Use Of Psychiatric Beds Research Articles

A mirror image study of the utility of long acting aripiprazole

Aims and backgroundAblify Maintena (AM) is a long acting injection of aripiprazole that received marketing authorisation in the UK in January 2014. It is costly compared to first generation antipsychotics (FGAs) LAIs and there are no robust trials comparing AM with FGAs. We examined the effectiveness and use of AM in a mental health trust.MethodsWe identified all patients prescribed AM in North Staffordshire (population: 470,000) since launch and examined records for demography, diagnosis, bed and medication use. We examined the effectiveness of AM using a mirror image design.ResultsThirty patients received AM in a time frame allowing a 1-year follow-up. Sixty-nine percent were male and the mean age was 39 years. Over half were detained under the 1983 Mental Health Act and 30% were inpatients on a psychiatric intensive care unit when AM was started. Twenty-eight patients had a psychotic diagnosis. There was a significant reduction in bed occupancy (63 v 6 days, P = 0.0001) and admissions (1.6 v 0.5, P = 0.0001). The median dose was 400 mg. Lack of effectiveness/poor adherence with prior treatments were the main reason for starting AM in 84%. Eighty-six percent of patients clinically improved on AM. Blood parameters were in the normal range.DiscussionWithin the limitations of the methodology, our results show a reduction in psychiatric bed use in the year following AM initiation on an intention to treat basis. The reduction in bed use equates to a minimum annual saving of £14,250 per patient. AM at the median study dose costs £2645 per year.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The dynamics of psychiatric bed use in general hospitals.

This study examines general hospitals' adjustments in psychiatric bed utilization practices in response to increases in psychiatric inpatient admissions. Using panel data from 439 hospitals, monthly observations (N=7,831) between 2007 and 2010 on psychiatric admissions, psychiatric bed occupancy rates, and average length-of-stay were created for psychiatric inpatients. In fixed-effects regressions, an increase in psychiatric admissions was associated with an increase in the probability of psychiatric bed use exceeding 100% occupancy and with a reduction of mean length-of-stay. These results were confirmed in instrumental variables models. General hospitals may dynamically adjust bed utilization practices in response to changing psychiatric bed needs. An implication of this dynamic adjustment model is that bed shortages are likely to be local, transitory events.

EPA-0236 – Paliperidone palmitate: a one year mirror image study

Aims and Background Paliperidone palmitate (PP) is a long acting depot antipsychotic that received marketing authorisation in the UK in 2011. It is costly compared to first generation antipsychotics (FGAs) and there are no robust trials comparing PP with FGAs. We examined the effectiveness and use of PP in a mental health trust as well as the characteristics of patients prescribed PP. Methods We identified all patients prescribed PP in North Staffordshire (population 470 000) since launch and examined records for demography, diagnosis, bed and medication use. We examined the effectiveness of PP using a mirror image design with bed use as the primary outcome. Results 52 patients received PP in a time frame allowing a one year follow up. 58% were male and the mean age was 41 years. Over half were detained under the 1983 Mental Health Act. 51 patients had a psychotic diagnosis. There was a significant reduction in bed occupancy (44 v 26 days, P=0.018) and admissions (1.1 v 0.2, P=0.0001). The mean dose was 100mg. Lack of effectiveness was the primary reason for starting PP in 84%. Two patients stopped due to side effects and 26% due to lack of efficacy. Discussion Within the limitations of the methodology our results show a reduction in psychiatric bed use in the year following PP initiation on an intention to treat basis. The reduction in bed use equates to a minimum saving of £5400 per patient. PP at the mean study dose costs £3769.

A two-model integrated personality disorder service: two-year follow up of effect upon psychiatric bed use

Purpose – Following on from an earlier published study, the purpose of this paper is to further clarify with a larger sample and over a longer timescale of two years the effect of a therapeutic-community informed personality disorder service intervention upon psychiatric in-patient bed use. The service integrates two psychoanalytical models; a mentalization-based treatment (MBT) and a service user network (SUN) model. Design/methodology/approach – The number of psychiatric bed days used by patients attending each arm of the service model (SUN and MBT) was collated using the electronic patient records system. Bed use in the six-12-18-and 24-month period before each patient started treatment was compared with bed use in the same periods after starting treatment. Findings – There appeared no significant increase after intervention in the group of patients using no psychiatric beds prior to intervention. Bed use in the second group (those using beds prior to intervention) appeared significantly reduced by six months and the reduction continued to prove significant at 12 and 18 months post-intervention. In relation to the component arms of the service, a significant reduction in bed use was seen in each of the MBT and SUN interventions at six, 12, 18 and 24 months after commencement. However, due to the small sample sizes, these results lacked sufficient power to afford a meaningful comment upon the effect of component arms. Research limitations/implications – Intervention by the TC informed two-model integrated personality disorder service had a statistically significant effect overall on reducing bed use, which was maintained at six and 12 months. Practical implications – The paper supports the finding of the authors’ previous study; a therapeutic model of care that significantly reduces psychiatric bed use. That the reduction in psychiatric bed use continues to further appear highly significant at 18 months suggest that our service has an enduring effect upon inpatient psychiatric resources. Originality/value – The paper describes a unique model of care currently successfully employed in the therapeutic management of people with personality disorder. The model is replicable and effective and offers some possibilities for the development of therapeutic-community informed practice.

Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: randomized controlled trial

Nidotherapy is the systematic modification of the environment to create a better fit for people. This is the first randomized controlled trial of its efficacy in an assertive community team. Patients in an assertive outreach team with continued management problems together with comorbid personality disturbance and severe mental illness were randomized to nidotherapy enhanced assertive treatment (up to 12 sessions) or to continued assertive outreach care. Use of psychiatric beds over one years (primary outcome) and change from base-line in other health service resources, psychiatric symptoms, social functioning and engagement with services were measured at 6 and 12 months (secondary outcomes). 52 patients were recruited over 13 months, with 49 and 37 assessed at 6 and 12 months. Patients referred to nidotherapy had a 63% reduction in hospital bed use after one year compared with control assertive care (P = 0.13) and showed non-significant improvement in psychiatric symptoms, social functioning and engagement than the control group. The mean cost savings for each patient allocated to nidotherapy was 4,112 pounds sterling per year, mainly as a consequence of reduced psychiatric bed use. Nidotherapy may be a cost-effective option in the management of comorbid serious mental illness and personality disorder, but larger confirmatory trials are necessary.

General psychiatric services in the community as an alternative to hospital admission: a review of recent research evidence

There have been a number of systematic investigations of alternative ways of delivering psychiatric care, a number of studies of so-called ‘alternatives’ to psychiatric care, and some studies of community care services received after in-patient care. This paper reviews research evidence which suggests that when general psychiatric services are located in community settings, for example psychiatric out-patient services in primary care settings, or multidisciplinary teams in a community base, the use of psychiatric beds in hospital can be reduced.

The impact of severe mental illness, co-morbid personality disorders and demographic factors on psychiatric bed use

The use of inpatient psychiatric services has been correlated with certain demographic and clinical variables. However, there is limited information about the impact of personality disorder. To describe the impact of severe mental illness, personality disorders and demographic variables on psychiatric bed use amongst people in contact with a Community Mental Health Team (CMHT). Two-year retrospective and 2-year prospective bed use by the caseload of one Community Mental Health Team. Psychotic disorders (odds ratio 2.7), personality disorders (OR 2.2), marital status (OR 2.1) and unemployment (OR 1.9) were significantly related to psychiatric admissions from community care. Gender, accommodation, drug and alcohol problems, and ethnicity were not. Psychosis, personality disorder and unemployment appear to have independent effects on psychiatric bed use. Patients with a combination of psychotic disorders and diffuse personality disorders were very high users of inpatient services. This suggests that this group have particular needs that community mental health teams find difficult to manage.

Social deprivation and the use of secure psychiatric beds

The objective of this study was to identify population-based characteristics that can predict and explain variations in secure psychiatric bed use at health authority level in England. Variables that characterize differences between health authority areas were first identified using factor analysis. A subset of these was then used in multiple regression analysis to predict variations in total secure bed days. A measure of the supply of supported housing was also entered into the model. Four-fifths of variation could be explained by Black ethnicity, Asian ethnicity, population density, number of people aged over 65, number of people single/widowed/divorced, number of people registered as permanently sick, and number of new registrations of drug use. The fit of the model was particularly good in inner London and other urban areas, but poorer in rural and 'maturer' -' areas. The addition of supported housing significantly increased the variation explained. Population-based data can be used to explain much of the variation in secure bed use, although the model is less satisfactory for non-urban areas. The supply of supported housing is associated with greater secure bed use.

National survey of use of hospital beds by adolescents aged 12 to 19 in the United Kingdom

Editorial by Macfarlane and Blum In contrast to North America and Australia, little attention has been paid to the use of health services by adolescents in the United Kingdom. The...

Psychiatric treatment of prisoners in general psychiatric wards exemplified by North Rhine-Westphalia and Rhineland-Pfalz

The study was intended to provide information on the frequency and general condition of inpatient and outpatient treatment of mentally disturbed prisoners in general psychiatry in Germany. Directors of psychiatric institutions and chief physicians of prisons in Nordrhein-Westfalen and Rheinland-Pfalz were interviewed via a standardized questionnaire. The use of inpatient psychiatric treatment was approximately 0.1 to 2.3% in 1997 with reference to the total admissions in 1997. The rare use of psychiatric beds in general psychiatry may reflect obstacles concerning the status of prisoners and reservations regarding difficult patients.

Social deprivation and the use of secure psychiatric beds

The objective of this study was to identify population-based characteristics that can predict and explain variations in secure psychiatric bed use at health authority level in England. Variables that characterize differences between health authority areas were first identified using factor analysis. A subset of these was then used in multiple regression analysis to predict variations in total secure bed days. A measure of the supply of supported housing was also entered into the model. Four-fifths of variation could be explained by Black ethnicity, Asian ethnicity, population density, number of people aged over 65, number of people single/widowed/divorced, number of people registered as permanently sick, and number of new registrations of drug use. The fit of the model was particularly good in inner London and other urban areas, but poorer in rural and 'maturer' areas. The addition of supported housing significantly increased the variation explained. Population-based data can be used to explain much of the variation in secure bed use, although the model is less satisfactory for non-urban areas. The supply of supported housing is associated with greater secure bed use.

Household crowding and compliance with outpatient treatment in patients with non-affective functional psychoses in São Paulo, Brazil.

Compliance with outpatient treatment can reduce the use of psychiatric inpatient services by people with severe mental disorders. In developing countries, socio-economic factors may be associated with compliance with outpatient treatment. A 2-year prospective cohort study was conducted of 99 patients with non-affective functional psychoses who were discharged from hospital. Standardized assessments were used for psychopathology, social functioning and use of psychiatric services. Forty-two patients (42.4%) missed all outpatient appointments for at least 2 consecutive months. Household crowding was the only variable associated with poor compliance, patients living in very crowded homes being more than twice as likely to show poor compliance as those living in less crowded homes. In large urban centres in developing countries, strategies to improve compliance with outpatient treatment targeted towards those living in overcrowded households may reduce use of psychiatric beds.

Deinstitutionalization and schizophrenia in Finland: I. Discharged patients and their care.

Finland has experienced one of the most rapid psychiatric deinstitutionalization processes in the world. Since 1980, the use of psychiatric beds has decreased about one-third. The effects of this deinstitutionalization were studied in the national Discharged Schizophrenia Patient Project. The study used three representative samples of patients with schizophrenia who were discharged from mental hospitals in 1982, 1986, and 1990, and followed them for 3 years. Patients with schizophrenia discharged at the beginning of the 1990s were older and more disturbed, and had been ill for a longer time than patients discharged at the beginning of the 1980s. The use of outpatient care increased and that of hospital care decreased, but because of the increased residential outpatient care, the total amount of residential care did not change during the study period. However, readmissions to the hospital increased. In patients with a long duration of illness, the increase in readmissions was exceptionally high; these patients also seemed to be losing their share of the residential outpatient services. On the whole, from the point of view of the psychiatric treatment system, deinstitutionalization seemed to have proceeded fairly successfully. The system proved able to redirect and use the available resources more effectively and to modify the structure of services according to the changing needs of patients discharged from hospitals. The well-developed social services have also supported this adaptation to the decreasing use of mental hospital beds.

Psychiatric service planning: Beds in perspective

The origins and validity of the British national planning “norm” for psychiatric beds are discussed. Evidence of present and future use of psychiatric beds is drawn from a number of studies relating to the remnant of earlier long-stay cohorts, the current accumulation of new long-stay patients, and the present use of beds for short and medium stays. The use of “beds” in the context of a comprehensive psychiatric service and the dangers of planning beds in isolation are discussed. Suggestions are made for an alternative approach to “norms” and psychiatric service planning.

Use of hospital beds in neighbouring East London boroughs.

SynopsisTwo adjacent areas of Greater London are compared to determine their respective use of psychiatric beds of different types. The one-day census is shown accurately to reflect average bed use in any year. The areas and hospitals involved employed different community and social work policies. A difference emerges in the use of long stay beds. A community-based social work service appears to make little impact on the use of short stay beds, and appears less successful than a hospital-related service in preventing hospital chronicity. Community social work services may identify psychogeriatric patients requiring hospital admission.