Long-stay Psychiatric Inpatients Research Articles

Audit of Physical Health Monitoring in Long-Stay Psychiatric Inpatients on Clozapine in NHS Ayrshire & Arran

AimsThere is a body of evidence showing the health inequalities faced by people with schizophrenia, with some studies indicating that their life expectancy is approximately 20 years less than that of the general population. The vast majority of patients with schizophrenia require long-term treatment with antipsychotic medications, such as Clozapine. These can lessen disease burden significantly however can be accompanied by adverse effects, including metabolic syndrome. This audit aimed to determine whether the local physical health monitoring guidelines for those on Clozapine are being carried out for long-stay patients in inpatient forensic and rehabilitation psychiatry services in NHS Ayrshire & Arran.MethodsThe guideline “National Standard for Monitoring the Physical Health of People Being Treated with Clozapine” was issued by the Scottish Government in 2017. This guideline advises on physical health parameters which benefit from monitoring during Clozapine titration and on-going therapy. This audit reviewed whether the parameters with specified frequencies, such as annual LFT monitoring, were being monitored within the recommended timeframes.ResultsIn our group of 18 patients on long-term Clozapine therapy, 10 had undergone a serum fasting blood glucose and 12 had a lipid profile checked in the preceding 6 months. Meanwhile, all 18 had liver function tests done within the last year prior to data collection. All patients had a BMI, heart rate and blood pressure reading documented in the last year, while 12 out of 18 had an ECG carried out in the same time period.ConclusionThis audit has revealed a mixed picture in terms of the adherence to guidelines for physical health monitoring for our long-stay forensic and rehabilitation patients on Clozapine therapy. A need for more fastidious blood test monitoring within the forensic service has been identified, with a particular focus on the measuring of serum fasting blood glucose and lipid panels. It was noted that a physical health monitoring checklist incorporating the above guidelines had previously been introduced into the rehabilitation ward, and the benefit of this was demonstrated in the 100% adherence they achieved. We have therefore decided to introduce a similar checklist to the forensic wards as our intervention, with a plan to re-audit in 6 months' time.

Multivitamin, mineral, and n-3 PUFA supplementation to reduce aggression among long-stay psychiatric inpatients: a randomized clinical trial

IntroductionAggression and violent incidents are a major concern in psychiatric inpatient care. Nutritional supplementation was found to reduce aggressive incidents and rule violations in forensic populations and in children with behavioral problems.ObjectivesTo assess whether multivitamin, mineral, and n-3 PUFA supplementation would reduce the number of aggressive incidents among long-stay psychiatric inpatients.MethodsThe trial was a pragmatic, multicenter, randomized, double-blind, placebo-controlled study. Data were collected from 25 July 2016 through 29 October 2019 at 8 local sites for mental healthcare in the Netherlands and Belgium. Participants were randomized (1:1) to receive either three supplements containing multivitamins, minerals, and n-3 PUFA or placebo for 6 months. The primary outcome was the number of aggressive incidents using the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcomes were the patients’ quality of life, affective symptoms, and adverse events.ResultsIn total, 176 participants were randomized (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (SD = 14.5), and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in those assigned to supplements (1.03 incidents per month; 95% confidence interval [CI]: 0.74-1.37) and placebo (0.90; 95% CI: 0.65-1.19), with a rate ratio of 1.08 (95% CI: 0.67-1.74; p = .75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes.ConclusionsSix months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric inpatients.DisclosureNo significant relationships.

Effects of multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation on aggression among long-stay psychiatric in-patients: randomised clinical trial

Aggression and violent incidents are a major concern in psychiatric in-patient care. Nutritional supplementation has been found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems. To assess whether multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation would reduce the number of aggressive incidents among long-stay psychiatric in-patients. The trial was a pragmatic, multicentre, randomised, double-blind placebo-controlled study. Data were collected from 25 July 2016 to 29 October 2019, at eight local sites for mental healthcare in The Netherlands and Belgium. Participants were randomised (1:1) to receive 6-month treatment with either three supplements containing multivitamins, minerals and n-3 polyunsaturated fatty acid, or placebo. The primary outcome was the number of aggressive incidents, determined by the Staff Observation Aggression Scale - Revised (SOAS-R). Secondary outcomes were patient quality of life, affective symptoms and adverse events. In total, 176 participants were randomised (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (s.d. 14.5) and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in supplement (1.03 incidents per month, 95% CI 0.74-1.37) and placebo groups (0.90 incidents per month, 95% CI 0.65-1.19), with a rate ratio of 1.08 (95% CI 0.67-1.74, P = 0.75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes. Six months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric in-patients.

Lessons learned from two clinical trials on nutritional supplements to reduce aggressive behaviour.

BackgroundSetting up and conducting a randomised controlled trial (RCT) has many challenges—particularly trials that include vulnerable individuals with behavioural problems or who reside in facilities that focus on care as opposed to research. These populations are underrepresented in RCTs.ApproachIn our paper, we describe the challenges and practical lessons learned from two RCTs in two care settings involving long‐stay psychiatric inpatients and people with intellectual disabilities. We describe five main difficulties and how these were overcome: (1) multisite setting, (2) inclusion of vulnerable participants, (3) nutritional supplements and placebos, (4) assessment of behavioural outcomes, and (5) collecting bio samples.ConclusionsBy sharing these practical experiences, we hope to inform other researchers how to optimally design their trials, while avoiding and minimising the difficulties that we encountered, and to facilitate the implementation of a trial. Both trials were registered in the Clinical Trials Register (RCT A: NCT02498106; RCT B: NCT03212092).

정신병원 장기입원환자에 대한 정신건강증진센터의 퇴원연계서비스 모형 개발을 위한 참여실행연구

본 연구는 참여실행연구방법을 이용하여 화성시 정신건강증진센터가 실행한 장기입원 정신질환자 지역사회 재배치 사업과정에서 드러난 문제 해결을 도모하고 그 과정에서 개발된 정신건강증진센터의 퇴원연계서비스 모형과 그 성과를 고찰하였다. 본 연구자는 화성시 정신건강증진센터는 장기입원 정신질환자의 재비치 사업에 자문위원으로 참여하여, 정신건강증진센터가 경기도 권역의 총 7개 정신병원에 재원한 54명의 장기입원환자들의 퇴원상담을 진행하는 과정에서 퇴원연계서비스모형 개발에 참여하였다. 이 과정에서 다양한 방법을 통하여 자료가 수집되고 분석되었다. 문헌조사와 정신건강증진센터의 내부업무자료 및 업무진행회의를 통하여 퇴원연계서비스 모형을 개발하고 실행하는 과정의 자료가 수집되었고, 이 서비스를 통하여 퇴원한 장기입원 환자들에 대한 사례관리 및 종단적인 추적조사 자료가 수집되었다. 연구의 주된 결과로서 지역사회 정신건강증진센터의 정신의료기관 장기입원 정신질환자에 대한 지역사회 퇴원연계서비스 모형을 제시하였고, 3차년도 6차년도 사업시점에서의 퇴원연계서비스 모형을 통하여 퇴원한 퇴원자 추적조사 결과를 제시하였다. 본 연구의 주된 함의는 정신건강증진센터의 장기입원 정신질환자 퇴원연계서비스를 통하여 장기입원 정신질환자의 지역사회복귀를 도모할 수 있는 중요한 ‘통로(pathway)

Long-term psychiatric inpatients\u2019 perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study

BackgroundObesity is a significant problem for people with serious mental illness. We aimed to consider body size from the perspective of long-stay psychiatric inpatients, focussing on: weight gain and its causes and impacts; diet and physical activity; and the perceived ability to make meaningful change in these domains.MethodA mixed methods study with 51 long-term psychiatric forensic and rehabilitation inpatients using semi-structured interviews combined with biometric and demographic data.Results94% of participants were overweight or obese (mean BMI 35.3, SD 8.1). They were concerned about their weight, with 75% of them attempting to lose weight. Qualitative responses indicated low personal effectiveness and self-stigmatisation. Participants viewed their weight gain as something ‘done to them’ through medication, hospitalisation and leave restrictions. A prevailing theme was that institutional constraints made it difficult to live a healthy life (just the way the system is). Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster. Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavour to achieve better health outcomes. Consulting people as experts on their experiences, preferences, and goals may help develop new solutions, remove unidentified barriers, and improve motivation.ConclusionsThe importance of an individualised, multifactorial approach in weight loss programmes for this group was clear. Patient-led ideas and co-design should be key principles in programme and environmental design.

정신병원 장기입원환자에 대한 퇴원적절성평가 도구 개발을 위한 실행연구

본 연구는 실행연구방법을 이용하여 화성시 정신건강증진센터의 중증정신질환자관리사업팀이 정신병원 장기입원원환자의 지역사회 재배치 사업에서 개발한 정신병원 장기입원환자에 대한 퇴원적절성 평가도구를 소개하고, 2016년까지 퇴원적절성 평가 도구를 사용하여 축척한 양적자료 및 질적자료를 분석하여 퇴원적절성 평가 도구의 임계치를 탐색하고자 하였다. 실행연구팀은 화성시 정신건강증진센터의 센터장과 3명의 중증정신질환자관사업팀원, 그리고 자문교수로 참여한 본 연구자로 구성되었으며, 2011년 1년 동안 중증정신질환자관리사업팀이 경기도 권역의 총 7개 정신병원에 11회 방문하여 81명에 대한 초기상담을 진행하면서 자료를 수집하고, 이에 대해 월2회의 자체 업무진행회의 및 총 5회의 자문회의를 통하여 퇴원적절성평가 도구를 개발하였다. 중증정신질환자관리사업팀은 2016년까지의 사업에서 90명의 퇴원적절성평가 점수를 축적하였고, 본 연구에서는 이를 이용하여 퇴원적절성에 대한 임계치를 탐색하였다. 본 연구의 주요 연구결과는 퇴원연계 과정에서 퇴원적절성을 체계적으로 평가할 10개의 항목(증상, 위험도, 퇴원 욕구, 재활기본능력, 가족협조, 나이, 병식, 약물관리, 입원기간, 직업력)으로 구성된 퇴원적절성 평가도구이며, 양적 질적 자료를 탐색한 결과 6점 또는 8점이 가장 변별력 있는 임계치로 나타났다. 본 연구 결과의 주된 함의를 논의하여 제시하였다.

S4. ASYMMETRIC DRUG-INDUCED PARKINSONISM IS RELATED TO PSYCHOPATHOLOGY

BackgroundDrug-Induced Parkinsonism (DIP) is the most common movement disorder induced by antipsychotics. The prevalence of DIP in chronic psychiatric populations ranges between 17 and 72% (1–3). Although, DIP is mostly symmetric, asymmetric DIP is reported in 18 to 54% of the patients. (4). There are no studies to the clinical relevance of asymmetric DIP. We investigated the prevalence of motor asymmetry in DIP and its relationship to the severity of psychopathology in a prospective study.MethodsIn a cohort study of 207 long-stay psychiatric inpatients the prevalence of DIP was assessed at least two times (mean follow-up 1.1 year) in each patient (5). DIP was assessed with the Unified Parkinson Disease Rating Scale (UPDRS) and the prevalence of persistent DIP was 56.2%. Patients with at least one time parkinsonism in the upper/lower limb(s) were included for analyses. Asymmetry of parkinsonism was calculated with the symmetry index (Figure 1). A cut-off value of ≥ 0,20 was used for the definition of asymmetric DIP. Multilevel mixed models were built to explore the relationship between asymmetry in DIP and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI).ResultsIn a cohort study of 207 long-stay psychiatric inpatients the prevalence of DIP was assessed at least two times (mean follow-up 1.1 year) in each patient (5). DIP was assessed with the Unified Parkinson Disease Rating Scale (UPDRS) and the prevalence of persistent DIP was 56.2%. Patients with at least one time parkinsonism in the upper/lower limb(s) were included for analyses. Asymmetry of parkinsonism was calculated with the symmetry index (Figure 1). A cut-off value of ≥ 0,20 was used for the definition of asymmetric DIP. Multilevel mixed models were built to explore the relationship between asymmetry in DIP and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI).DiscussionDIP is asymmetric in 1 of 5 patients. Therefore, the clinical rule that Parkinson’s disease always starts asymmetrically and such may be helpful to differentiate between Parkinson’s disease and DIP is not valid. Asymmetric presentation of DIP is of clinical relevance as it is related to the severity of psychopathology. Asymmetric DIP may alert the clinician of more severe psychopathology. Replication is indicated to examine the robustness of the relationship.

Prise en charge de pathologie cancéreuse avancée chez des patients institutionnalisés en psychiatrie: une étude pilote

BackgroundThe prevalence of cancer is not well established and probably underestimated in long-stay psychiatric inpatients. Psychiatric patients do not have the same access for cancer screening and care. Therapeutic decision-making is a real ethical problem. In this context, access to medical care should be provided by the establishment of guidelines and/or recommendations for this specific population. The aim of our study was to assess how cancer was managed among long term psychiatric inpatients. MethodologyFor this pilot study, we used a mixed methodology: a quantitative part with a retrospective chart review of cancer patients in a psychiatric institution and a qualitative part based on semi-structured interviews with psychiatrists with discourse analysis. Results and discussionDelay in cancer diagnosis can be explained by communication and behavior disorders, inadequate screening, and additional tests often refused by patients. Compliance and ethical issues (i.e. obtaining informed consent) are many pitfalls to optimal cancer care that should be explored in further research.

New long-stay psychiatric in-patients: a comparison of UK and Irish national audit.

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Risk Factors for Overweight and Diabetes mellitus in Residential Psychiatric Patients

Objective: To investigate the prevalence of and risk factors for overweight and diabetes mellitus in long-stay psychiatric inpatients. Method: Statistical analysis of data collected from medical, laboratory, and pharmacy files. Results: 80% of the 256 patients were suffering from schizophrenia or other psychotic disorders. The prevalence of diabetes mellitus was 15%. The prevalence of a disturbed glucose tolerance was 14%. Severe overweight (BMI > 30) was positively associated with the use of clozapine (odds ratio (OR) = 2.7; 95% confidence interval (CI): 1.31–5.75), but negatively with the diagnosis schizophrenia (OR = 0.4; 95% CI: 0.22–0.88). Diabetes mellitus was associated with severe overweight (OR = 3.5; 95% CI: 1.57–7.69). Caucasian patients were at a lower risk for diabetes mellitus (OR = 0.2; 95% CI: 0.08–0.54). Conclusions: In residential psychiatric patients, diabetes mellitus is especially associated with overweight and non-Caucasian origin. In this survey, the use of clozapine was associated with overweight, but not directly with diabetes mellitus. Diabetes mellitus is highly prevalent, which calls for screening for diabetes mellitus at regular intervals.

A comparison of 25-hydroxyvitamin D serum levels in acute and long-stay psychiatric inpatients: A preliminary investigation

summary Background and aims: Little is known about the vitamin D status of patients with severe psychiatric disorders, a potential contributing factor to elevated rates of morbidity and mortality. This descriptive study assessed serum 25-hydroxyvitamin D [25(OH)D] levels in hospital patients with schizophreniaspectrum disorder, compared to a non-patient control group. Methods: Assessment of serum 25(OH)D levels in 20 acute care (� 60 days), 20 long-stay (� 6 months) adult public psychiatric hospital inpatients with schizophrenia-spectrum disorders, compared to 20 normal controls. Results: High rates of hypovitaminosis D were found in all three groups with no significant differences in

Bone mineral density and general health of long-term residential psychiatric inpatients.

The aim of this study was to determine the rates of osteopenia and osteoporosis and other general health problems in a long-stay male psychiatric unit. All 15 patients underwent a semi-structured clinical interview and a full physical examination including calculation of Body Mass Index, central obesity (abdominal circumference) and blood pressure measurement. All patients had blood sampling examining FBC, U&E, LFTs, TFTs, PSA, prolactin, lipid profile and glucose. The rates of metabolic syndrome were calculated according to the International Diabetes Federation consensus worldwide definition. Bone mineral density was determined in the lumbar vertebrae and left hip by DEXA scanning. The prevalence of osteopenia or osteoporosis was 46%, and bone mineral density was inversely correlated with serum prolactin levels (r = -0.595, p = 0.041) and chlorpromazine equivalence (r = -0.645, p = 0.017). The prevalence of obesity was 53%, while central obesity was present in 87% of patients. Metabolic Syndrome was present in 27% of patients. More attention should be given to diagnosing and treating osteopenia and osteoporosis in patients on long-term antipsychotic agents and preventative measures should form part of any treatment regime in these individuals. Frequent input from dietitians should also be available for long-stay psychiatric inpatients to reduce the prevalence of obesity.

Audit of metabolic syndrome in adults prescribed clozapine in community and long-stay in-patient populations

Aims and MethodsTo calculate the prevalence of metabolic syndrome in patients receiving clozapine in community and long-stay in-patient settings. Patients were assessed using measures specified by the Expert Panel of the US National Cholesterol Education Program.ResultsThe prevalence of the metabolic syndrome was calculated as 53% in the community groups and 11% in the in-patient group, although both sample sizes (particularly the in-patient group) were small. Women were more frequently affected than men in the community population.Clinical ImplicationsThe higher percentage of metabolic syndrome in the community patients receiving clozapine has implications with respect to physical health. The reasons for the lower percentage in the in-patient group are unclear. Our findings point to a possible difference in the physical health of long-stay psychiatric in-patients and patients in the community.

Autonomy of long-stay psychiatric inpatients

To assess personal autonomy of long-stay psychiatric inpatients, to identify those patients who could be discharged and to evaluate the impact of sociodemographic variables, social functioning, and physical disabilities on their autonomy was also assessed. A total of 584 long-stay individuals of a psychiatric hospital (96% of the hospital population) in Southern Brazil was assessed between July and August 2002. The following instruments, adapted to the Brazilian reality, were used: independent living skills survey, social behavioral schedule, and questionnaire for assessing physical disability. Patients showed severe impairment of their personal autonomy, especially concerning money management, work-related skills and leisure, food preparation, and use of transportation. Autonomy deterioration was associated with length of stay (OR=1.02), greater physical disability (OR=1.54; p=0.01), and male gender (OR=3.11; p<0.001). The risk estimate of autonomy deterioration was 23 times greater among those individuals with severe impairment of social functioning (95% CI: 10.67-49.24). In-patients studied showed serious impairment of autonomy. While planning these patients' discharge their deficits should be taken into consideration. Assessment of patients' ability to function and to be autonomous helps in identifying their needs for care and to evaluate their actual possibilities of social reinsertion.

Improving the physical health of long-stay psychiatric in-patients

Research evidence has shown that morbidity and mortality rates are higher in psychiatric patients than in the general population. This article describes factors that affect the physical health of psychiatric patients living in institutions and the steps that can be taken to review, monitor and improve their physical health. The physical health care of long-stay patients should reach the same standards as those expected in the general population.

Long-term outcome of long-stay psychiatric in-patients considered unsuitable to live in the community. TAPS Project 44.

Whereas the majority of long-stay in-patients have been successfully resettled in the community, there is a group of such patients who are too disturbed or disturbing to be managed in standard community homes. To study the long-term outcome of a group of 72 long-stay psychiatric inpatients, regarded as unsuitable for community placement. A prospective cohort study with follow-ups at 1 year and 5 years. The patients' mental state remained unchanged after 1 year and 5 years. The level of functioning and social behaviour showed minimal change after 1 year, but then improved over the next 4 years. The profile of problematic behaviours changed significantly over 5 years, with a reduction of 50% in their frequency. Physical aggression practically disappeared. The improvements in behaviour enabled 29 patients (40% of the study group) finally to be resettled in various care homes, gaining better access to community amenities and living more independently. A high proportion of patients with severe disabilities, designated as 'difficult to place' in the community, could benefit from slow-stream rehabilitation within specialised facilities, enabling them to move into ordinary community homes.

Self and Illness: Changing Relationships in Response to Life in the Community Following Prolonged Institutionalisation

Increasingly since the 1950s mentally ill people in the Western world have been removed from institutional care. In this paper I am concerned primarily with the response of psychiatric patients to living in a ‘normal’ community environment, in particular the extent to which they are able to assume new social roles and identities after long periods of institutional care. I conclude that despite persistent mental illness, deinstitutionalised patients have developed new roles and new identities, a new sense of independence, new coping abilities and a capacity to articulate future goals and desires.The findings are drawn from two and a half years fieldwork in an Australian capital city, where a group of long‐stay psychiatric in‐patients, who would not normally be considered for discharge, were given the opportunity to live in mainstream society. This accompanied the reduction of in‐patient beds and the eventual closure of a large psychiatric hospital as it amalgamated with another hospital nearby.

Moving out and moving on: some ethnographic observations of deinstitutionalization in an Australian community.

Since the 1950s deinstitutionalization has taken place for people with mental illnesses in the Western world. The growth of community care and residential facilities, as well as planning and implementation of policies, has varied in timing and orientation. An appreciation of the process of change affecting people discharged to the community highlights their strength, resilience, and vulnerabilities. This paper outlines a two and a half year ethnographic qualitative study undertaken in Australia, where 47 long-stay psychiatric inpatients were discharged to the community. The process accompanied the amalgamation of two major psychiatric hospitals, resulting in the closure of one. Findings demonstrated slow but positive change for residents as they reintegrated into the community. A separate quantitative and economic study was undertaken alongside the qualitative study (for results see Hobbs, et al., 2000; Newton, et al, 2000; Lapsley, et al., 2000).

Community placement of long-stay psychiatric patients in northern Finland.

Rapid deinstitutionalization occurred in Finland in the 1990s, a decade later than in many other Western countries. A four-year follow-up study in northern Finland examined community placements of 253 long-stay psychiatric inpatients after deinstitutionalization in 1992 and at follow-up at the end of 1995. About 70 percent of the patients were discharged. Only 15 percent were able to live outside the hospital without continuous support. No patient was homeless at follow-up. Being unmarried, living in the city of Oulu, and having greater severity of illness were associated with hospitalization at follow-up. The results showed that long-stay patients are dependent on considerable support. Alternative residential facilities have made deinstitutionalization possible.