users". Heavy utilization of psychiatric inpatient care could be reduced by well directed community based services. Heavy users should, therefore, be identified at the beginning of a period of heavy service consumption. For this reason, a screening instrument (SPSI) was developed. Six predictors of heavy utilization of inpatient care were included as items in the SPSI. Weighting of items and examination of the instrument were carried out with a sample of 184 schizophrenia patients, whose utilization of inpatient care was recorded prospectively over a period of 30 months. 83 percent of heavy users and 85 percent of ordinary users were correctly identified with the SPSI test at a cutoff score of - 6.7. The SPSI is a short questionnaire which could be used without special rater training in psychiatric care in order to offer identified heavy users well directed community based services, which are less costly than inpatient care, but at least just as appropriate for the special needs of these patients.     

The reform of psychiatric care in Poland--2001

Both positive and negative effects of the reform of the health care financing system are noted. Low prices offered by Sickness Funds for particular services (a bed-day, a visit) should be regarded as a negative effect of the reform. Particularly insufficient were the prices of services in some specialised psychiatric wards and in outpatient clinics. Prices in many community-based psychiatric facilities were also considerably underestimated. Undoubtedly, the reform has led to positive changes in the organization of inpatient care. These changes include: further reduction of beds in large hospitals organisational structure as well as a marked increase in the number of psychiatric wards at general hospitals, which should be the key units of psychiatric inpatient care. Increase in the number of day hospitals is another positive effect of the reform. The programme of psychiatric care transformation is presented mostly in the Mental Health Programme. The main goal of this programme is to ensure appropriate care for the mentally disordered people, namely comprehensive and accessible health care as well as other forms of help and and support necessary for living in family and in society. This goal will be accomplished by health care and other forms of help mentioned in the Mental Health Act and in the Social Help Act. Community-based model of psychiatric care is the key element of this system. Also, the Programme states desired accessibility rates for staff, number of beds and number of particular forms of psychiatric and alcohol treatment care. Separate rates for adult and children/youth population have been elaborated.     

Has the attempt to reduce psychiatric inpatient treatment been successful in Finland?

The deinstitutionalisation process in Finland's psychiatric healthcare did not start until the late 1980s. Our aim is to evaluate how the use of psychiatric inpatient treatment was associated with deinstitutionalisation given the changes in the modality of treatment ideology (years 1987--1991) as well as being due to economic pressures (years 1991--1995). Special emphasis is given on the inpatient treatment of schizophrenia and other psychotic disorders.Data was retrieved using the national hospital discharge register of all treatment periods in psychiatric hospitals and treatment periods due to psychiatric disorders in other hospitals. Three years (1987, 1991, and 1995) were compared. Four healthcare districts in northern Finland were studied. Resource use was measured by number of treatment periods and inpatient days in relation to population. Psychiatric inpatient treatment was reduced in 1987--1991, when resources in community care increased. During the period of economic pressures (1991--1995), when community care resources no longer increased, inpatient treatment started to rise again. Over the whole period, psychiatric treatment in primary care institutions increased.Reduction of psychiatric beds results in increasing inpatient treatment in non-specialist institutions, especially when community care fails to serve the patients. In the future it is important to evaluate whether the quality of care remains in the standard of specialised services when treatment shifts away from the specialist level.     

Costs and characteristics of heavy inpatient service users in outer London

"Heavy users" is a new term often used to describe those who occupy a disproportionate number of psychiatric beds. In this study we identified the heaviest 10% (193) inpatient service users in one London borough over a 6 year period and compared these with a control group of 400 ordinary inpatient users. A weighting index was used to combine frequency of admission with duration. Heavy users were diagnostically and demographically similar to ordinary inpatient service users and only differed by their extensive use of services, about 3 times more than ordinary users in terms of health care costs, during the measured year. Their heavy use mainly depended on occupying hospital beds, and their use of outpatient, day patient and community services was relatively light.     

Effectiveness of a High End Users Program for Persons with Psychiatric Disorders

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A pre-post study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.     

The Nordic Comparative Study on Sectorized Psychiatry: contact rates and use of services for patients with a functional psychosis

As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, contact rates and use of services for patients with a functional psychosis during a 1-year follow-up period were investigated. The highest contact rates were found in two large city catchment areas in Stockholm and Copenhagen. Compared to other patients in the cohorts, patients with a functional psychosis were more often found to be unemployed and living alone. They also showed more extensive service use in terms of both voluntary and compulsory admissions, and in the use of day-care facilities. In addition, they were more often multiple users of inpatient care (≥=3 admissions during the follow-up period). Large differences in service use among patients with a functional psychosis were discovered between the catchment areas, with the most extensive use of voluntary inpatient care and day-care facilities in Frederiksberg. Patients most frequently had compulsory admissions in Bodö and least frequently had them in Frederiksberg. Out-patient services were most frequently used in Stockholm. Correlations between levels of resources and use of services for patients with a functional psychosis were in general low, except for the rates of short-term beds, which showed a strong and significant correlation wit the number of days in voluntary in-patient care (r=0.89).     

Institutions and services of psychiatric care in Saxony-Anhalt: assessment with the European Services Mapping Schedule.

This article describes and analyses the availability of outpatient, inpatient and community-based psychiatric care in Saxony-Anhalt, one of the federal states in the eastern part of Germany. The European Services Mapping Schedule was used to classify 365 institutions. Outpatient care was provided by an average of four private practice psychiatrists per 100,000 inhabitants, which is low when compared to the German average. Ten secure beds (forensic), 48 acute beds, 13 elective beds and 13 day hospital places per 100,000 inhabitants were available for inpatient care. Non-acute non-hospital residential services with indefinite stay and with 24 h support amounted to 240 places per 100,000, with regional differences ranging from less than 100 to more than 1000. Other facilities offering paid work or work-related activities were scarce and some services providing structured activity or social contact were available only in urban agglomerations. Overall, psychiatric care in Saxony-Anhalt is fragmented as regards providers and funding.     

Time trends in mental health care utilization in a Dutch area, 1976–1990

This paper concerns time trends in mental health care utilization in a Dutch area from 1976 to 1990. In general, there was an increase in the use of psychiatric services during the study period, both in terms of the number of new patients (per 1000 population) and in terms of the amount of care utilized per patient. When only intramural services were taken into account the number of new psychiatric patients remained approximately constant, but the number of patients in care at a certain point in time (point prevalence) showed a rising trend. For most part, the increase in inpatient point prevalence rates could be ascribed to the increase in the elderly population (75 years or more). In addition to the proportional increase of the ageing population, a growing amount of psychosocial problems and broadening of the concept of illness were tentatively assumed to be related to the increase in mental health care utilization. Unlike some other countries, deinstitutionalization hardly occurred in the Netherlands. Accepted: 19 August 1997     

Forty years of deinstitutionalization of psychiatric services in Canada: an empirical assessment.

OBJECTIVE: To empirically analyze the implementation of the policy of deinstitutionalization of psychiatric services over a 40-year period. METHOD: We assessed the policy of deinstitutionalization in terms of the following components: 1) population-based psychiatric beds, days of care in psychiatric hospitals (PHs); 2) days of care in psychiatric units in general hospitals (GHs); and 3) per capita expenditures on psychiatric services. RESULTS: There was a rapid closure of beds in PHs in the 1970s and 1980s, but this was associated with an increasing rate of days of care in psychiatric units in GHs (that is, transinstitutionalization). It was not until the 1990s that the overall days of inpatient care began to decrease. Per capita expenditures on community-based psychiatric services increased throughout this period. CONCLUSIONS: Standardized rates reveal tremendous variation among the provinces in the timing and intensity of deinstitutionalization.     

Current need versus treatment history as predictors of use of outpatient psychiatric care

The authors conducted a study of treatment utilization and outcome on a sample of 116 psychiatric outpatients at a Veterans Administration (VA) hospital. Utilization and outcome measures were obtained at a follow-up interview 18 months after a baseline assessment. Comparisons between patients with high and low rates of utilization revealed negligible relationships between use of services and severity of illness, clinical change, or demographics. However, previous use of VA outpatient and inpatient psychiatric services and VA psychiatric disability rating predicted utilization of psychiatric care during the study. The authors conclude that use of VA outpatient psychiatric care may reflect patients' help-seeking history more than their current clinical need.     

The Nordic comparative study on sectorized psychiatry: rates of compulsory care and use of compulsory admissions during a 1-year follow-up

Background: As part of a Nordic comparative study on contact rates of new patients and use of services in seven catchment areas, rates of compulsory care and use of compulsory admissions were explored and analyzed. The total cohort comprised 2834 patients. Results: A total of 219 patients, 7.7%, were subject to compulsory care during the follow-up. The proportion of compulsorily admitted patients of all admitted patients ranged from 6% to 58% in the seven psychiatric services, and the rate of compulsory care per 1,000 inhabitants, from 0.14 to 0.99. The diagnostic subgroup most commonly committed to inpatient care was functional psychosis, comprising around 50% of all compulsory admissions. The strongest predictor of being compulsorily admitted was the specific psychiatric service the patient was in contact with, followed by having a psychosis diagnosis. High consumption of care was also associated with compulsory care, while social variables played only a minor role in predicting compulsory care. Conclusions: There was a great variation in rates of compulsory care. No consistent rural-urban pattern in rates of commitment was found. It is discussed whether a formal referral procedure to the psychiatric service is associated with higher rates of compulsory care. Accepted: 3 September 1998