Psychiatric Inpatient Settings Research Articles

Risk assessment for aggressive behaviour in schizophrenia.

Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings. To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses. We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies. We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia. At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach. We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs. Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.

Cannabis Vaping Is Associated With Past 30-Day Suicide Attempts and Suicidal Ideation Among Adolescents in a Psychiatric Inpatient Setting

Cannabis Vaping Is Associated With Past 30-Day Suicide Attempts and Suicidal Ideation Among Adolescents in a Psychiatric Inpatient Setting

The effectiveness of iso principle mood modulation playlists in inpatient psychiatry: A post-hoc analysis

This post-hoc data analysis study investigates the impact of iso principle-informed mood modulation playlists (MMPLs) on mood ratings using a Likert scale. Pre- and post-listening mood ratings were collected as part of routine music therapy procedures in an inpatient psychiatric setting and de-identified for analysis. The study comprised 125 pairs of mood ratings. The results of the Wilcoxon signed-rank post-hoc analysis revealed a significant improvement in post-test mood ratings compared to pre-test mood ratings (mean rank = 8.34 vs 5.02, respectively, Z = -9.59, p = 0.001). These findings highlight the therapeutic value of individualized MMPLs facilitated by music therapists in enhancing patient mood. The utilization of MMPLs allows patients to purposefully modulate their mood in desirable ways, demonstrating the potential of music therapy as a valuable tool in improving well-being.

Racial disparities with PRN medication usage in inpatient psychiatric treatment

Racial disparities in psychiatric diagnoses and treatment have significant public health implications, contributing to inequities in healthcare outcomes. We specifically examined racial disparities regarding pro re nata (PRN), or as needed, medications. Data from 14,616 encounters across 2019–2020 within Community Health Network’s inpatient psychiatric setting in Indianapolis, Indiana were included in this study. Due to the demographic sample size, analyses were narrowed to Black and White patients. Primary outcomes included comparisons across race for all PRN administrations and PRN administrations of antipsychotics vs. non-antipsychotics. Logistic regression was used to examine associations between race and PRN administrations by medication category, including all antipsychotics vs. non-antipsychotics overall, hydroxyzine, and lorazepam, independently. Significant differences in the percentage of administrations between Black and White patients were observed. Black patients received more PRN medications overall (71.0%) compared to White patients (67.7%) (p < 0.01). Further, while 17.7% of Black patients were administered PRN antipsychotics, this was true for only 8.2% of White patients (p < 0.001). When comparing antipsychotic PRNs with non-antipsychotic, hydroxyzine, and lorazepam PRNs, independently, Black patients were 58% (OR 1.58, p < 0.001), 109% (OR 2.09, p < 0.001), and 32% (OR 1.32, p < 0.001), more likely to receive antipsychotic PRNs, respectively, than White patients, controlling for sex, age, length of stay, and psychotic disorder diagnosis. Our study identifies yet another area of medical care with significant racial disparities. In this analysis of PRN medications during psychiatric admission, we identified significant differences in medication utilization by race. This information provides a basis for further investigation of disparities in patient-centered data.

Poetry Workshop in the Acute Inpatient Psychiatric Setting: Feasible, Acceptable, and Significantly Beneficial

Objective: We investigated the feasibility and acceptability of establishing a therapeutic poetry writing workshop in an acute inpatient psychiatric setting, as well as the impact of participation on measures of mood, hope, and recovery orientation. Methods: Participants were recruited from the inpatient psychiatric units of an academic medical center. As a pre/post measure of effect of the poetry intervention, participants completed the Herth Hope Index (HHI) and the Mental Health Confidence Scale (MHCS) at baseline and follow-up, as well as a Brief Mood Survey (BMS) immediately before and after each instance of participation in the poetry workshop. Student’s t-tests were used to assess for changes on HHI, MHCS, and BMS, as well as to compare the before vs after in these metrics for individuals who attended only one workshop session versus those who attended two or more sessions to assess for dose-dependent effect of the intervention. Workshop participants also optionally completed a satisfaction survey of their qualitative experience of the group. The protocol for leading a workshop is described in detail. Results: There was a statistically significant improvement in multiple subscales of mood according to the pre- and post-measures on the BMS. Results of the HHI indicated a trend toward increased hopefulness. Results of the MHCS showed statistically significant improvement in participants’ confidence in managing day-to-day life with a mental illness. Results of satisfaction surveys indicate that participants had an overwhelmingly positive experience of the group. Conclusions and Implications for Practice: Workshops designed to foster writing and sharing poetry in a group format are likely to be clinically helpful to improve mood for patients in an acute inpatient psychiatric setting. Future research may examine the adaptability of this intervention for outpatient and virtual settings. Impact and Implications: We conducted a poetry workshop for patients in an acute inpatient psychiatric unit. Participation in the workshop even just once provided a statistically significant and clinically meaningful improvement in multiple subscales of mood and confidence in managing day-to-day life with a mental illness. Our study describes in detail the protocol for a mental health clinician to recreate a similar poetry workshop in their own clinic or hospital.

Reduced prevalence of drug-related problems in psychiatric inpatients after implementation of a pharmacist-supported computerized physician order entry system - a retrospective cohort study.

In 2021, a computerized physician order entry (CPOE) system with an integrated clinical decision support system (CDSS) was implemented at a tertiary care center for the treatment of mental health conditions in Lübeck, Germany. To date, no study has been reported on the types and prevalence of drug-related problems (DRPs) before and after CPOE implementation in a psychiatric inpatient setting. The aim of this retrospective before-and-after cohort study was to investigate whether the implementation of a CPOE system with CDSS accompanied by the introduction of regular medication plausibility checks by a pharmacist led to a decrease of DRPs during hospitalization and unsolved DRPs at discharge in psychiatric inpatients. Medication charts and electronic patient records of 54 patients before (cohort I) and 65 patients after (cohort II) CPOE implementation were reviewed retrospectively by a clinical pharmacist. All identified DRPs were collected and classified based on 'The PCNE Classification V9.1', the German database DokuPIK, and the 'NCC MERP Taxonomy of Medication Errors'. 325 DRPs were identified in 54 patients with a mean of 6 DRPs per patient and 151.9 DRPs per 1000 patient days in cohort I. In cohort II, 214 DRPs were identified in 65 patients with a mean of 3.3 DRPs per patient and 81.3 DRPs per 1000 patient days. The odds of having a DRP were significantly lower in cohort II (OR=0.545, 95% CI 0.412-0.721, p<0.001). The most frequent DRP in cohort I was an erroneous prescription (n=113, 34.8%), which was significantly reduced in cohort II (n=12, 5.6%, p<0.001). During the retrospective in-depth review, more DRPs were identified than during the daily plausibility analyses. At hospital discharge, patients had significantly less unsolved DRPs in cohort II than in cohort I. The implementation of a CPOE system with an integrated CDSS reduced the overall prevalence of DRPs, especially of prescription errors, and led to a smaller rate of unsolved DRPs in psychiatric inpatients at hospital discharge. Not all DRPs were found by plausibility analyses based on the medication charts. A more interactive and interdisciplinary patient-oriented approach might result in the resolution of more DRPs.

The role of psychology in a multi-disciplinary psychiatric inpatient setting: perspectives from the multidisciplinary team

BackgroundThe availability of consistent psychological therapy within acute inpatient psychiatric units and the integration of psychologists into multi-disciplinary inpatient teams is a newly evolving development in mental healthcare. To the authors’ knowledge, there has been no examination of the inpatient multi-disciplinary team’s (MDT) perspective on how psychology can be best integrated into the team in Lebanon. This study aims to explore the perceptions of different medical personnel working within an MDT on the role of psychologists in an acute psychiatry inpatient unit in Lebanon. It is qualitative in nature, using a semi-structured interview design. The overarching aim of this study is to assess and identify the gaps in the MDT’s insight into the various responsibilities of psychologists which may result in more efficient collaborative teamwork and hence overall patient care.ResultsFour primary themes are identified from the findings of our study. The themes highlighted the value of a multidisciplinary approach to patient care, the vital roles that psychologists play in direct clinical work and supporting other staff members, important factors related to patient-centered psychological care, limitations that exist in the inpatient unit, and suggestions for improvement.ConclusionThis study served as a baseline for more research and development of psychological services in the psychiatric inpatient units of Lebanon, emphasizing the integral role of psychology in patient care.

Gender Identity and Mental Health Symptom Severity Among Adolescents Admitted to an Inpatient Psychiatric Hospital.

Transgender youth are at an increased risk of suicide, substance use, experiencing violent assaults, and reporting major depressive episodes and greater psychological distress compared to their cisgender counterparts. This study examined mental health symptom severity in adolescents admitted to an inpatient psychiatric hospital who wished they were of a different gender compared to those who did not. A group of 180 adolescents admitted to an inpatient psychiatric hospital completed assessments to measure mental health symptom severity at admission. Gender diverse (n = 90) and cisgender (n = 90) groups were established. Analyses of variance (ANOVA) were used to examine between group (gender diverse vs. cisgender) difference on depression, anxiety, suicide risk, nighttime sleep quality, and emotion regulation problems. Results revealed significant differences in emotion regulation difficulties at admission, specifically in nonacceptance and awareness. There were no significant differences on measures of depression, anxiety, suicide risk, and nighttime sleep quality at admission. This study is one of the first to measure mental health symptom severity in gender diverse adolescents while admitted to an inpatient psychiatric setting. Adolescents in the gender diverse group had significantly higher level of difficulty with emotion regulation, which may indicate an increased risk of developing psychiatric symptoms such as depression and anxiety. This paper demonstrates the importance of using targeted interventions to address difficulties with emotion regulation in at-risk adolescents.

How Inpatient Psychiatric Units Can Be Both Safe and Therapeutic.

Inpatient psychiatric units should be therapeutic environments that support dignity and recovery. When adverse outcomes (eg, self-harm, violence) happen in these settings, clinicians and administrators can face litigation and other pressures to prioritize risk management over supporting patients' access to personal belongings, exercise equipment, and private spaces. This article describes these downward pressures toward sparser, controlling environments in inpatient psychiatric settings as a safety funnel and suggests strategies for balancing safety, humanity, and recovery in these contexts.

Should Dignity Preservation Be a Precondition for Safety and a Design Priority for Healing in Inpatient Psychiatry Spaces?

Therapeutic security in inpatient psychiatric settings requires careful planning and implementation if it is to support patients' safety and dignity. This commentary on a case considers patients' dignity experiences when restrictions on their freedom are used to keep them safe.

AMPlifying metabolic screening for inpatients on antipsychotic medications with a nurse-driven protocol

IntroductionPatients on antipsychotic medications are at higher risk of developing metabolic syndrome; nevertheless, metabolic screening for patients on antipsychotics is suboptimal. MethodsThis project developed and implemented AMP (Antipsychotic Metabolic screening Protocol), a nurse-driven protocol on inpatient psychiatric units that allowed nursing staff to collect all components of a metabolic screening. Nurses working on units with AMP were surveyed pre- and post-implementation on perception of AMP and empowerment. ResultsAMP significantly increased overall metabolic screening as well as the most frequently missing component (lipid panel). The screening rates pre-intervention were similar to those found in the literature (on average, only two-thirds of patients were screened). However, AMP improved the rate such that nine out of every ten patients on the units were screened. Nurses had a negative perception and no change in empowerment from AMP implementation. ConclusionsAMP can be used to increase metabolic screening for patients on antipsychotics. Further research is needed to better understand adoptability of nurse-driven protocols in the psychiatric inpatient setting as well as other applications, such as smoking cessation or safety sitters.

Evaluating Wilson sims tool: Quality improvement on fall risk in UAE psychiatric patients

BACKGROUND Falls among patients in psychiatric inpatient healthcare settings present a significant global challenge, despite ongoing efforts to reduce the risks. Falls negatively impact patient safety, post-treatment recovery, and medical costs. AIM This study aimed to evaluate the predictive validity of the Wilson Sims Fall Risk Assessment Tool (WSFRAT), investigate predictors of falls, and determine the optimal cut-off point for the WSFRAT. Additionally, we aimed to assess the predictive validity of clinical judgement in identifying individuals at high risk of falls. METHODS We conducted a psychometric study at a specialized psychiatry hospital in Dubai, United Arab Emirates, using data collected from hospital-wide quality projects between April 16, 2019, and March 31, 2021. Our sample comprised 492 patients. RESULTS Contrary to the recommended cut-off point of 7 in the literature, this study results indicate that the optimal cut-off point for the WSFRAT was 5+. This yielded an accuracy of 87%, a diagnostic odds ratio (DOR) of 0.728, a kappa value of 0.208, a sensitivity of 83%, and a specificity of 87%. Furthermore, the regression analyses identified significant predictors of fall risk, including age, gender, assistive device, WSFRAT, and evaluation duration. Notably, clinical judgement did not significantly predict fall risk (p=0.331). CONCLUSION In conclusion, the present research demonstrates that the WSFRAT is a reliable tool with high sensitivity and specificity for predicting falls in psychiatric inpatient settings. The findings emphasize the importance of employing evidence-based tools and a comprehensive assessment approach to prevent falls. Furthermore, our findings challenge the recommended cut-off point of 7 and highlight the need for further research to confirm the optimal cut-off point. Finally, this investigation revealed that clinical judgement alone is not an effective method for predicting falls in this population.

Patient Satisfaction with Psychological Treatment on a Voluntary Inpatient Psychiatric Unit.

Despite the empirical literature suggesting the benefits of providing patient support and psychotherapy, research examining patient satisfaction with psychological services integrated within inpatient psychiatric treatment settings remains scarce. A sample of 122 adults within a voluntary inpatient psychiatric unit, who were receiving psychological services completed a satisfaction questionnaire. Overall, participants reported high levels of satisfaction with psychological services and perceived them as helpful to their overall care. These results remained consistent when exploratorily examining satisfaction and helpfulness prior to and during the COVID-19 pandemic. These findings suggest the importance of integrating psychologists within inpatient psychiatric treatment settings. Future research may investigate the influence of psychological services on patient outcomes and how psychologists are perceived by other treatment team members.

Psychiatric inpatient care for persons with dissociative identity disorder: a scoping review protocol

IntroductionPsychiatric inpatient care (PIC) is often characterised by high pressure and thresholds for admission, brief periods of care and limited time for caring activities. Dissociative identity disorder (DID) is a...

Translating an integrative metacognitive model of psychotherapy for serious mental illness into a group format: A pilot investigation on feasibility.

Metacognitive reflection and insight therapy (MERIT) is an one-on-one intervention that targets insight with the aim to help people with serious mental illness develop more integrated ideas about themselves and others in order to respond to their psychological and social challenges more adaptively. There is a growing body of evidence on MERIT's effectiveness. Considering the clinical demand for more cost-effective group psychotherapies, we modified the original individual MERIT format to a group-based intervention (MERITg) for application in inpatient and outpatient psychiatric settings. Thirty-one participants (inpatient = 10; outpatient = 21) with serious mental illness were surveyed on their experience of MERITg, which was offered adjunctively to their routine clinical care. Program evaluation measures were used to assess the feasibility and acceptance of the group. Across locations, more than half of all participants attended more than one group. Participants reported attending the group initially because they thought writing would be helpful, and further reported that they liked the group because they enjoyed writing and the discussion, and that they found it interesting to hear the perspectives and writings of others. Findings further support the need for future research on the efficacy and effectiveness of the group and its relationship to changes in metacognitive capacity and recovery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychological provision in acute inpatient settings: An evaluation of indirect input.

INTRODUCTION: The role of Psychologists in psychiatric inpatient settings is well established and involves intervention at various levels; however, quantitative exploration of the effectiveness of staff-level interventions is lacking. The aim of the study was to examine the effectiveness of a variety of staff-level interventions provided by a Psychology team within a psychiatric inpatient setting. The evaluation used a mixed methods approach incorporating pre-post quantitative data and post-intervention feedback. Additional data were collected via survey. Results indicated all staff-level interventions were effective in achieving their aims and were highly valued by staff. Qualitative data supported the quantitative findings and showed tentative suggestion of a change to clinical practice. Indirect psychology provision was found to significantly impact a range of staff attitudes and was highly valued by the staff team, supporting previous qualitative findings in psychiatric inpatient settings. Further quantitative evidence of the impact of staff-level interventions should be sought. Staff-level interventions are effective and valued by mental health nursing staff and should be considered in allocation of psychology resources. Furthermore, there is potential for people with lived experience to participate in these interventions, which could facilitate the therapeutic relationship and reduce restrictive practices, however this requires future research.

Protocols to reduce seclusion in inpatient mental health units.

The use of seclusion to manage conflict behaviours in psychiatric inpatient settings is increasingly viewed as an intervention of last resort. Many protocols have, thus, been developed to reduce the practice. We conducted a systematic review to determine the effectiveness of protocols to reduce seclusion on process outcomes (e.g., seclusion, restraint), patient outcomes (e.g., injuries, aggressive incidents, satisfaction), and staff outcomes (e.g., injuries, satisfaction). We searched Medline, Embase, the Cochrane Register of Clinical Trials, PsycINFO, CINAHL, cairn.info, and ClinicalTrials.gov for protocols to reduce seclusion practices for adult patients on inpatient mental health units (from inception to September 6, 2022). We summarised and categorised reported elements of the protocols designed to reduce seclusion using the Behaviour Change Wheel Intervention Functions and resources needed to implement the protocol in psychiatric units. We assessed risk of bias and determined certainty of evidence using GRADE. Forty-eight reports addressed five approaches to reduce seclusion: hospital/unit restructuring (N = 4), staff education/training (N = 3), sensory modulation rooms (N = 7), risk assessment and management protocols (N = 7), and comprehensive/mixed interventions (N = 22; N = 6 without empirical data). The relationship between the various protocols and outcomes was mixed. Psychiatric units that implement architecturally positive designs, sensory rooms, the Brøset Violence Checklist, and various multi-component comprehensive interventions may reduce seclusion events, though our certainty in these findings is low due to studies' methodological limitations. Future research and practice may benefit from standardised reporting of process and outcome measures and analyses that account for confounders.

Interpersonal trauma and discharge symptom severity among individuals with psychotic disorders: A population-based cohort study in Ontario

Interpersonal trauma is associated with poorer prognoses for individuals with psychotic disorders; however, its association with symptom severity at hospital discharge is unknown. Among 57,106 individuals hospitalized for a psychotic disorder in Ontario, Canada (2009–2019), 12,805 (22.4 %) with and 44,301 (77.6 %) without a history of interpersonal trauma were compared on the positive symptom scale (PSS) score at discharge. In a subcohort of individuals with an elevated PSS score of at least 6 on admission, we calculated the relative risk of positive symptom remission (PSS<6) at discharge comparing those with and without interpersonal trauma. Interpersonal trauma was associated with a higher PSS discharge score. Effect sizes were greater for those with who experienced interpersonal trauma in the past year. Results were similar by type of trauma (physical, sexual, emotional) and specific diagnosis (schizophrenia, schizoaffective disorder, other psychotic disorder). In the subcohort, fewer inpatients with vs. without a history of interpersonal trauma had PSS<6 at discharge. Thus, individuals with psychotic disorders who have a history of interpersonal trauma are at risk for elevated symptom burden at hospital discharge. Integration of trauma-informed frameworks and trauma-focused therapies in the inpatient psychiatric setting may optimize outcomes at discharge.

Blended-ALMAMAR app for inpatient mental health care for refugees: study protocol for a multicenter implementation study within the I-REACH consortium (Internet based REfugee mentAl healtH Care)

BackgroundRefugees are at high risk for developing mental illnesses. Due to language and cultural barriers, there is need for specifically adapted therapeutic procedures for refugees in inpatient mental health care settings. Internet-based applications in refugee mother tongues have the potential to improve the outcomes of mental health care for this vulnerable population. The key research question of the present implementation study is whether the newly developed “blended ALMAMAR” app for Arabic and Farsi speaking refugees in Germany is used and accepted by patients and professionals in routine inpatient mental health care (blended care).MethodsWe present the design of an observational, prospective multicenter implementation study in eight psychiatric hospitals. We plan to recruit 100 Farsi or Arabic speaking refugees receiving in-patient treatment due to depression, anxiety disorder, posttraumatic stress disorder or substance use disorders. These patients will get access to the “blended ALMAMAR” app during their inpatient stay in a blended-care approach. We will assess the usage (e.g., duration and frequency of use of the app) as well as subjective acceptability and usability of the intervention. To identify sociodemographic and clinical factors associated with “blended ALMAMAR” usage, we will also perform clinical and questionnaire assessments.DiscussionThe newly developed “blended ALMAMAR” app may help to close communication gaps for the hard-to reach and vulnerable group of refugees in inpatient mental health care. It is the first blended-care intervention that addresses severely mentally ill refugees in an inpatient psychiatric setting in Germany.Trial registrationThe trial was registered in the German Clinical Trials Register on November 11, 2021 (DRKS00025972) and adapted on November 14, 2023.

Patient experience of a virtual reality calm room in a psychiatric inpatient care setting in Sweden: a qualitative study with inpatients

ObjectiveCalm rooms have been developed and implemented in psychiatric inpatient care settings to offer patients a dedicated space for relaxation in a convenient and safe environment. Recent technology developments have...