Acute Psychiatric Admission Research Articles

Coping With Mental Illness: A Family's Struggle for Peace

Families struggle with the day-to-day worrying about behaviors of acting out at school and work, and the loss of normalcy that they used to have in their everyday lives. Families with a loved one with mental illness live in an almost constant state of uncertainty due to the unpredictability of the illness. This article addresses the challenges inherent to the acute psychiatric admission process of a patient and family.

Predictors of involuntary hospitalizations to acute psychiatry

IntroductionThere is little knowledge of predictors for involuntary hospitalizations in acute psychiatric units. MethodThe Multi-center study of Acute Psychiatry included all cases of acute consecutive psychiatric admissions in twenty acute psychiatric units in Norway, representing about 75% of the acute psychiatric units during 2005–2006. Data included admission process, rating of Global Assessment of Functioning and Health of the Nation Outcome Scales. ResultsFifty-six percent were voluntary and 44% involuntary hospitalized. Regression analysis identified contact with police, referral by physicians who did not know the patient, contact with health services within the last 48h, not living in own apartment or house, high scores for aggression, level of hallucinations and delusions, and contact with an out-of office clinic within the last 48h and low GAF symptom score as predictors for involuntary hospitalization. Involuntary patients were older, more often male, non-Norwegian, unmarried and had lower level of education. They more often had disability pension or received social benefits, and were more often admitted during evenings and nights, found to have more frequent substance abuse and less often responsible for children and were less frequently motivated for admission. Involuntary patients had less contact with psychiatric services before admission. Most patients were referred because of a deterioration of their psychiatric illness. ConclusionInvoluntary hospitalization seems to be guided by the severity of psychiatric symptoms and factors “surrounding” the referred patient. Important factors seem to be male gender, substance abuse, contact with own GP, aggressive behavior, and low level of social functioning and lack of motivation. There was a need for assistance by the police in a significant number of cases. This complicated picture offers some important challenges to the organization of primary and psychiatric health services and a need to consider better pathways to care.

A rural/urban comparison of psychiatric inpatient admissions in Ireland

PurposeThere is a body of evidence that indicates mental illnesses are more prevalent in urban settings. However, to date no research has been carried out on the urban/rural incidence of mental illness in Ireland. This paper seeks to examine the micro level determinants of admissions to psychiatric hospitals between urban and rural areas.Design/methodology/approachData from the National Psychiatric In‐patient Reporting System (NPIRS) and multivariate regression models are used.FindingsResults from this analysis found that, in Ireland, rural residents had a higher probability of being admitted to a psychiatric hospital for schizophrenia and depression compared to urban residents.Research limitations/implicationsThe results presented here are only applicable to individuals that have been admitted to a psychiatric hospital. Findings cannot be extrapolated to the general population. Future research will involve the simulation of mental health characteristics for the entire Irish population.Originality/valueThe analysis presented in the paper contributes to the current understanding of the social and spatial profile of psychiatric admissions in Ireland, whilst providing additional research to the international debate regarding urban/rural differentials in acute psychiatric hospital admissions.

Retrospective review of trends in assaults and seclusion at an acute psychiatric ward over a 5-year period

In developing countries such as South Africa, not much is known about the prevalence of assaults and seclusion occurring in mental health wards over time. Here, we describe a 5-year trend in assaults and seclusions, stratified by gender, at Stikland Hospital, South Africa. A retrospective review of clinical records of patients admitted to the acute psychiatric admission wards at Stikland and involved in assault and secluded was undertaken between 1 January 2005 and 31 December 2010. Data on the number of patient and staff assaults as well as seclusions, gender, age, marital status, level of education, level of income, duration of hospital admission and primary psychiatric diagnosis were collected. Significantly (P < 0.01) more men than women engaged in patient assaults, while significantly (P < 0.01) more men were secluded than women. On a monthly basis, the number of gender-stratified patient assaults and seclusions significantly increased (P < 0.01) throughout the study period. In conclusion, we show here that gender had a significant effect on both patient assault and seclusion numbers, which increased towards the end of the study period. Monitoring of these events is therefore important to continuously improve quality of care.

Associations of homelessness and residential mobility with length of stay after acute psychiatric admission

BackgroundA small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures.MethodsCross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression.ResultsResidential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor.ConclusionsHomelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.

Pharmacological treatment and adherence one week prior to acute psychiatric admissions

Background and aims: To describe use of and adherence to psychotropic medication 1 week prior to acute admission to a psychiatric inpatient department. Methods: All acute inpatient admissions to a department serving a catchment area were included. Results and conclusions: Of the 227 admissions, 158 were prescribed psychotropic medication and 129 of the 158 had taken at least 75% of the prescribed dose. Among 59 patients with affective disorders, 23 were not prescribed medication prior to admission and two refused medication, while the rest were adherent. Conclusion: The high adherence to medication 1 week prior to admission might be related to increased experience of serious symptoms. Lack of opportunity to receive pharmacological treatment is a major problem.

The Risk Factors for Elderly Patients With Bipolar Disorder Having Cerebral Infarction

Patients with bipolar disorder are at high risk of developing strokes in the older life. Silent cerebral infarctions (SCIs) could be common in the elderly patients with bipolar disorder, but only small sample size reports are available. The purpose of this study was to assess the proportion of SCIs and determine the risk factors for cerebral infarction in elderly patients with bipolar disorder. We recruited 43 patients with bipolar disorder over the age of 60 to undergo whole-brain magnetic resonance imaging (MRI). We divided them into 2 groups depending on whether infarction was present, and compared the potential variables of these 2 groups. There were 28 elderly patients with bipolar disorder (65.1%) having MRI-proven cerebral infarction. The SCIs were detected in 59.5% (N = 22) of 37 patients without a history of stroke, including 61.3% of 13 patients with late-onset age (>50 years) and 46.7% of 30 patients with typical-onset age (<50 years). Logistic regression revealed that comorbidity with metabolic diseases (95% confidence interval [CI] for odds ratio [OR] = 1.24-40.59) was most strongly associated with cerebral infarction. The leukocyte counts (95% CI for OR = 1.10-3.93) and fasting blood sugar (95% CI for OR = 1.00-1.07) during the most recent acute psychiatric admission may be substituted as the risk factors. Cerebral infarctions tend to be neglected in more than half of the elderly patients with bipolar disorder, regardless of their age at onset. Metabolic abnormality and systemic inflammation may be the risk factors.

Timing, prevalence, determinants and outcomes of homelessness among patients admitted to acute psychiatric wards

To document the prevalence, timing, associations and short-term housing outcomes of homelessness among acute psychiatric inpatients. Cross-sectional study of 4,386 acute psychiatric admissions discharged from a single NHS Trust in 2008-2009. Homelessness occurred in 16%. Most homelessness (70%) was either recorded as present at admission or started within 1 week. It was associated with younger age; male gender; ethnicity other than White British or Black African/Caribbean; being single, divorced, separated or widowed; diagnosis of drug and alcohol disorder; detention under a forensic section of the Mental Health Act; having no previous admission or alternatively having a longer previous admission; having a low score on the depressed mood or hallucinations and delusions items of the Health of the Nation Outcome Scales (HoNOS); and having a high score on the HoNOS relationship difficulties and occupation and activities items. Of those who were followed-up for 28 days after discharge, 53% had a new address recorded; of those who were not, only 22% did. Homelessness affects a substantial minority of psychiatric admissions in the UK. Housing outcomes are uncertain, and it is possible that more than half continue to be homeless or living in very transient situations. Demographic and diagnostic associations with homelessness were consistent with US studies; associations with HoNOS item scores and having had no admission in the preceding 2 years suggest that, in many cases, social adversity predominates over active psychopathology at the time of admission.

What about the Crisis Centre's contribution?

Barker et al [1][1] argue that the introduction of a ‘high fidelity’ model of a crisis resolution and home treatment team (CRHTT) in Edinburgh is responsible for a marked reduction in acute psychiatric admissions. The authors found a decrease of 24% in acute psychiatric admissions in the year

Door locking and exit security measures on acute psychiatric admission wards

Locking the exit doors of psychiatric wards is believed to reduce the risk of patients absconding. The aims of the study were to investigate both the prevalence of door locking and other exit security measures on UK admission wards, as well as whether door locking appears to be effective in keeping inpatients in. A cross-sectional survey on 136 acute psychiatric wards in the UK was conducted, in which a range of data on patients, staff, and conflict and containment events, including door locking and absconding, were collected from shift to shift during a period of 6 months. About one-third of the participating wards (30%) operated with their ward exit door permanently locked, whereas another third (34%) never locked the ward door. Univariate analyses suggested little association between exit security measures and absconding. A more robust multilevel statistical analysis, however, did indicate a reduction of about 30% of absconding rates when the ward door was locked the entire shift. Although locking the ward door does seem to reduce absconding to a certain extent, it far from completely prevents it. As it may be unrealistic to strive for a 100% absconding-proof ward, alternative measures for door locking to prevent absconding are discussed.

Impact of crisis resolution and home treatment services on user experience and admission to psychiatric hospital

Aims and methodCrisis resolution and home treatment (CRHT) teams began operating in Edinburgh in late 2008. We ascertained service users' and carers' experiences of CRHT using a standardised questionnaire. We also assessed the impact of CRHT on psychiatric admissions and readmissions by analysing routinely collected data from November 2003 to November 2009.ResultsThere was a 24% decrease in acute psychiatric admissions in the year after CRHT began operating, whereas the previous 5 years saw an 8% reduction in the admission rate. The mean duration of in-patient stay fell by 6.5 days (22% decrease) in the 12 months following CRHT introduction, alongside a 4% decrease in readmissions and a 17% reduction in Mental Health Act 1983 admissions. Although the mean response rate was low (29%), 93% of patients reported clinical improvement during CRHT care, 27% of patients felt totally recovered at discharge from CRHT, 90% of patients felt safe during CRHT treatment, and 94% of carers said their friend or relative got better with CRHT input.Clinical implicationsCrisis resolution and home treatment service in Edinburgh had a positive impact during the first 12 months in terms of reduced admissions, reduced duration of in-patient stay and reduced use of the Mental Health Act. The service can catalyse a more efficient use of in-patient care. Service users and carers report high rates of improvement and satisfaction with CRHT.

P03-266 - Innovation and modification of criteria for prevention of venous thromboembolism in psychiatric patients

Venous thromboembolism (VTE) may represent a serious complication in the treatment of hospitalized psychiatric patients with a reduced movement. Immobilization due to a physical restraint, pharmacotherapy with antipsychotics and/or benzodiazepines, a total reduction of mobility, obesity, and dehydration may participate in etiopathogenesis of VTE. We prospectively followed individuals with a reduced mobility hospitalized at an acute psychiatric admission ward. Forty-four patients (women N = 9) with a reduced locomotion for eight hours at least presented the study sample. VTE prevention in the naturalistic setting was compared to the our previously published guidelines for VTE control in every case. The observed VTE prevention was found to be in accordance with the published guidelines in 55% of cases (N = 24). Low molecular weight heparin (LMWH) was applied to 25% of immobilized patients (N = 11), according to their grade of VTE risk. After the analysis we adjusted the VTE prevention algorithm based on our clinical experience, knowledge on the observed cases, and new literary evidence. The new version of recommended procedures (physical exercises of lower extremities, sufficient hydratation, graduated compression stockings and administration of LMWH in high risk patients) is more simple, and makes the decision on VTE prevention in hospitalized psychiatric patients easier.

A retrospective review of trends and clinical characteristics of methamphetamine-related acute psychiatric admissions in a South African context

Epidemiological studies indicate that methamphetamine (MA) abuse poses a major challenge to health in the Western Cape. The objectives of this study were to retrospectively assess the trends, clinical characteristics and treatment demand of MA-related admissions to a psychiatric ward in this region. The clinical records of patients admitted to an acute psychiatric admission ward at Tygerberg Hospital from 1 January 2002 to 30 June 2002 and 1 January 2006 to 30 June 2006, were retrospectively reviewed. Admission numbers including those of adolescent and adult substance users were compared for both study periods. Study samples comparing demographic profile, admission status, length of stay, psychopathology, treatment requirements and referral pattern to other disciplines between MA users and non-users were collected for the 2006 period. There was a significant (p <0.01) increase in adolescent substance user admissions between the study periods. A significant (p <0.01) increase in adolescent and adult MA user admissions was also noted. MA users were significantly (p = 0.04) younger than non-MA users, whilst the former presented mainly with psychotic features associated with aggression, requiring involuntary admission of an average of 8 weeks. MA users required significantly (p = 0.007) more benzodiazepines compared to non-MA users. Although MA use is relatively recent to the Western Cape, its adverse psychiatric effects and consequences have become a major challenge. These effects in both adolescent and adult patient populations and the associated impact on psychiatric services demand urgent intervention strategies as well as prospective study.

Psychoactive substance use among patients admitted to an acute psychiatric ward: Laboratory findings and associations with clinical characteristics

Background: Estimates of psychoactive substance use among acutely admitted psychiatric patients vary among studies, and few have used comprehensive laboratory methods. Aims: This study used chromatography-based analyses of blood and urine to identify the rates of substance use among acute psychiatric admissions, and to study the associations with socio-demographic variables, clinical characteristics and patients’ reports of symptoms, substance use and need for treatment. Methods: A cross-sectional study was conducted in 2006/2007 in Oslo, Norway. Blood and urine samples were collected from 298 acute psychiatric admissions and extensively analysed for alcohol, medicinal and illicit drugs. Psychotic symptoms were assessed with the positive subscale of the Positive and Negative Syndrome Scale. Patient self-report questionnaires included the Alcohol and Drug Use Disorder Identification Tests. Patients were also asked if they needed professional help for substance use. Results: Psychoactive substances were detected in 63% of the 298 admissions, medicinal drugs in 46%, alcohol in 12% and illicit drugs in 28%. Patients using alcohol had a high suicidal risk score at admission and the shortest length of stay (median 1 day). Use of illicit drugs was associated with psychotic symptoms and readmission. Self-report questionnaires indicated harmful use of alcohol for half of the patients and of other substances for one-third. A need for professional help for substance use was reported by one-third of patients. Conclusion: Given the high rates of substance use and the important clinical associations, drug screening seems warranted in acute psychiatric settings. Interventions designed for substance-using patients should be developed and integrated.

Security rules and banned items in psychiatric acute admission wards in Athens, Greece

Mental health nurses play a key role in maintaining the safety of patients, themselves, and others during hospitalization. The aim of the research was to evaluate the safety measures that are taken by mental health nurses to identify the security policies that exist in acute mental health wards. The Ward Safety and Security Rules Survey was used as a method of data collection. Descriptive analysis and content analysis were carried out in order to identify nurses' practices. The total sample consisted of 172 mental health nurses and nurses' assistants who worked in 14 acute inpatient psychiatric wards in three psychiatric hospitals in the greater area of Athens, Greece. The results show a minimum number of security features existing in the wards. Only one of the 14 wards had an intercom system. In only nine wards, there was a panic alarm in the office, and in eight, an emergency response telephone extension. A wide range of practices were noted concerning banned items and patient searches upon admission and return from leave. The results indicate the significant lack of protocols and specific safety rules to guide nurses' actions across psychiatric acute admission wards in Athens.

Recent Substance Intake Among Patients Admitted to Acute Psychiatric Wards

This cross-sectional study of acute psychiatric admissions compared physicians' assessments of recent substance intake and on-site urine testing with comprehensive laboratory drug analyses. The sample comprised 325 consecutive admissions from 2 acute psychiatric wards. Physicians on call were asked to judge if the patient had recently taken benzodiazepines, opiates, alcohol, amphetamines, cannabis, or cocaine. Blood and urine samples were obtained and analyzed with chromatographic laboratory methods for a wide range of substances. A routine on-site urine screening test was performed in 92 of the cases. Physicians' assessments and on-site urine testing were compared with the reference standard of laboratory analyses. The sensitivity of the physician's assessment was highest for amphetamines (76%), followed by benzodiazepines (61%), opiates (57%), cannabis (55%), and cocaine (50%), whereas specificity was greater than 90% for all substances. The sensitivity of the on-site test ranged from 76% for amphetamine to 97% for cannabis, and specificity ranged from 82% for cannabis to 100% for cocaine. The study indicates clinical underdetection of recent substance intake among acute psychiatric admissions. On-site urine testing identified substance use that was not recognized by the physician's initial assessment, although specificity for cannabis and benzodiazepines was low. Chromatographic methods, which offered important supplementary information about substance use, should be considered for the routine screening of acutely admitted psychiatric patients.

Short admission in an emergency psychiatry unit can prevent prolonged lengths of stay in a psychiatric institution

Characterize and compare acute psychiatric admissions to the psychiatric wards of a general hospital (22 beds), a psychiatric hospital (80) and of an emergency psychiatry unit (6). Survey of the ratios and shares of the demographic, diagnostic and hospitalization variables involved in all acute admissions registered in a catchment area in Brazil between 1998 and 2004. From the 11,208 admissions, 47.8% of the patients were admitted to a psychiatric hospital and 14.1% to a general hospital. The emergency psychiatry unit accounted for 38.1% of all admissions during the period, with a higher variability in occupancy rate and bed turnover during the years. Around 80% of the hospital stays lasted less than 20 days and in almost half of these cases, patients were discharged in 2 days. Although the total number of admissions remained stable during the years, in 2004, a 30% increase was seen compared to 2003. In 2004, bed turnover and occupancy rate at the emergency psychiatry unit increased. The increase in the number of psychiatric admissions in 2004 could be attributed to a lack of new community-based services available in the area beginning in 1998. Changes in the health care network did affect the emergency psychiatric service and the limitations of the community-based network could influence the rate of psychiatric admissions.

Residential alternatives to acute psychiatric hospital admission: systematic review

Reducing use of hospital wards and improving their quality are central aims of mental health service policy. However, no comprehensive synthesis is available of evidence on residential alternatives to standard acute psychiatric wards. To assess the effectiveness and cost-effectiveness of and satisfaction with residential alternatives to standard acute in-patient mental health services. A systematic search identified controlled studies comparing residential alternatives with standard in-patient services. Studies were described and assessed for methodological quality. Results from higher quality studies are presented and discussed. Twenty-seven relevant studies were identified. Nine studies of moderate quality provide no contraindication to identified alternative service models and limited preliminary evidence that community-based alternatives may be cheaper and individuals more satisfied than in standard acute wards. More research is needed to establish the effectiveness of service models and target populations for residential alternatives to standard acute wards. Community-based residential crisis services may provide a feasible and acceptable alternative to hospital admission for some people with acute mental illness.

Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature.

Catatonia is a motor dysregulation syndrome described by Karl Kahlbaum in 1874. He understood catatonia as a disease of its own. Others quickly recognized it among diverse disorders, but Emil Kraepelin made it a linchpin of his concept of dementia praecox. Eugen Bleuler endorsed this singular association. During the 20th century, catatonia has been considered a type of schizophrenia. In the 1970s, American authors identified catatonia in patients with mania and depression, as a toxic response, and in general medical and neurologic illnesses. It was only occasionally found in patients with schizophrenia. When looked for, catatonia is found in 10% or more of acute psychiatric admissions. It is readily diagnosable, verifiable by a lorazepam challenge test, and rapidly treatable. Even in its most lethal forms, it responds to high doses of lorazepam or to electroconvulsive therapy. These treatments are not accepted for patients with schizophrenia. Prompt recognition and treatment saves lives. It is time to place catatonia into its own home in the psychiatric classification.

Safety and security in acute admission psychiatric wards in Ireland and London: a comparative study

The comparative element of this study is to describe safety and security measures in psychiatric acute admission wards in the Republic of Ireland and London; to describe differences and similarities in terms of safety and security patterns in the Republic of Ireland and London; and to make recommendations on safety and security to mental health services management and psychiatric nurses. Violence is a serious problem in psychiatric services and staff experience significant psychological reactions to being assaulted. Health and Safety Authorities in the UK and Ireland have expressed concern about violence and assault in healthcare, however, there remains a lack of clarity on matters of procedure and policy pertaining to safety and security in psychiatric hospitals. A descriptive survey research design was employed. Questionnaires were circulated to all acute wards in London and in Ireland and the resulting data compared. A total of 124 psychiatric wards from London and 43 wards from Ireland were included in this study and response rates of 70% (London) and 86% (Ireland) were obtained. Differences and similarities in safety and security practices were identified between London and Ireland, with Irish wards having generally higher and more intensive levels of security. There is a lack of coherent policy and procedure in safety and security measures across psychiatric acute admission wards in the Republic of Ireland and London. Given the trends in European Union (EU) regulation, there is a strong argument for the publication of acceptable minimum guidelines for safety and security in mental health services across the EU. There must be a concerted effort to ensure that all policy and procedure in safety and security is founded on evidence and best practice. Mental health managers must establish a review of work safety and security procedures and practices. Risk assessment and environmental audits of all mental health clinical environments should be mandatory.