Hospital Psychiatric Unit Research Articles

Crisis hospitalization on a psychiatric emergency service

The availability of short-stay beds for brief admissions to a Psychiatric Emergency Service (PES) is a model that meets a variety of patient and system needs, allowing time to develop alternatives to hospitalization or gain diagnostic clarity, serving a respite function, providing a hospital setting that does not gratify dependency needs, and relieving inpatient census pressures. An eight-bed service for brief inpatient stays of up to 3 days was developed on a PES which serves a large nine-country catchment area in northeastern New York State. Admissions to this unit would otherwise have gone to a medical school teaching hospital psychiatric unit or a state psychiatric center. Fifty-one consecutive admissions were studied. The majority of patients were dischargeable in the short time frame and did not require transfer for longer-term care. The patients as a group showed improvement in psychiatric symptomatology and rated high satisfaction with the program. Most patients were diagnosed with schizophrenia or personality disorder (PD). Suicidality and substance abuse were frequent. The PD patients had a strong association with suicidality and some association with substance abuse, whereas the schizophrenics had more psychiatric symptomatology. PD patients were more likely to be discharged, leading us to propose a rationale for why this group may be uniquely suited to this approach. The study was replicated after a year on another sample of 51 consecutive admissions, confirming the earlier results and providing a 1-year follow-up on the program. The admission rate to the program was up 24%, and more PD patients and fewer schizophrenics were treated. Representative patients who benefited from the program were presented. A review of the treatment of two patients showed dramatic savings in utilization of inpatient resources.

Inpatient suicide in a general hospital psychiatric unit: A consequence of inadequate resources?

The incidence of suicide and high lethality attempted suicide in the 20-bed inpatient psychiatric unit of a general hospital was reviewed over a 10-year period. Although locating accurate records was difficult, a trend suggestive of increasing incidence was identified. We noted that this observation corresponded with an increase in the number of patients being treated by staff on the ward, reduced length of stay, and an increase in the proportion of severely disordered patients. Although the ward was accepting a greater number of patients, the available facilities (both physical resources and personnel) were not changed until the early results of this study were known (late 1991). We suggest that the clinical demands placed upon a psychiatric facility may affect the incidence of suicide and attempted suicide. This has particular significance in the general hospital setting where resources may be limited by competing requirements from other units and the current trend to close large mental hospitals places more demand upon them.

A prospective study of psychiatry patients' attitudes toward the seclusion room experience

The seclusion room is an integral component of hospital psychiatry. This study prospectively surveyed 50 patients shortly after each was released from an isolation room in a voluntary general hospital psychiatric unit. Fifty-eight percent of the sample were diagnosed with mood disorders. Previous studies found generally negative attitudes toward seclusion. These data revealed that patients often found seclusion to be restful and therapeutically helpful. The clinical implications of these data are discussed.

Recent trends in mental health services in Italy: an analysis of national and local data.

This paper reviews trends in Italian mental health services after the implementation of the 1978 Mental Health Act. Data available at the national level on public and private inpatient services, community mental health centres, residential and day care facilities are presented and discussed. Findings from two case-register areas, where comprehensive community services according to the Mental Health Act have been implemented, are discussed. Public mental hospitals are no longer used for psychiatric treatment, except for a small number of long stay patients. General hospital psychiatric units are the only setting in the public sector where psychiatric patients can be admitted. In private mental hospitals, the number of residents has decreased, while admissions have remained stable. However, community services are unevenly distributed and residential facilities are generally lacking. Little is known about quality of care provided, although data from some pilot studies are encouraging. Stable admission rates to forensic mental hospitals suggest that the criminalization of mentally ill has not increased. The effect of changing patterns of mental health care on suicide rates are discussed.

Mentally Retarded Patients on General Hospital Psychiatric Units

Difficulties in the placement of two recurrently assaultive mentally retarded men who had been admitted to acute admission units for assessment led staff to hypothesize that mentally retarded patients were being inappropriately diverted into psychiatric services. To test this hypothesis, the charts of all mentally retarded patients admitted over two years were reviewed retrospectively. Contrary to expectations, there was no difference between the average length of stay of the mentally retarded patients and a comparison group of psychiatric patients. Furthermore, the mentally retarded patients presented with a full range of Axis I disorders, schizophrenia being the most common. It was concluded that, in general, the acute psychiatric services were being used appropriately for this group of mentally retarded patients.

How many bed-days for an area's psychogeriatric patients?

Data were obtained concerning all admissions during a four-year period of persons aged 65 years and over, from a defined catchment area, to the general hospital psychiatric units in the area or to the nearest psychiatric hospital. The mean length of stay was 41.3 days. Of 449 admissions, 55% were diagnosed as having affective disorder or adjustment disorder with depressed mood, but this group accounted for 65% of the bed-days in the acute units with a mean length of stay of 49.2 days. Dementia cases accounted for 24% of admissions and 23% of bed-days. At present, the recommended number of acute psychogeriatric beds to serve this population of 34,000 elderly is 22; development of a comprehensive psychogeriatric service with appropriate community staffing may make it possible to reduce this number.

Effects of Treatment and Alternative Care on Length of Stay on a General Hospital Psychiatric Unit — Results of an Audit

Quality controls are becoming an important part of our health care system. A medical audit is one way of evaluating quality of care, and this paper describes the results of an audit conducted to investigate the reasons for a prolonged stay on a psychiatric inpatient unit. The results showed a decrease in the mean length of stay over a five year period, although the figure remained substantially above provincial norms. A review of the hospital charts of a random sample of one in six patients whose hospital stay exceeded 30 days was carried out. It revealed that in 50.0% of cases the reasons were "medically acceptable," in 10.3% the reasons were "medically unacceptable" and in 39.7% the reasons were "social and administrative" and beyond the control of the treating psychiatrist. The implication of these results are discussed.

The Role of General Hospitals in the Privatization of Inpatient Treatment for Serious Mental Illness

For almost three decades, many have regarded general hospital psychiatric units as the most appropriate setting for acute treatment of persons with serious mental illness who were once treated mostly in state hospitals. The extent to which this transfer has taken place and the differences between public and private general hospitals have been unclear. Using data from the 1988 National Mental Health Facilities Study and published data from the 1970s, the authors found that nearly half of all general hospitals providing psychiatric services treat persons with serious mental illness. Significant differences in case and payer mix were observed between public and private general hospitals, although these differences were smaller than in the 1970s. The findings suggest increased involvement by private general hospitals in treating patients reimbursed by public payers, but the findings also indicate that persons with serious mental illness and those using Medicaid are still more prevalent in public general hospitals than in private ones.

Community mental health services in Malaysia

The need to confine and restrain psychotic patients at the turn of the last century saw the building of a few large asylums which soon became overcrowded with the growth of the population. These asylums were the only service available to the mentally ill until 1959 when the trend to decentralise began with the building of general hospital psychiatric units.

Outcome of discharged psychiatric patients after short inpatient treatment: an Italian collaborative study.

This paper presents the results of an Italian multicentre study on the 6-month outcome of psychiatric patients discharged after short-term in-patient treatment from 21 general hospital psychiatric units. Two outcome measures were used: relapses (defined as readmissions for psychiatric treatment or suicide) and community tenure. The data showed, on average, a fairly high relapse rate (43% in 6 months) combined with a good community tenure. The findings are discussed in the light of the heterogeneity in patterns of care provision observed in Italian psychiatric services after the changes introduced by the 1978 Mental Health Act, reported in a previous paper.

Planning mental health services: I. Background and key issues.

Planning mental health services is a complex task requiring an understanding of background developments and key issues related to mental health services. In Canada, the deinstitutionalization of patients attempted to shift the locus of care from provincial psychiatric hospitals to general hospital psychiatric units. This resulted in the isolation of provincial psychiatric hospitals, general hospital psychiatric units and community mental health programs, with little overall accountability for the services provided--three solitudes. To move toward the creation of responsible, integrated systems a number of issues must be addressed: target population(s); the roles of provincial psychiatric and general hospitals; community support services; continuity of care; co-morbidity; consumerism; and methods of integration. In the development of a comprehensive mental health plan, each issue should be recognized and decisions made which are in keeping with current knowledge. A companion report will survey Canadian initiatives in mental health planning and discuss approaches to many of the issues identified.

Predicting Success in a Community Treatment Program for Substance Abusers

As reimbursement for hospital substance abuse programs becomes more limited, new addictions treatment alternatives are needed to provide high-quality care while reducing costs. These new treatment alternatives are particularly needed in the community hospital setting. The authors describe an addictions day-treatment (ADT) program developed on a community hospital psychiatric unit. Substance abuse patients were randomly assigned to an ADT or traditional inpatient treatment program. Study results show the relevance of ADT for most patients as a component of care in the continuum of programs that a community hospital psychiatric service may offer. ADT was at least as effective up to 18 months after discharge as traditional inpatient care. Moreover, ADT is less expensive than inpatient treatment, and ADT patients are as satisfied with their care as are inpatients.

An audit of substance use disorders on a general hospital psychiatric unit.

This study found that one-fifth of patients admitted to a general hospital psychiatric unit meet the diagnostic criteria for abuse of, or dependence on, psychoactive substances other than alcohol. Many of the substances involved are prescribed medications. Dependence on benzodiazepines and other sedatives was the most common substance use disorder among patients with a variety of other psychiatric diagnoses. We are also concerned by the extent of reported abuse of analgesic compounds and feel it is necessary to modify our initial diagnostic assessments so that patients with these disorders can be recognized at an early stage and managed appropriately.

An evaluation of two systems of in-patient care in a general hospital psychiatric unit I: staff and patient perceptions and attitudes.

This study reports a comparison of a single ward versus a two-ward system of acute in-patient care in a general hospital psychiatric unit. It focuses on staff and patient perceptions and attitudes towards the two types of ward. A continuous care ward system was preferred by the majority of staff who described an improvement in 'ward atmosphere'. Patients who had experienced both ward systems also preferred the continuous care system. Both patients and staff felt that the continuous care system still needed to place greater emphasis on 'ward atmosphere' dimensions of involvement, support and spontaneity. The implications of these findings for improving the functioning of the preferred ward are discussed.

The Worcester Development Project.

"The philosophy of Community Care has resulted in the closure of several mental hospitals in this country. The ethos of the Worcester Development Project saw the closure of St Wulstan's and Powick Hospitals, and their replacement by a community-based service. This paper briefly describes the outcome of a three-year retrospective study completed in 1988 following the closure of both hospitals. The findings provide a comparison of the two hospitals, including details of the destination of all the patients. It is suggested that the term 'hospital replacement' might be preferable to 'hospital closure'." "The Worcester Development Project began in 1968 when the Department of Health and Social Security brought together the Worcester and Kidderminster Hospital Management Committee and the County Council in a co-ordinated joint planning venture. Powick Hospital was chosen as the location for testing the hypothesis that closing a mental hospital and replacing it with general hospital psychiatric units, supported by a variety of community facilities, would provide a more economical and better service. This paper describes the outcome of this unique opportunity to study the problems involved in closing a mental hospital and its replacement with other facilities."

Deaths in psychiatric care

AbstractThe significance of deaths among psychiatric inpatients has been reviewed in brief and a glimpse of the future suggested by a study of the characteristics of 100 patients dying in a general hospital psychiatric unit. Though suicide was a common cause of death among the few young patients dying, it did not occur among the elderly, who usually died of natural causes. Dementia and depression were more frequent diagnoses than schizophrenia and “other diagnoses” which still dominate mental hospital deaths and very long terminal admissions were unusual. Most patients had been admitted on more than one occasion and had received a great deal of extramural care and treatment—they represent a very disabled group. Multiple physical pathology was identified in many at the time of admission and new pathology arose during admission. Almost half of male deaths were sudden, but women often endured prolonged and distressed deaths and these require enlightened management.

"Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit": Erratum.

"Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit": Erratum.

Psychiatrists' Compliance with Nonpsychiatric Consultations: Does Compliance Affect Concordance?

Utilizing a systematic methodology (The Consultation-Liaison Outcome Evaluation System), the compliance of nonpsychiatric consultations within a general hospital psychiatric unit staffed by private practitioners was assessed. Thirty-one percent of the patients received such consultations and these patients had a longer length of stay than those without a consultation. Psychiatrists were generally compliant with both medication and diagnostic recommendations; but in only half the discharge summaries was the consultant's primary medical diagnosis fully reflected. The implications of these data are discussed.

Christmas census at a district general hospital psychiatric unit

AbstractWe present a descriptive study discussing the reasons why patients remained as in-patients within the psychiatric unit over the Christmas period. In over 50% of cases continuation of in-patient stay was necessitated by the severity of mental illness. However, a significant minority of patients were unable to leave because of either poor family support or reduced input from the community mental health services. There was some evidence of Christmas good will influencing admission policy with a significantly greater number of patients admitted with alcohol problems over the week before Christmas all of whom were lonely and expressed a preference to be in hospital.A more long term problem was also evident as an important minority of patients' hospital stay was unnecessarily prolonged because of unavailability of suitable community placements.

Length of stay in a general hospital psychiatric unit

Fifty psychiatric inpatients with a prolonged length of stay were compared to 50 control admissions for factors associated with prolonged hospitalizations in a general hospital. Seven variables were found to be significantly overrepresented among the long stayers, including treatment with electroconvulsive therapy, medical consultations, underemployment, dementia, disposition to a place other than home, absence of alcohol or drug abuse, and presence of psychosis without affective symptoms. The clinical and policy implications of these finding are discussed.