Inpatient Mental Health Services Research Articles

Sex differences among children, adolescents and young adults for mental health service use within inpatient and outpatient settings, before and during the COVID-19 pandemic: a population-based study in Ontario, Canada

ObjectivesThe pandemic and public health response to contain the virus had impacts on many aspects of young people’s lives including disruptions to daily routines, opportunities for social, academic, recreational engagement...

Peer support for discharge from inpatient to community mental health care: the ENRICH research programme

Peer support for discharge from inpatient to community mental health care: the ENRICH research programme

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AimThe research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression). BackgroundPreventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions. MethodsData were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted. ResultsThree themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) ‘who watches the watchers’, were identified by the experts as well as areas to enhance EPAs prior to introduction into practice. ConclusionsEPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Experiences of clinical staff who work with patients who self-harm by ligature: An exploratory survey of inpatient mental health service staff.

Self-harm by ligature is common within inpatient mental healthcare settings and is a dangerous method of self-harm. Most fatal and non-fatal suicidal behaviours in inpatient settings are a result of ligature use. There is a lack of research which has explored the experiences of staff members who work within inpatient settings where patients may self-harm by ligature. Key issues related to self-harm by ligature reported by staff included (1) understaffing increasing risk of ligature incidents, (2) spreading of self-harm by ligature within inpatient settings and (3) negative attitudes of staff related to patients who self-harm by ligature. Working with self-harm by ligature can have negative impacts on staff's personal (e.g. fear of blame) and professional lives (e.g. increased cautiousness). Many staff members currently feel underprepared by training related to working with self-harm by ligature, and unsupported after responding to a ligature incident. Training about self-harm by ligature needs to be improved and be accessible for all inpatient mental healthcare staff. Training should be coproduced, and could include practical components, education on potential reasons for self-harm, and acknowledgement of the emotional impact on staff. Support for staff members who respond to ligature incidents should be available for all staff members who respond to self-harm by ligature incidents. Stigma associated with accessing support should be challenged, alongside blame cultures within the workplace. INTRODUCTION: Self-harm by ligature is a common form of self-harm within inpatient mental health services in England, where most suicides within inpatient settings involve hanging or suffocation. However, little research has examined the experiences of staff members working with this method of self-harm. We explored the experiences of clinical staff who work with patients who self-harm by ligature. A staff survey was developed and disseminated to clinical staff working in inpatient settings in England. Quantitative data were analysed using descriptive statistics, and qualitative data using the framework approach. The study was STROBE checklist compliant. 275 staff members participated. Challenges most frequently reported about working with self-harm by ligature included understaffing (210, 76.6%), spreading of ligature incidents (198, 72.8%) and negative attitudes held by clinical staff towards such patients (185, 68.5%). Participants' responses indicated that this work could have significant impacts on their professional and personal lives. Staff often reported inadequate training and lack of preparedness, alongside insufficient support opportunities following ligature incidents. Staff had a diverse range of professional and personal experiences and identified multiple challenges associated with working with patients who have self-harmed by ligature. There is a need to improve accessibility, format and content of training and support for staff working within inpatient settings where patients may self-harm by ligature.

Striking the Right Balance and Supporting Social Aspirations: How Agency and Choice Play out in a Recovery-Oriented Mental Health Service

Introduction There has been an increasing drive for a transformation of the mental health system towards recovery orientation, with research identifying a series of key recovery principles. It has been argued that these principles remain rhetoric rather than routine practice, and it remains unclear how these are operationalised and promoted within inpatient settings. Aim To address the knowledge gap of how staff and service-users enact recovery principles during the daily workings of an inpatient mental health service. Method Twenty-one interviews were conducted with staff and service-users at a recovery-oriented inpatient service in the United Kingdom. Data was analysed using framework analysis. Findings Analysis of research interview data identified three subcategories grouped under the category of choice. These categories were: a delicate balancing act, acceptability of choices, and social issues impacting choice. Discussion Staff were uncertain of their role in promoting choice, resulting in service-users feeling unsupported in their recovery. Staff had to adopt a titrated approach to social inclusion, to protect service-users from discrimination and rejection. Implications Mental health professionals need to take a more proactive role in enabling service-users to realise their social aspirations, as well as managing any adverse impacts of stigma and discrimination.

Leaving the Past Behind: Exploring the Adverse Childhood Experiences of Males Detained to a Secure Specialist Deaf Inpatient Mental Health Service

ABSTRACT Deaf people, and those who engage in criminal offending have independently been identified as groups at risk for childhood trauma, though consideration of their intersectional impact is limited. The adverse childhood experiences (ACEs) of 26 males detained to a deaf secure mental health service were explored. Overall, 92.3% of participants had experienced an ACE. Most participants had experienced multiple adversities (Median = 6), with 73.1% exposed to four or more, and 57.7% exposed to six or more. Most participants (76.9%) had experienced both child maltreatment and household adversity. The most prevalent ACEs were emotional neglect and parental separation (76.9%). Participants who had been subject to a care order reported more child maltreatment ACEs (p = .02). Given the pervasive ACE histories of deaf people in secure mental health services, the integration of trauma-informed practices within an environment that is sensitive and responsive to the complex trauma needs of this population is of paramount importance.

Effectiveness of the early intervention service for first-episode psychosis in Navarra (PEPsNa): Broadening the scope of outcome measures.

This study compares the effectiveness of a new early intervention service for firstepisode psychosis (FEP) in patients under conventional treatment. Six primary and 10 secondary outcome measures are used to better characterize the comparative effectiveness between two FEP groups. This study plans to enroll 250 patients aged 15-55 years with FEP from all inpatient and outpatient mental health services and primary health care from January 2020 until December 2022. The control group will be composed of 130 FEP patients treated in mental health centers in the 2 years prior to the start of PEPsNa (Programa de Primeros Episodios de Psicosis de Navarra). The primary outcome measures are symptomatic remission, functional recovery, personal recovery, cognitive performance, functional capacity in real-world settings, and costs. The secondary outcome measures are duration of untreated psychosis, substance abuse rate, antipsychotic monotherapy, minimal effective dose of antipsychotic drugs, therapeutic alliance, drop-out rate, number of relapses, global mortality and suicidality, resource use, and general satisfaction in the program. This study arises from the growing need to broaden the scope of outcome measures in FEP patients and to account for unmet needs of recovery for FEPs. It aims to contribute in the dissemination of the NAVIGATE model in Europe and to provide new evidence of the effectiveness of early intervention services for stakeholders of the National Health Service.

An analysis of the barriers and enablers to implementing the Safewards model within inpatient mental health services.

Mental health inpatient units can provide a sanctuary for people to recover from mental illness. To support a therapeutic environment, the safety and well-being of service users and staff need protection through reduced conflict and containment rates. The Safewards model identifies 10 interventions to prevent conflict and containment. This paper aims to present barriers and enablers to implementing Safewards by analysing current literature on the Safewards model. It will also compare the Safewards model to New Zealand's Six Core Strategies. In a systematic search of 12 electronic databases following the PRISMA flow chart, 22 primary studies were included in this analysis. JBI tools were used for quality appraisal and deductive content analysis was used to organize and interpret data. Four categories were identified: (a) designing the Safewards interventions and implementation; (b) staff participation and perception of Safewards; (c) healthcare system influences on Safewards implementation; (d) service user participation and perception of Safewards. To support successful Safewards implementation in future practice, this review recommends that Safewards implementation is enabled through robust design of the Safewards interventions and implementation methods; staff participation and positive perception of the Safewards model; a resourced healthcare system that prioritizes Safewards implementation; service user awareness and participation in Safewards interventions. Interactionist perspectives may support the implementation of Safewards. This analysis is limited by research settings mostly being inpatient adult services and inadequate capturing of the service user voice. An ongoing review of barriers and enablers is important for supporting future Safewards implementation.

The Impact of Smoking Regulations on the Daily Routine of Patients within an Irish Mental Health Setting

A high prevalence of smoking has been reported among people receiving care within inpatient and forensic mental health services. An Irish inpatient mental health service introduced a “smoke free campus” policy in 2018. Six semi-structured interviews were completed with patients within this setting in 2019. Using thematic analysis, five themes were identified: Experience of stakeholder support, routine, experience of being an inpatient, the meaning of smoking, and the experience and perception of the smoking policy and governing bodies. The findings have implications for staff who work in mental health inpatient settings or who develop policies regarding smoking on hospital sites.

Restrictive measures in forensic mental health and their role in recovery: a narrative literature review

Forensic mental health inpatient services are required to use restrictive interventions within their care and treatment, in the interests of security and risk management of people with mental illness and a history of criminal offence. However, such restrictive practices can often hinder the patient's process of recovery as well as the mental health professional's ability to provide recovery-oriented care. As some research suggests that restrictive measures are often favoured over more therapeutic options, there is a need to understand the influence this has on rehabilitation and the available alternatives. A narrative literature review was conducted to identify the specific restrictive measures that are used within these services and suggest alternative therapeutic strategies. A variety of methods of coercive treatment were identified, leading to recommendations around areas such as training, processes and therapeutic milieu.

Sensory modulation implementation strategies within inpatient mental health services: an organisational case study

PurposeSensory modulation is an emerging approach that aims to reduce distress and agitation in mental health service users and potentially avoid the necessity for coercive practices such as seclusion and restraint. Despite the growing use of this intervention, there has been limited research exploring the implementation of sensory modulation at an organisational level, both internationally and within the New Zealand context. The purpose of this study is to investigate the implementation of a sensory modulation programme in two New Zealand inpatient mental health services using an exploratory organisational case study design.Design/methodology/approachOrganisational case study design methodology was used to explore the implementation of a sensory modulation programme in two New Zealand acute adult inpatient mental health services. This study explored how key organisational and staff factors (including policies and practices related to de-escalation and seclusion reduction) influence sensory modulation implementation. Cases were described and examined the pattern of findings.FindingsStrategies found to support implementation were identified at environmental, organisational, group and individual staff levels. Aspects highlighted as being particularly important included taking an inter-professional approach in leadership and training, rostering flexibility and leeway in staffing levels to support training attendance and responsiveness to crises.Practical implicationsThe facilitators and strategies highlighted in this study may be used to support the design and implementation of future sensory modulation programmes in New Zealand and internationally.Originality/valueThe complexity of factors that influenced the implementation of the sensory modulation approach within an inpatient setting made determining the effectiveness of the approach challenging. However, the general principles and strategies identified in this study offer useful insights for the design and implementation of future sensory modulation programmes.

Management of medically assisted withdrawal from alcohol in acute adult mental health and specialist addictions in-patient services: UK clinical audit findings.

Medically assisted alcohol withdrawal (MAAW) is increasingly undertaken on acute adult psychiatric wards. Comparison of the quality of MAAW between acute adult wards and specialist addictions units in mental health services. Clinical audit conducted by the Prescribing Observatory for Mental Health (POMH). Information on MAAW was collected from clinical records using a bespoke data collection tool. Forty-five National Health Service (NHS) mental health trusts/healthcare organisations submitted data relating to the treatment of 908 patients undergoing MAAW on an acute adult ward or psychiatric intensive care unit (PICU) and 347 admitted to a specialist NHS addictions unit. MAAW had been overseen by an addiction specialist in 33 (4%) of the patients on an acute adult ward/PICU. A comprehensive alcohol history, measurement of breath alcohol, full screening for Wernicke's encephalopathy, use of parenteral thiamine, prescription of medications for relapse prevention (such as acamprosate) and referral for specialist continuing care of alcohol-related problems following discharge were all more commonly documented when care was provided on a specialist unit or when there was specialist addictions management on an acute ward. The findings suggest that the quality of care provided for medically assisted withdrawal from alcohol, including the use of evidence-based interventions, is better when clinicians with specialist addictions training are involved. This has implications for future quality improvement in the provision of MAAW in acute adult mental health settings.

Evaluating Veterans Response Teams and Police Interventions on Veterans' Health Care Utilization.

This study examined the effects of veteran-specific cooperative police interventions, including a Veterans Response Team (VRT) and broad collaboration between local police departments and a Veterans Affairs (VA) medical center police department (local-VA police [LVP]), on veterans' health care utilization. Data were analyzed on 241 veterans (51 received VRT and 190 received LVP intervention) in Wilmington, Delaware. Nearly all veterans in the sample were enrolled in VA health care at the time of police intervention. Veterans who received VRT or LVP interventions showed similar increases in use of outpatient and inpatient mental health and substance abuse treatment services, rehabilitation services, ancillary care services, homeless programs, and emergency department/urgent care services after 6 months. These findings suggest the importance of relationship building among local police departments, VA Police, and Veterans Justice Outreach to create pathways to care to ensure that veterans are connected to needed VA health care services.

A psychiatric mobile clinic in rural Ghana as a model to deliver professional services to a huge catchment area, review of 12 years experience

IntroductionThe population in remote areas in Ghana as in other low- and middle- income countries (LMIC’s) are known to suffer from limited access to quality mental health services. The challenges include limited inpatient and outpatient mental health services at the regional and district levels, shortage of well-trained professionals, poor funding by the government and difficulties for the patients to pay for medical costs, poor telecommunication services and the lack of adequate infrastructure.ObjectivesWe present a novel model of professional psychiatric mobile clinic, Gye Nyame Mobile Clinics, in remote areas in Ghana. This comprehensive service package connects the current loose ends of existing structural efforts in the subdistricts, trains regularly district hospital teams and bridges the gap between district hospital, primary health posts down to every patient.MethodsIn this retrospective descriptive study we collected demographic data of all the patients who visited the Gye Nyame professional mobile clinic in Psychiatry (GNMC) from November 1, 2008 to October 31, 2019 in the ten health posts of Ghana’s Ashanti RegionResultsBetween November 2008 and October 2019, we counted 16.370 visits of patients with psychiatric/ neurological diagnosis. The patients suffered mostly from schizophrenia in 24,1%, general convulsions in 40,8 % and other psychotic disorders in 5,9% of the visits. 78,5% returned to our mobile clinic for follow-up, 100% could be treated on outreach.ConclusionsThis community-based approach delivers psychiatric services to subdistrict and district levels and to patients who have no other access to these professional services. According to the results, a wide spectrum of pathologies and quantity of patients are seen – especially patients with no former treatment- the most common diagnosis in the rural area are schizophrenia, other psychotic disorders and generalized convulsions, followed by intellectual disabilities/autism spectrum disorder and cerebral malaria neuropsychiatric complications.This is the first study to evaluate the implemented impact of integrated psychiatric services into existing structures in remote areas of LMIC`s.Disclosure of InterestNone Declared

The impact of the COVID-19 pandemic on children and adolescent mental health inpatient service use in England: An interrupted time-series analysis of national patient records

IntroductionDuring the COVID 19 pandemic children and young people (CYP) faced significant restrictions. The virus and restrictions also affected how health services could function, including mental health. Research analysing the COVID 19 pandemic is important to ensure dynamic and resilient service design in case of future national emergencies.ObjectivesTo investigate the impact of COVID-19 lockdowns on CYP psychiatric admission trends during lockdowns 1 (started 26 March 2020) and 2 (started 20 November 2020) of the COVID 19 pandemic in England.MethodsRoutinely collected, retrospective, English, administrative data looking at the CYP hospital admissions, length of stay and patient demographics were analysed using an interrupted time series analysis to compare pre-pandemic service use with service use during COVID 19 lockdowns 1 and 2. The analysis used an ordinary least squares (OLS) approach with Newey–West standard errors to handle autocorrelation and heteroscedasticity.ResultsTable 1.Patient characteristics in the entire sample (n=6,250)VariablePre-pandemicPost-pandemicTotal sample(n=1,156)(n=94)(n=6,250)Mean age at admission (SD) [Median; IQR]15.3 (1.7) [16;3]15.6 (1.6) [16;2]15.3 (1.7) [16;3]GenderFemale70%72%70%Missing1%2%1%BAME backgroundYes18%18%18%Missing7%6%7%Looked afterYes11%8%11%Missing14%13%14%In full educationYes43%34%43%Missing35%47%35%Mean number of admissions per patient (SD) [Median; IQR]1.7 (1.2) [1;1]1.2 (0.6) [1;0]1.7 (1.2) [1;1]Mean length of stay (SD) [Median; IQR] n93 (94) [68;94] 6,06565 (65) [43;77] 7193 (94) [67;94] 6,136Mean number of out-of-area admissions per patient (SD) [Median; IQR]0.48 (0.8) [0;1]0.33 (0.6) [0;1]0.48 (0.80) [0;1]SD: standard deviation; IQR: Interquartile rangeImage:Image 2:Image 3:ConclusionsDuring lockdown 1 and 2, psychiatric admissions for CYP were fewer and shorter. The rise in admissions for more deprived CYP and looked after children suggests these CYP may have been disproportionately affected by the pandemic.Disclosure of InterestNone Declared

Examining the outcomes of the first one hundred residents in a community based residential rehabilitation unit for people affected by severe and persistent mental illness.

Community-based residential rehabilitation for people experiencing severe and persistent mental illness (SPMI) is increasingly available as an alternative to psychiatric inpatient care. Understanding who accesses these services and their outcomes will inform the optimal allocation of limited public mental health resources. This retrospective cohort study explored the outcomes of the first 100 consumers supported by a new Australian Community Care Unit (CCU). The primary outcome focus was acute mental health service use (emergency department presentations, acute mental health inpatient admission days), and secondary outcome foci were accommodation independence and substance use. When the 365 days before and after CCU support were compared, significant reductions in acute mental health bed days were observed (22days, W = 3.373, p = .001); greater reductions were noted for those staying >182 days (31days, W = 3.373, p = .001). Additionally, significant improvements in accommodation independence were found, (W = 3.373, p = .001). CCU consumers experienced reductions in acute mental health inpatient service use and improved accommodation independence. These observations are consistent with the intended functioning of the residential rehabilitation service.

Mental health and neurocognitive disorder–related hospitalization rates in immigrants and Canadian-born population: a linkage study

ObjectivesMental health and neurocognitive conditions are important causes of hospitalization among immigrants, though patterns may vary by immigrant category, world region of origin, and time since arrival in Canada. This study uses linked administrative data to explore differences in mental health hospitalization rates between immigrants and individuals born in Canada.MethodsHospital records from the Discharge Database and the Ontario Mental Health Reporting System for 2011 to 2017 were linked to the 2016 Longitudinal Immigrant Database and to Statistics Canada’s 2011 Canadian Census Health and Environment Cohort. Age-standardized hospitalization rates for mental health–related conditions (ASHR-MHs) were derived for immigrants and the Canadian-born population. ASHR-MHs overall and for leading mental health conditions were compared between immigrants and the Canadian-born population, stratified by sex and selected immigration characteristics. Quebec hospitalization data were not available.ResultsOverall, immigrants had lower ASHR-MHs compared to the Canadian-born population. Mood disorders were leading causes of mental health hospitalization for both cohorts. Psychotic, substance-related, and neurocognitive disorders were also leading causes of mental health hospitalization, although there was variation in their relative importance between subgroups. Among immigrants, ASHR-MHs were higher among refugees and lower among economic immigrants, those from East Asia, and those who arrived in Canada most recently.ConclusionDifferences in hospitalization rates among immigrants from various immigration streams and world regions, particularly for specific types of mental health conditions, highlight the importance of future research that incorporates both inpatient and outpatient mental health services to further understand these relationships.

A comparison of patient-reported quality between inpatient services for mental and physical health: A tertiary-hospital-based survey in China.

It is widely acknowledged that quality of mental health services is routinely worse than physical health services across countries. However, studies separately investigating mental health services often report high-level satisfaction, even comparing with physical health services. Therefore, this study aimed to compare patient-reported quality between inpatient services for mental and physical health in China. An inpatient survey was conducted among service users of mental and physical health services. Patient-reported quality was measured by the responsiveness performance questionnaire after patient discharge and based on patients' multiple experiences of hospitalization in the past 3 years. Chi-square tests were performed to compare the two patient groups' ratings on inpatient services for mental and physical health, and multivariate logistic regression was performed to adjust covariates in the group comparison. Inpatient services for mental health were rated better than those for physical health on "treating with respect" (AOR = 3.083, 95% CI = 1.102-8.629) and "choosing a healthcare provider" (AOR = 2.441, 95% CI = 1.263-4.717). However, mental health services had poorer ratings on "asking patient's opinions" (AOR = 0.485, 95% CI = 0.259-0.910). For other responsiveness items, no significant difference was detected between the two types of inpatient services. Mental health inpatient services provided by China's tertiary hospitals could perform as well as physical health inpatient services in most aspects and even better perform regarding dignity and choice of healthcare providers. However, neglecting patients' voices is more severe in inpatient services for mental health.

Imprisonment following discharge from mental health units: A developing trend in New Zealand.

Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years. A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health. Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission. We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.

Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach.

INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.