Changing aspects of psychiatric inpatient treatment

This paper presents data obtained in a one-day census investigation in five European countries (Austria, Hungary, Romania, Slovakia, Slovenia). The census forms were filled in for 4191 psychiatric inpatients. Concerning legal status, 11.2% were hospitalised against their will (committed) and 21.4% were treated in a ward with locked doors. There was only a small correlation between commitment and treatment in a locked ward. More frequent than treatment of committed patients in locked wards was treatment of committed patients in open wards (Austria, Hungary) and treatment of voluntary patients in closed wards (Slovakia, Slovenia). Concerning employment, 27.7% of patients aged 18-60 held a job before admission. The vast majority of patients (84.8%) had a length of stay of less than 3 months. A comparison of these data with the results of a study performed in 1996 and using the same method shows a decrease of rates of long-stay patients. In 1996 the rates of employment were significantly higher in Romania (39.3%) and Slovakia (42.5%) compared to Austria (30.7%). These differences disappeared in 1999 due to decreasing rates of employment in Romania and Slovakia. The numbers of mental health personnel varies between types of institution (university or non-university) and countries, being highest in Austria and lowest in Romania. A considerable increase in the numbers of staff was found in Slovakia.     

Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring

ABSTRACT: BACKGROUND: The high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples.The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients' perceived coercion and to increase patient satisfaction, their quality of life and empowerment. METHODS: This paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study.In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge. DISCUSSION: Innovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.Trial registrationCurrent Controlled Trials ISRCTN63162737.     

Functional encopresis: psychiatric inpatient treatment

Encopresis can be considered an indication for psychiatric hospitalization in the multiproblem child, such as the one described in this report. Integration of observations from multiple treatment modalities were helpful in assessing the patient's progress and guiding interventions.     

Three-year follow-up of child psychiatric inpatient treatment

 Eighty child psychiatric inpatients with behavioral and emotional disorders were evaluated from multiple perspectives on admission and at 5-month and 3-year follow-ups. A majority of the patients showed a significant improvement in functioning during the 3-year follow-up. About half of the patients were functioning within clinical range at 3-year follow-up on parental (CBCL) and/or teacher (TRF) ratings. A less favorable outcome was predicted by disruptive behavioral disorder, severity of initial dysfunction, high antisocial and hyperkinetic symptoms, adoptive household and postdischarge institutional placement. Pure anxiety or affective disorder was associated with favorable outcome. Age, sex, place of treatment, and length of hospital treatment were not related to outcome variables. Received: 24 February 1997 Accepted: 3 October 1997     

Variables affecting length of psychiatric inpatient treatment

To discover whether variables such as gender, ethnicity, pay code, and diagnostic category affect length of psychiatric inpatient treatment, patient records for a recent 18-month period (January 1988 to June 1989) in a Midwestern teaching hospital setting were examined and statistically analyzed. Variables that emerged as related to length of stay are ethnicity, Axis I diagnosis of adjustment disorder, and presence of any Axis II diagnosis. Comparisons with length of stay statistics from an earlier period (1981) lead to conclusions about inpatient psychiatric services since the implementation of diagnosis related groups. Further, implications of this study's findings are discussed in relation to mental health service delivery.     

Guidelines for acute inpatient psychiatric treatment review

Inpatient psychiatric care accounts for a major part of the health care dollars spent for mental illness. In this article the authors review the history and literature behind the process of psychiatric peer review and quality assurance and discuss the development of standard criteria for admission to the hospital. These criteria include (1) imminent danger to oneself and others, (2) acute impairment of ability to perform activities of daily life, (3) impulsive or assaultive behavior, and (4) management of withdrawal states. The authors then present an outline of the typical course of the hospital stay. Finally, through a series of questions, criteria for continued stay on an acute care unit are indicated. The essential criterion is medical necessity based on a standard of severity of illness and intensity of treatment required. Criteria for admission, a sense of the typical course of the hospital stay, and criteria for continued stay then become the relevant issues for psychiatric peer review and quality assessment.     

Involuntary medication in psychiatric inpatient treatment.

The aim of this study was to examine involuntary medication in psychiatric inpatient treatment. A retrospective chart review of 1543 consecutive admissions of working aged civil patients from well-defined catchment areas to three psychiatric centres were evaluated regarding events of involuntary medication. 8.2% of the admissions included involuntary medication episode(s). Involuntary medication was associated with a diagnosis of schizophrenia, involuntary legal status and having previously been committed. One of the studied centres used less involuntary medication than the other two, even if patients with schizophrenia were over-represented in that centre. Although involuntary medication mainly takes places in the treatment of patients who are conceptualised most ill and perhaps resist treatment most, treatment culture obviously also plays a role. In future, it is important to study the aspects of treatment culture to fully understand the use of involuntary medication in psychiatry.     

Mortality of patients with organ-induced psychiatric disorders during inpatient psychiatric treatment

In this paper data from seven psychiatric hospitals in Baden-Württemberg, which can be regarded as representative for this region, are analysed. All patients with organic mental disorders of the ICD-9 categories 290, 293, 294 and 310 were included, while patients with alcohol- or psychoactive drug-induced psychoses were excluded. During the period from 01.01.1984 to 30.06.1986, 1821 episodes of treatment were recorded. 41% of all patients were male, the mean age of the population was 72.4 +/- 15.1 years. During their stay in hospital 137 patients died from natural causes, which is to compare with an expected number of deaths of 18.3, calculated according to the age- and sex-adjusted mortality rates of the German population. With a ratio of 7.5 the mortality of the whole study population was significantly raised. In all diagnostic subgroups a correlation with raised mortality was found, the risk being highest in patients with acute organic psychosis. An inverse relationship between age and mortality could be established. The main causes of death were cardiovascular disorders and pneumonias. The data of this investigation indicate an unequivocally increased mortality risk of patients with organic mental disorder during their stay in acute psychiatric units. The causes for this phenomenon are discussed, as well as potential consequences for hospital care of patients with organic mental disorder.     

The changing face of adolescent inpatient psychiatric treatment

Widespread changes in the criteria and resources for psychiatric inpatient treatment of adolescents present enormous challenges and demand serious and far-reaching adaptive efforts. Among these efforts may be a redesigning of the inpatient treatment milieu to accommodate different patient populations for whom different models of treatment and therapeutic strategies are necessary. This paper describes the redesigning and successful integration of an adolescent inpatient unit at a private psychiatric hospital to include separate treatment tracks for three different patient populations. An intensive/reconstructive treatment track provides the long-term inpatient treatment of youth with treatment-refractory personality disorders who have the clinical justification and resources for therapy that aspires to effect structural personality change. An acute crisis intervention track provides short-term inpatient treatment with an adaptation-oriented and highly focused approach to patients who have had limited previous treatment, are confined to short lengths of stay by financial constraints, or for whom regression should be discouraged. Finally, a psychosocial skills treatment group conducts longer term inpatient treatment for neurobiologically impaired patients. Psychotic, severely developmentally disturbed, profoundly abused patients, and those with extremely primitive personalities characterized by an abundance of deficits cannot tolerate the emotional and interpersonal intensity of a reconstructive treatment approach, but can benefit from a supportive, developmental, ego-building strategy.     

Paranoia in African-American men receiving inpatient psychiatric treatment

The present study tested a continuum model of paranoid symptom expression in a sample of African-American men receiving inpatient treatment in a state psychiatric hospital. The continuum measure comprised the scales of Distrust (DST), Perceived Hostility of Others (PHO), and False Beliefs and Perceptions (FBP) from the Psychiatric Epidemiology Research Interview (PERI), reflecting mild to severe paranoia, in the order listed. They were interviewer administered with other self-report symptom measures, within three weeks of hospital admission, by ethnically matched interviewers. A multivariate model with repeated measures for the continuum of paranoia revealed that scores on the PERI paranoia scales correlated similarly with scores on the Fenigstein measure of interpersonal paranoia, but correlated differentially with the Politic/Law subscale of the Cultural Mistrust Inventory, a measure of cultural paranoia. Diagnosis and treatment of African-American men for mental health problems in correctional and inpatient settings should be sensitive to the distinction between clinical and cultural aspects of their experiences.     

Coercion and restrictions in psychiatric inpatient treatment.

To find out to what extent coercion and restrictions are used in psychiatric inpatient treatment and with which patient characteristics the use of coercion is associated. To this end, the hospital records of 1,543 admissions (six-month admission samples) to the psychiatric clinics in three Finnish university towns were evaluated by retrospective chart review. The study clinics provide all psychiatric inpatient treatment for the working-age population in their catchment areas. Use of coercion and restrictions was recorded in a structured form. Coercion and restrictions were applied to 32% of the patients. Mechanical restraints were used on 10% of the patients, and forced medication on 8%. Compared to international statistics the figures in the current study are high.     

Predictors of outcome of short-term child psychiatric inpatient treatment

In this study, 85 children were prospectively followed after discharge from short-term inpatient treatment. Outcome was defined as functioning within normal range at the follow-up or as improvement in the child's behavior problems. Rutter Parent's Questionnaire was used as a measure on admission and at the 5-month follow-up after discharge. The child's more frequent individual behavior problems, antisocial behavior and disengaged family interaction on admission predicted both functioning outside normal range and less improvement at follow-up. Previous treatment because of developmental or behavioral problems and hyperkinetic symptoms on admission predicted functioning outside normal range. Parent's previous psychiatric hospital treatment was negatively associated with improvement. Pure emotional disorder predicted normal range functioning at follow-up. The child's age, gender, place of treatment and length of short-term treatment were not related to outcome. The results also stress the importance of taking into account both parents' and teachers' evaluations on admission.     

The use of drug monotherapy in psychiatric inpatient treatment

OBJECTIVE: Monotherapy has always been the goal in psychiatric drug treatment, but it does not seem to be very common in everyday practice. METHOD: The available literature on the frequency of monotherapy or polytherapy with psychotropic agents in psychiatric inpatient treatment is reviewed. FINDINGS: Taken all together (28 studies on 42 treatment facilities), the mean number of psychotropics prescribed was 2.47, the rate of monotherapy was 36.2% and 37.9% of inpatients received > or = 3 different drugs. Comparing the last three decades, a significant decline of the rate of monotherapy was found, topping at 47.8% in the 70s and falling to 19.6% in the 90s. The mean number of psychotropic drugs prescribed rose from 2.2 to 2.9 and the number of patients receiving > or = 3 psychotropics rose from 27.5 to 49.7%. CONCLUSION: Though it is still mandatory to avoid unsound polypharmacy, we must assume that the occasions for polypharmacy are increasing. New psychotropic drugs, increasing comorbidity and augmentation strategies may be incentives for polydrug use. Since in most countries the number of psychiatric beds declines, inpatient treatment has to deal with the most severe, often treatment-resistant patients requiring special therapies.     

Contrasting models for combined medical and psychiatric inpatient treatment

The authors contrast the clinical, administrative, and reimbursement aspects of two units offering combined medical and psychiatric inpatient treatment, one under medical auspices (the medical/psychiatric model), the other under psychiatric auspices (the psychiatric/medical model). The typical patient on both units suffered from depression with prominent somatic symptoms. The psychiatric/medical model was clinically advantageous because of its greater capacity for containing agitated, psychotic, and suicidal behavior and because of its potentially longer lengths of stay for refractory patients. Furthermore, the psychiatric/medical model offers more predictable payment for psychotherapy under fee-for-service insurance and is less likely to be adversely affected by the current prospective payment system based on diagnosis-related groups.