Acute Psychiatry Research Articles

Psychiatry in the Harvard Medical School–Cambridge Integrated Clerkship: An Innovative, Year-Long Program

The authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education. A longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry "immersion" experiences, and a variety of clinical and didactic teaching sessions. The longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average. Longitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

A new model for quality improvement in acute inpatient psychiatry: observational data from an acute assessment unit

ObjectivesThere is little research into the constituents of effective psychiatric inpatient care. The aim of this study was to assess the effectiveness of a newly adopted model of inpatient care; the acute assessment ward.DesignReview of data collected over a year-long period.SettingAcute assessment ward in North London.ParticipantsAll Admissions between 8 October 2009 and 7 October 2010.Main outcome measuresDuration of stay, need for readmission, patient satisfaction and frequency of conflict behaviours.ResultsA total of 485 admissions over the yearlong study period. The median stay to discharge from the assessment ward was 6 days, whereas in those transferred it was 19 days. Readmission within 28 days following discharge from the assessment ward was 13.9%, whereas those discharged from other wards was 9.2% (P = 0.1). Patient satisfaction was no lower, for all domains, than for other wards in the trust. Frequency of conflict behaviour was equal to previous studies,1 but self harm was significantly less common (P = 0.01).ConclusionsOur data show that focusing on the ‘point of entry’ to inpatient services means that some admission times can be reduced without an increase in 28-day readmission rates or conflict behaviours. The acute assessment model attempts to address the need for the NHS to deliver more for less, whilst remaining focused on service-user and staff satisfaction. Research into which areas of this complex intervention are effective is challenging, but we would urge others who run services with novel structures to publish data about their functioning.

Patterns of hypnotic medication use for sleep disturbance amongst hospital inpatients

The objective of this article is to examine patterns of temazepam prescribing amongst inpatients at a Sydney teaching hospital. The study involved a retrospective file audit of 98.8% (n=410) of patients discharged from psychiatry, medical, surgical and obstetric and gynaecology wards of Nepean Hospital during a one-week period. Data was collected on patient demographics, temazepam and other sedative-hypnotic use, falls risk and analgesia use. Sixteen per cent (n=64) of patients were prescribed temazepam during their stay. All patients from the psychiatry wards had been prescribed temazepam. Fifteen per cent (n=6) of falls risk patients had been prescribed temazepam. Temazepam prescription was associated with an increased length of stay, psychiatry and surgical wards, and higher use of analgesia. Temazepam continues to be a frequently prescribed medication in the acute psychiatry setting. Its frequent prescription to patients in surgical wards and to those prescribed analgesic agents indicates that it still has a role in settling patients to sleep in the hospital setting.

Social Support and Risk of Compulsory Admission: Part IV of the Amsterdam Study of Acute Psychiatry

Social support for patients with a mental illness has been associated with a lower rate of hospitalization. It is important to clarify the role played by a lack of social support as a possible predictor of emergency compulsory admission. A random sample of 252 patients who were evaluated by two psychiatric emergency teams in Amsterdam from September 2004 to September 2006 were interviewed approximately one month later about their social networks and social interactions. The number of emergency compulsory admissions was recorded for 244 patients during a two-year follow-up period after the interviews. Patients who lived alone had a higher risk of compulsory admission (p≤.05) and had fewer people in their social network (4.6 versus 6.1, p≤.001) compared with patients who lived with others. Among patients who lived alone, the percentage of patients with a compulsory admission was significantly higher among the patients with a high score for negative interactions than among patients with a low score (34% versus 13%, p≤.05). Of the social support variables, living alone proved to be the only predictor of emergency compulsory admission and readmission, and patients who lived alone had a smaller social network. A high level of negative social interactions increased the risk of compulsory admission among patients who lived alone.

Key stakeholder perceptions regarding acute care psychiatry in distressed publicly funded mental health care markets.

The role of acute care inpatient psychiatry, public and private, has changed dramatically since the 1960s, especially as recent market forces affecting the private sector have had ripple effects on publicly funded mental health care. Key stakeholders' experiences, perceptions, and opinions regarding the role of acute care psychiatry in distressed markets of publicly funded mental health care were examined. A qualitative research study was conducted using semi-structured thematic interviews with 52 senior mental health system administrators, clinical directors and managers, and nonclinical policy specialists. Participants were selected from markets in six regions of the United States that experienced recent significant closures of acute care psychiatric beds. Qualitative data analyses yielded findings that clustered around three sets of higher order themes: structure of care, service delivery barriers, and outcomes. Structure of care suggests that acute care psychiatry is seen as part of a continuum of services; service delivery barriers inhibit effective delivery of services and are perceived to include economic, regulatory, and political factors; outcomes include fragmentation of mental health care services across the continuum, the shift of mental health care to the criminal justice system, and market-specific issues affecting mental health care. Findings delineate key stakeholders' perceptions regarding the role acute care psychiatry plays in the continuum of care for publicly funded mental health and suggest that public mental health care is inefficacious. Results carry implications for policy makers regarding strategies/policies to improve optimal utilization of scarce resources for mental health care, including greater focus on psychotherapy.

Family systems psychiatry in an acute in‐patient setting: the implementation and sustainability 5 years after its introduction

From 2003 to 2008 a multicentre research project, systems therapy methods in acute psychiatry (SYMPA), attempted to establish structured in‐patient treatment based on systemic interventions in German non‐university psychiatric hospitals. Utilising multi‐professional family systems training for team members in six in‐patient wards, its main goal was to improve the involvement of familial and non‐familial important others. This follow‐up study explores the sustainability of family systems psychiatry by evaluating the frequency of the utilisation of four core systemic interventions; elements of a systemic organizational culture in psychiatry; and institutional barriers to this new approach. The degree of implementation was high to moderate, depending on the intervention. More intense communication developed among staff of different professions and the status of nursing staff improved. Organizational barriers to implementation included the ambiguous role of junior doctors in teams, continuously understaffed wards and frequent over‐occupancy.

Managing risk and conflict behaviours in acute psychiatry: the dual role of constant special observation

This is a report of a study of events before and after the use of constant special observation on acute psychiatric wards, and the characteristics of patients who received it. Constant special observation is a method of preventing acutely disturbed inpatients from harming themselves or others. It has been characterized as impersonal, intrusive and non-therapeutic. The circumstances of its use and place in broader intervention strategies are not well understood. A sample of 522 patients were recruited from 84 acute psychiatric wards in 31 hospital locations in London and surrounding areas during 2009-2010. Data were collected for the first 2 weeks of admission from patients' case notes. Sixteen per cent of patients received constant special observation during the first 2 weeks in hospital (7% at the point of admission and 11% after admission), but with variation between hospitals. Absconding, violence and self-harm were the most common events to precede constant special observation during a shift. Other methods of containment, especially intermittent special observation, were frequently tried first. Episodes of constant special observation often involved de-escalation and extra medication. Aggression was more prominent during than before constant special observation. Attempted suicides were limited to postadmission episodes. Constant special observation is usually used in combination with other forms of containment, irrespective of when it is initiated. Placing patients considered at risk of suicide under constant special observation on admission may have a protective effect.

Signs and symptoms of acute mania: a factor analysis

BackgroundThe major diagnostic classifications consider mania as a uni-dimensional illness. Factor analytic studies of acute mania are fewer compared to schizophrenia and depression. Evidence from factor analysis suggests more categories or subtypes than what is included in the classification systems. Studies have found that these factors can predict differences in treatment response and prognosis.MethodsThe sample included 131 patients consecutively admitted to an acute psychiatry unit over a period of one year. It included 76 (58%) males. The mean age was 44.05 years (SD = 15.6). Patients met International Classification of Diseases-10 (ICD-10) clinical diagnostic criteria for a manic episode. Patients with a diagnosis of mixed bipolar affective disorder were excluded. Participants were evaluated using the Young Mania Rating Scale (YMRS). Exploratory factor analysis (principal component analysis) was carried out and factors with an eigenvalue > 1 were retained. The significance level for interpretation of factor loadings was 0.40. The unrotated component matrix identified five factors. Oblique rotation was then carried out to identify three factors which were clinically meaningful.ResultsUnrotated principal component analysis extracted five factors. These five factors explained 65.36% of the total variance. Oblique rotation extracted 3 factors. Factor 1 corresponding to 'irritable mania' had significant loadings of irritability, increased motor activity/energy and disruptive aggressive behaviour. Factor 2 corresponding to 'elated mania' had significant loadings of elevated mood, language abnormalities/thought disorder, increased sexual interest and poor insight. Factor 3 corresponding to 'psychotic mania' had significant loadings of abnormalities in thought content, appearance, poor sleep and speech abnormalities.ConclusionsOur findings identified three clinically meaningful factors corresponding to 'elated mania', 'irritable mania' and 'psychotic mania'. These findings support the multidimensional nature of manic symptoms. Further evidence is needed to support the existence of corresponding clinical subtypes.

The scope for replacing seclusion with time out in acute inpatient psychiatry in England

The use of seclusion is unpalatable to nurses and frequently unpleasant for patients. Time out is rated by nurses and patients as more acceptable. Several countries have initiated exercises to reduce the use of seclusion, but England has not. In this study, data were collected on the sequence of conflict (aggression, rule breaking, absconding etc.) and containment (coerced medication, restraint, special observation etc., including time out and seclusion) for the first 2 weeks of 522 acute admissions on 84 wards in 31 English hospitals between June 2009 and March 2010. Data were analysed to describe what preceded and followed time out and seclusion episodes in a nursing shift. Seclusion was used with 7·5% of patients, and time out with 15·5%. Both containment methods were used with similar patients in similar circumstances, and both brought disturbed behaviour to a close in half of the cases. Some seclusion appeared to follow less serious disturbed behaviour. There was an important variation in rates of seclusion between hospitals. Seclusion and time out had equally good outcomes in the management of physical violence to others. There is good evidence that seclusion rates can be reduced safely, and time out can sometimes be used as a substitute. A national registration and reporting system should be introduced in England, and serious efforts made to reduce seclusion use in hospitals where rates are high.

Developmental Transformations: Improvisational Drama Therapy with Children in Acute Inpatient Psychiatry

This article describes the use of Developmental Transformations drama therapy in groups within an acute psychiatric setting, exploring issues specific to group work with child psychiatric inpatients. Case material from a series of sessions is used to explore how group members can use the process for mutual support as well as to increase flexibility and capacity for creative expression. Connections are drawn between Developmental Transformations and social group work theories to illustrate parallels between the two practice methods.

Successful Treatment With Hydroxyzine of Acute Exacerbation of Panic Disorder in a Healthy Man

To the Editor: In a given year, approximately 6 million American adults aged 18 years or older have panic disorder.1,2 To the best of our knowledge, this is the first report to document the successful treatment of acute exacerbation of panic disorder with hydroxyzine in a healthy adult. Case report. Mr A, a 25-year-old man with a history of panic disorder, presented in 2010 to the emergency department complaining of chest pain, tachycardia, palpitations, hyperventilation, shortness of breath, sweating, nausea, and vomiting. Moreover, he reported derealization, a sense of doom, and constant fear of having another panic attack. Mr A stated that he had been having panic attacks about 3 or 4 times daily for the previous week. Myocardial infarction was ruled out. Blood workup was inconclusive for any other medical cause. Mr A had been on venlafaxine 75 mg/d orally for the previous 6 months. He had taken paroxetine 40 mg/d orally with no improvement for the 6 months prior to starting venlafaxine. Past medical, surgical, and family histories were not significant for any major illnesses. He was employed and single and smoked half a pack of cigarettes daily, but had no history of alcohol or illegal drug use. The patient denied having any psychosocial stressors. Physical examination findings revealed no abnormalities. Mr A was admitted to the acute psychiatry unit for observation. Upon admission to the unit, hydroxyzine 25 mg 3 times daily was started with no other changes in medication or therapy. The patient received prompt relief, and there were no further panic attacks during his 3-day admission or his 1-month follow-up. To the best of our knowledge, there are no published cases of successful treatment of acute exacerbation of panic disorder with hydroxyzine in healthy adults. There has been clear evidence of the anxiolytic efficacy of hydroxyzine. In a controlled trial in generalized anxiety disorder patients, hydroxyzine demonstrated greater and more rapid cognitive improvement compared to lorazepam.3 Moreover, it has also shown a lack of organ toxicity and an absence of dependency. As reported in our case, an acute exacerbation of panic disorder was effectively managed by hydroxyzine in a healthy adult. If practitioners recognize this association, extensive use of benzodiazepines may be prevented.

Staff morale in English mental health hospitals: a national study

Background/Objectives: A series of initiatives aimed at reforming the UK acute mental health care system has been introduced in the past decade, intended to improve the therapeutic environment and patient experiences and outcomes. Successful implementation of such reforms requires recruitment and retention of a skilled and motivated workforce. Evidence has been lacking on the factors that promote good morale in acute inpatient settings. This large national mixed methods investigation was intended to address this gap, facilitating the implementation and maintenance of service improvement initiatives in acute psychiatry.

A narrative review of studies of refusal of psychotropic medication in acute inpatient psychiatric care

This paper offers a narrative review of the 22 studies of medication refusal in acute psychiatry. Because of varied definitions of medication refusal, diverse methodologies and few rigorous studies, it has not been possible to draw firm conclusions on the average rate of refusal of psychotropic medications in acute psychiatry. However, it is clear that medication refusal is common and leads to poor outcomes characterized by higher rates of seclusion, restraint, threats of, and actual, assaults and longer hospitalizations. There are no statistically significant differences between refusers and acceptors in gender, marital status and preadmission living arrangements. Although no firm conclusions on the influence of ethnicity, status at admission and diagnosis on refusal, the refusers are more likely to have higher number of previous hospitalizations and history of prior refusal. The review indicates that staff factors such as the use of temporary staff, lack of confidence in ward staff and ineffective ward structure are associated with higher rates of medication refusal. Comprehensive knowledge of why, and how, patients refuse medication is lacking. Research on medication refusal is still fragmented, of variable methodological quality and lacks an integrating model.

Mature care and reciprocity: Two cases from acute psychiatry

In this article we elaborate on the concept of mature care, in which reciprocity is crucial. Emphasizing reciprocity challenges other comprehensions where care is understood as a one-sided activity, with either the carer or the cared for considered the main source of knowledge and sole motivation for caring. We aim to demonstrate the concept of mature care's advantages with regard to conceptualizing the practice of care, such as in nursing. First, we present and discuss the concept of mature care, then we apply the concept to two real life cases taken from the field of acute psychiatry. In the first example we demonstrate how mature care can grasp tacit reciprocal aspects in caring. In the other, we elucidate a difficulty related to the concept, namely the lack of reciprocity and interaction that affects some relationships.

Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses' decision to restrain

Ethical standards and current law demand that acute care psychiatric patients be treated with respect, using the least restrictive interventions. Unfortunately, as restraint use has decreased, assault and injury of mental health care workers has increased. Violence against those working in acute care psychiatry is a serious global issue that needs further examination. This study provides current, in depth information about the nature, frequency and severity of assaults and injuries of psychiatric nurses. This study also examined assault and injury in relation to the nurse's decision to restrain. The findings of this study were compared with findings of an earlier study carried out by one of the authors (Moylan) prior to the institution of policies, which are more restrictive in the use of restraint. In a sample of 110 nurses from five institutions, 80% of the nurses were assaulted, 65% had been injured and 26% had been seriously injured. Injuries included fractures, eye injuries and permanent disability. The number and severity of injuries have increased significantly since the 1996 study. Nurses who had been injured decided to restrain later in the progression of aggression than those who had not been injured.

Why do Adolescents Return to an Acute Psychiatric Unit?

The aim of this paper is to determine potentially modifiable factors associated with the high proportion of patients who are readmitted to adolescent psychiatric units. The case notes of 112 adolescents admitted over 1 year to an acute adolescent psychiatry unit were reviewed. Socio-demographic and clinical variables were compared between those who were readmitted over a 12-month period post discharge and those who were not. The readmission rate over a 12-month period was 31%. Males were significantly more likely to be readmitted. No other statistically significant predictors of readmission were identified. There was a trend towards readmission for those with bipolar disorder and a trend away from readmission for those with adjustment disorders. A history of sexual abuse and cluster B personality traits were significantly related to a history of previous admission, but not with subsequent readmission. Readmission is influenced by a number of factors, which may not be easily identified by a chart review. Prospective studies which follow-up adolescents for several years after discharge are needed.

Locked doors: a survey of patients, staff and visitors

• Locking of psychiatric wards doors is more frequent, but the impact is unknown. • Staff patients and visitors returned a questionnaire about the issue. • Patients did not like the door being locked as much as staff, and being on a locked ward was associated with greater rejection of the practice. • Staff working on locked wards were more positive about it than those who did not. Locking the door of adult acute psychiatric wards has become increasingly common in the UK. There has been little investigation of its efficacy or acceptability in comparison to other containment methods. We surveyed the beliefs and attitudes of patients, staff and visitors to the practice of door locking in acute psychiatry. Wards that previously participated in a previous study were contacted and sent a questionnaire. A total of 1227 responses were obtained, with the highest number coming from staff, and the smallest from visitors. Analysis identified five factors (adverse effects, staff benefits, patient safety benefits, patient comforts and cold milieu). Patients were more negative about door locking than the staff, and more likely to express such negative judgments if they were residing in a locked ward. For staff, being on a locked ward was associated with more positive judgments about the practice. There were significant age, gender and ethnicity effects for staff only. Each group saw the issue of locked doors from their own perspective. Patients registered more anger, irritation and depression as a consequence of locked doors than staff or visitors thought they experienced. These differences were accentuated by the actual experience of the ward being locked.

Psychometric properties of the Turkish version of the Depression Coping Self‐efficacy Scale

Reliable and valid instruments are needed to assess and deal with the problems that are encountered by depressed patients in psychiatric nursing practice. The aim of this study was to assess the reliability and validity of the Turkish version of the Depression Coping Self-efficacy Scale. A descriptive and correlation design was used to determine the psychometric properties of the Scale. The study population was 105 depressed inpatients from acute psychiatry services. The study confirmed that the Scale is reliable and valid for assessing depression coping self-efficacy of depressed patients in acute psychiatric wards in Turkey.

The Severe Impairment Battery Predicts Functional Abilities in an Inpatient Geriatric Population

There is limited research examining the relationship between cognition in severe dementia and functional skills. The aim of the present study was to examine the relationship between the Severe Impairment Battery (SIB) and functional abilities as measured by the Assessment of Instrumental Function (AIF) in an acute inpatient geriatric psychiatry setting. Analyses showed significant correlation between the SIB and the AIF. Multiple regression demonstrated that SIB scores accounted for 44% of the variance in adaptive functioning. These results replicate some of the prior data examining the relationship between the cognition and functional abilities and extend these findings into the inpatient setting with more severely impaired patients.

V-RISK-10: Validation of a screen for risk of violence after discharge from acute psychiatry

BackgroundCurrent violence risk assessment instruments are time-consuming and mainly developed for forensic psychiatry. A paucity of violence screens for acute psychiatry instigated the development and validation of the V-RISK-10. The aim of this prospective naturalistic study was to test the predictive validity of the V-RISK-10 as a screen of violence risk after discharge from two acute psychiatric wards. MethodsPatients were screened with V-RISK-10 before discharge, and incidents of violence were recorded 3, 6, 9 and 12 months after discharge. A total of 381 of the 1017 patients that were screened completed the follow up. ResultsThe ROC-AUC values for any violent behaviour were 0.80 and 0.75 (p<0.001) for the 3 and 12 months follow-up periods, respectively, and significant for both genders. The most accurate risk estimates were obtained for severe violence. For persons without a known history of violence prior to the screening, AUCs were 0.74 (p=0.004) and 0.68 (p=0.002). ConclusionsResults indicate that the V-RISK-10 is a valid and clinically useful screen for violence risk after discharge from acute psychiatry, and even significant for patients without a known previous history of violence.