Revolving Door Patients Research Articles

Mobile Delivery Program to Prevent Relapse and Improve Functioning in Patients With Psychiatric Diseases.

The term "revolving door patients" refers to those who are frequently rehospitalized for relapse. This phenomenon can be explained by a multitude of factors, including a lack of medical and/or social support. On the basis of a review of various modalities of psychiatric treatment, such as long-acting injectables, assisted outpatient treatment, and telehealth, it is clear that a major underlying issue among people with psychiatric diseases who lack insight into their mental and physical health is medication nonadherence. Therefore, we propose a mobile delivery program (MDP) in which health care professionals deliver medications and care to psychiatric patients in their own homes. The target patient population for MDP is patients with medication nonadherence, frequent emergency department visits, and missed appointments. Patients with mental illnesses, especially schizophrenia, are disproportionately represented among the homeless and incarcerated populations. By implementing MDP, we can help break the cycle of incarceration for patients with mental illnesses and homelessness. In addition, the cost of transportation and salaries for the mobile delivery team would be considerably lower than the billions of dollars spent each year due to relapses, emergency department visits, inpatient admissions, and crime leading to long-term stays in correctional facilities. This model has the potential to reduce relapse, improve functioning, and reduce excess morbidity and mortality. Substantial cost savings for health services can, in turn, be expected.

Risk Factors for Revolving Door in Children and Adolescents with Psychiatric Disorders.

Revolving Door (RD) is a frequent phenomenon afflicting children and adolescents with psychiatric diagnoses. Nevertheless, risk factors for RD are still a matter of debate. To better understand RD phenomenon, we conducted a retrospective study on 224 children and adolescents (165 females and 59 males, aged 6–16 years) with a psychiatric hospitalization, taking the multiple risk factors together. At this aim, 108 patients with multiple hospitalizations and 116 patients with only one hospitalization were compared on demographic characteristics, clinical conditions, psychiatric ward stay, and post-discharge management factors. More than half of psychiatric patients were readmitted within three months of discharge. RD patients presented greater severity of illness, needed longer stays, and were more frequently placed in residential facilities than non-RD patients. Non-suicidal self-injurious and adoption were the main predictors of RD. Clinical instruments that detected behavioural and emotional symptoms, suicidal ideation severity, and level of impairment of the person’s functioning were useful to identify patients at high risk for RD. In conclusion, our findings pointed out that several risk factors have to be considered to better understand and, in the future, prevent RD phenomenon.

P84 Implementation of advanced practice rheumatology clinics

Abstract Background Ashford and St Peters NHS Trust implement an iMSK Service with an aim to deliver biopsychosocial assessment and care across Orthopaedics, Pain and Rheumatology settings. Our impression was the Rheumatology Service could be assisted by the implementation of Advanced Clinical Practitioners Clinics considering the benefits that had been offered to Orthopaedic and Pain Services. The Rheumatology Service had high waiting times to see a Consultant, were understaffed in relation to national recommended ratio of Consultant to catchment population and were motivated to promote a biopsychosocial approach to patient care. There were poor links between Rheumatology and the MSK Triage Service as well as the Physiotherapy Service which were recognised as areas for improvement and integration for both patient and staff. The plan was to improve the efficiency of pathway into Rheumatology, reduce unnecessary contacts for the patient and offer best practice advice at first contact. An aim to reduce non-inflammatory referrals to consultants, in turn reducing overall waiting times for inflammatory presentations. Methods We researched and benchmarked against existing services, learning from experiences and various models of implementation. We audited our MSK triage process, to include numbers of referrals into the Rheumatology Service. We developed an ACP Triage Criteria as a multi-disciplinary team to highlight our skillset and best fit to the service needs. We observed the existing MDT in clinic to include consultant and nurse specialists as well as undertaking injection, bloods and radiology training. We collaborated with the service managers to implement ACP clinics for the assessment of non-inflammatory presentations and widespread pain. We are collecting PREM data with the 'CARE' patient satisfaction questionnaire, as well as clinical outcome data collection to include the Widespread Pain Index, Symptom Severity Score and evaluation of patient onward referral destination and management plan. Results We have seen over 60 patients and continue to collate our data. Over 50% of patients have been discharged at first appointment to confidently begin a self-management approach to their care. We have referred only 2 patients onto rheumatology consultant appointments - therefore saving a minimum of 35 Consultant Hours within our service in a 3-month period. We have had 100% positive feedback for patient's who have completed satisfaction questionnaires PREM data after appointment. Conclusion We continue to collect and analyse our data but can already highlight a positive trend for successful implementation of ACP's into the Rheumatology Service within only a 3 month period. We feel this is a starting point for the further development of a Widespread Pain Pathway across the MSK Service to further incorporate integration of Rheumatology, Pain and Physiotherapy Services in the prevention of duplicate or unnecessary appointments and reduction in the ‘revolving door patients’ across all 3 services. Disclosures L.M. Gotting None.

CYP2D6 genotypes in revolving door patients with bipolar disorders: A case series.

In psychiatric disorders, interindividual differences in cytochrome P450 (CYP)2D6 (CYP2D6) enzymatic activity could be responsible of adverse drug reactions (ADRs) and therapeutic failures (TFs) for CYP2D6-metabolized drugs, contributing to the periodical hospital readmissions of the revolving door (RD) condition. We investigated CYP2D6 genotypes in a controlled series of 5 consecutive RD patients with Bipolar Disorder (BD). Psychiatric patients affected by Bipolar Disorder. We defined TFs as a difference at the Brief Psychiatric Rating Scale score ΔBPRS < 25% at each 1-week of stable treatment, and ADRs as the onset of extrapyramidal symptoms and/or metabolic impairment with weight gain. At 3 months, a mean number of 2.75 ± 1.26 ADR and a mean ΔBPRS score of 16.07 ± 0.05% were observed. At 6 months of follow-up, compared to the only patient without BD (ΔBPRS < 32.10%), BD patients (n = 4) showed TFs (ΔBPRS < 25%). CYP2D6 genotyping revealed intermediate metabolizer phenotypes for BD patients and an extensive metabolizer phenotype for the patient without BD. In BD patients, the ratio of drugs maintained/discontinued for TFs or ADRs was 1.75 for non-CYP2D6 versus 0.33 for CYP2D6 interacting drugs, while the proportion of ADR:TF was 0:4 versus 6:3. Our findings may suggest that CYP2D6 clinically relevant genotypes may be involved in the unwanted outcomes observed in RD patients with BD.

Revolving door respiratory patients: A rehabilitative perspective.

Rehabilitation is an integral component of care for patients affected by either acute or chronic pulmonary diseases. The key elements of rehabilitation treatment for critical respiratory patients are as follows: weaning from mechanical ventilation, respiratory therapy, physical reconditioning, and occupational therapy. It should be noted that patients affected by pulmonary diseases are prone to hospital re-admission due to frequent exacerbations, especially in cases with more severe stages of chronic obstructive pulmonary disease. A periodical worsening of clinical conditions is common in asthma, acute respiratory distress syndrome survivors, obstructive sleep apnea syndrome, and pulmonary fibrosis, as well as in patients with severe neuromuscular diseases. These patients are often identified as "revolving door patients". Pulmonary patients are typically forced to maintain bed rest, or at least spend most of their waking hours dealing with mobility limitations, due to various pathological conditions including dyspnea, fatigue, and poor tolerance of movements. Alterations in mood are common in pulmonary patients who experience a decreased quality of life and limited social interactions. These negative emotional and cognitive aspects can be a major limitation to the provision of care, because to enhance and facilitate a degree of autonomy, the patient must be cooperative and pro-active.

The Revolving Door Phenomenon in an Italian Acute Psychiatric Ward: A 5-Year Retrospective Analysis of the Potential Risk Factors.

To highlight the revolving door (RD) phenomenon in an acute psychiatric ward, we retrospectively identified the patients hospitalized three or more times in a calendar year from 1/1/2009 to 31/12/2013 as RD patients (RDP). We collected sociodemographic and clinical variables of RDP and statistically analyzed the potential RD risk factors. We divided RDP into "high" and "extremely high" utilizers and evaluated the variables related to more frequent readmissions. RDP represented 5.68% of all patients and their hospitalizations (RDH) 25% of all admissions. The statistically significant risk factors for all RDH were "disability pension," "substance abuse/dependence," "mild/severe aggressiveness," and "psychiatric and social rehabilitative programs". The comparison between "high" and "extremely high" utilizers showed that "manic episodes" and "personality disorders," among the diagnoses, "familial relational conflicts" and "violence/suicidality", among the hospitalization reasons, were statistically significant risk factors for more frequent readmissions. RD phenomenon was greatly affected by severe clinical conditions with social disability.

Psychosocial factors associated with frequent rehospitalization of patients with mental health disorders

International research, which focuses on frequent users of the psychiatric services and on the psychosocial factors that are associated with frequent rehospitalization, emphasize that the problem of revolving door patient still stands and is severe. Research concerning the above mentioned issue has not been conducted in Georgia, therefore, this study aimed to explore the revolving door patients and psychosocial factors that contribute to their relapse and frequent readmission to acute psychiatric unit. Study was conducted at psychiatric department of Ghudushauri National Medical Center. Qualitative and quantitative analysis based on medical files of 34 adult patients with psychotic disorders, rehospitalized in acute psychiatric unit 60 days after their last discharge in 2012–2014 years, was conducted. Results of the study are in line with international research findings concerning the psychosocial factors that contribute to frequent rehospitalization of patients with psychotic disorders, such as: unemployment (97%), lack of support system (76,5%), non-compliance with treatment (91.2%), emotional reactivity to stressful life events, etc. However, according to the study, family atmosphere turned out to be the central problem which influences the index of conflict and expressed aggression in the family, has impact on the size of patient's support system, on substance abuse, on patient's relapse and on their emergency rehospitalization. According to the results of the study, family atmosphere is one of the most active and multifaceted factors that contribute to patient's relapse and frequent rehospitalization in Georgia. Therefore, implementing and developing interventions discussed in the research paper that will target this factor is essential.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Kaleidoscope.

One criticism was that the 12-month follow-up failed to capture a true clinical picture, and that more time was necessary to demonstrate their worth. The team that carried out this original work have now published 3-year data on 330 individuals detained under section of the Mental Health Act,1 randomised on discharge to CTO or voluntary status via Section 17 leave. No improvements in readmission rates, time to first readmission, or duration of readmissions were found for those placed on CTOs. The findings are even more powerful than the original results; CTOs now exist in various forms in over 75 jurisdictions, but no solid scientific evidence has yet been produced to support them. If there are subpopulations for whom (or specific circumstances in which) they work, such characteristics have yet to be delineated. A ‘least restrictive’ principle underpins the Mental Health Act, and a strong rebuttal is needed to justify ongoing CTO use – so-called ‘revolving-door patients' should not be replaced by revolving-door policy.

The “revolving Door Phenomenon” in an Acute Psychiatric Ward: a 5-year Retrospective Analysis

Introduction The term ‘revolving door (RD) phenomenon” was coined to define recurrent hospitalizations of chronically ill patients after closure of psychiatric hospitals and implementation of community treatments. Objectives Continued readmissions require a large portion of Mental Health Departments’ resources. Aims To analyze the RD phenomenon in an acute psychiatric ward during a 5-year period. Methods We retrospectively selected all patients with 3 or more hospitalizations per year from 01/01/ 2009 to 31/12/2013 in SPDC-Modena Centro. From their medical records we collected selected variables, potential predictors of RD phenomenon. Data were statistically analyzed. Results In the 5-year period, a sample of 105 patients (47 females, 58 males) with an average age of 40.25 years (± 13.47 SD), 5.68 % of all inpatients (n = 1850), realized 778 hospitalizations, 23.94 % of all admissions (n=3250). The most frequent reason for admission was ‘worsening of psychiatric symptomatology” (55.27%). The most frequent diagnoses at discharge were ‘Schizophrenia” (41.26%) and ‘Personality Disorders” (25.32%). Most of RD patients (87%) were Italian, only 15 % were employed and 50 % lived with family. The mean duration of RD hospitalizations (12.23 days ± 18.37 SD) was statistically significantly different from all others in the 5-year period (10.39 days ± 11.09 SD, p=0.0008, t test) as was the frequency of compulsory admissions (RD hospitalizations 18% vs. 26% all others, chi2, p Conclusions Our RD patients represented a small percent of all inpatients but required many and long hospitalizations, probably due to severe and disabling illness.

Factors associated with the use of community treatment orders.

In his article Curtis1 highlights one of the limitations of the OCTET study,2 in that patients selected for randomisation may not have been suitable for community treatment order (CTO) placement in the first place. In his conclusions he suggests there may be a small subgroup of patients for whom CTOs are enormously beneficial. Perhaps clinicians need more clarity of the characteristics of the ‘revolving door’ patient better to assess suitability for supervised community treatment. Most clinicians will have a personal construct of the epidemiological and clinical characteristics of revolving door patients, although this may not be explicitly defined. There is no consistency in the literature as to the definition of revolving door, and previous research in the UK has shown that predictors of readmission are varied and not consistently replicated across studies. Research carried out when the practice of ‘long leash’ Section 17 leave was widespread showed that those placed on extended leave had a history of more frequent compulsory admissions, increased recent dangerousness to others, and decreased adherence to their out-patient follow-up prior to admission.3 A case-control study was conducted at Leeds Partnership NHS Foundation Trust in 2010, and approved by the local research and development department as a service evaluation. The aim was to compare characteristics of patients placed on CTOs and those discharged from Section 3, to elicit which factors were associated with CTO placement. All patients placed on a CTO between November 2008 and February 2010 were included as cases, and controls were randomly selected from patients who had been detained under Section 3 of the Mental Health Act, but whose Section was rescinded within the same week that the CTO was commenced. A ratio of two controls for each case increased the power of the study. This amounted to 56 cases and 112 controls. Characteristics chosen for analysis were those which previous research had suggested may be of importance and where collection was feasible. The characteristics of the patients placed on CTOs were broadly similar to those recruited into OCTET. Analysing variables individually, patients on CTOs were significantly more likely (P<0.05) to be single, have a principal diagnosis of schizophrenia, a history of violence, a higher number of previous admissions, a history of criminal conviction and a higher number of convictions within the past year. On logistic regression analysis, patients on CTOs were significantly more likely to have a principal diagnosis of schizophrenia and a higher number of previous admissions. There remains the outstanding question of who belongs to the elusive group of patients for which CTOs are effective, if indeed this group exists. This study provides insight into the demographic and historical factors that are influencing clinicians’ decisions to implement CTOs. There is no proof so far that CTOs are effective in their aims. Perhaps we need to look again at who the truly ‘revolving door’ patients are and take this objective evidence into consideration at the point of deciding whether to initiate supervised community treatment.

PTU-261 Alcohol misuse: refer and deter. Reducing re-admission rates for inpatient detoxification

IntroductionAlcohol abuse and related diseases are growing public health concerns. In the UK 26% of adults consume harmful quantities of alcohol.1 Alcohol related admissions are increasing by 11% each year.2...

P-601 - Understanding the revolving door syndrome

The term “revolving door” describes a subpopulation of chronically mentally ill patients frequently readmitted to psychiatric units. Policy of deinstitutionalization in mental health services during the past decades has highlighted the theme. Literature review indicates that patients at higher risk for revolving-door phenomenon are more likely to be younger, single males, with a diagnosis of a psychotic illness and high number of previous admissions. Patients with poor support networks, lower levels of education and challenging social environments are likely to remain well for shorter periods. Non-adherence to prescribed medications contributes significantly to relapse rates. The most consistently identified predictor is the number of previous hospitalizations. Authors pretend to identify patients with a high number of admissions to Coimbra University Hospitals (CUH), analyze their clinical and socio-demographic characteristics, causes of readmission and social network, and give examples. Retrospective cohort study, in which the medical records of individuals admitted to CUH during the last year were analyzed to identify those with the highest frequency of inpatient admissions (at least more than two within 18 months). Our preliminary results are consistent with those from the literature, regarding the clinical and social characteristics of patients with revolving-door phenomenon, however the most severe cases are found between female patients. Considering the social burden and the pressure on inpatient services caused by revolving door patients, it is important to understand the factors that may contribute to this phenomenon to develop interventions that could reduce the prevalence of recidivism.

P-1318 - Determinants of the « revolving door » syndrom in tunisian population of patients with schizophrenia

Revolving Door Syndrome usually corresponds to what might be called “hospital multiple readmissions phenomenon”. Beyond consequences to the patients and their families, frequent re-readmissions also heavily increase healthcare cost and cause burn out among medical and paramedical staff. The objective of this study was to find the characteristics of Tunisian patients with “revolving door” syndrome. The purpose of this study was to identify factors associated to short-term readmissions in a sample of Tunisian patients with schizophrenia. The authors conducted a retrospective study on 50 patients with schizophrenia or schizo-affective disorders from November to february 2009 in Razi Hospital's “Psychiatry C” service. Patients included in the study had been hospitalized at least 4 times. The patients were analyzed for socio-demographic characteristics, total readmissions and the number of admissions in the last year. Their medication adherence was evaluated by MARS (Medication Adherence Rating Scale) and their insight was evaluated by the Q8 scale. The sample was composed of 50 patients with schizophrenia or schizo-affective disorders according to DSM-IV, more than 18 years of age, which have been hospitalized more than 4 times. The sample was composed of 80% men. 74% of the sample was single and 66% were living with their parents. 88% were unemployed. 54% of patients were bad observers and 88% had lack of insight. The authors found that the typical Tunisian revolving door patient is a single man, living at his parent's, unemployed and with a lack of observation skills and insight.

‘They told me I had this personality disorder … All of a sudden I was wasting their time’: Personality disorder and the inpatient experience

Background. Qualitative research has neglected the experience of being on an inpatient unit for individuals with a personality disorder.Aims. The purpose of the study was to explore the inpatient experiences of service users with a personality disorder.Method. Ten service users from a community personality disorder service (CPDS) took part in a focus group. The transcript was analysed using thematic analysis.Results. Five super-ordinate themes were identified: practicalities of ward life; having a voice; revolving door patients; the power of sectioning and the ‘PD’ label.Conclusions. The focus group led to a range of issues, including concerns over staff attitudes and inpatient safety, which need to be addressed in the NHS to improve the inpatient experience for those with a personality disorder. Equally important, positive developments were recognised; including listening to inpatient feedback and joint decision making.

Do we need community treatment orders in Ireland?

Re-admissions to inpatient psychiatric care are now so frequent as to be designated the 'revolving door' phenomenon and constitute 72% of admissions to Irish inpatient psychiatric units and hospitals. It is commonly believed that treatment non-adherence with aftercare following inpatient discharge contributes to readmission. Attempts to improve adherence and reduce or shorten readmission through compulsory community treatment orders have been made in several countries including Scotland in 2005 and, from November 2008, England and Wales. Provision for conditional discharge in Ireland has already been furnished by the Criminal Law (Insanity) Act 2006 but has been compromised by the inability to impose enforcement of conditions. The paper aims to determine whether compulsory community treatment orders are effective in improving adherence and reducing re-admission and whether, in consequence, their introduction in Ireland should be considered. The legislative measures adopted to improve treatment adherence and thereby reduce re-admissions are presented. The evidence of their effectiveness is examined. Evaluation of the effectiveness of community treatment orders is limited and hindered by confounding factors. What evidence there is does not provide convincing evidence of their utility. It is concluded that there is insufficient evidence to advocate their early introduction in Ireland in civil mental health legislation. Instead a wait and see policy is suggested with critical assessment of the outcome of such developments in Scotland and England and Wales. In addition further research on the characteristics of revolving door patients in Ireland and the circumstances determining their readmission is advocated. There is an anomaly in the Criminal Law (Insanity) Act 2006 which allows of conditional discharge but does not provide for its enforcement.

Revolving-door Patients in Public Psychiatric Hospital in Israel: Cross Sectional Study

AIM. To study social, demographic, clinical, and forensic profiles of frequently re-hospitalized (revolving-door) psychiatric patients. METHODS. The study included all patients (n=183) who were admitted to our hospital 3 or more times during a 2-year period from 1999 through 2000. We compared these patients to 2 control groups of patients who were admitted to our hospital in the same period. For comparison of forensic data, we compared them with all non revolving-door patients (n=1056) registered in the computerized hospital database and for comparison of medical and clinical data we compared them with a random sample of non revolving-door patients (n=98). The sample was sufficiently large to yield high statistical power (above 98%). We collected data on the legal status of the hospitalizations (voluntary or involuntary) and social, demographic, clinical, and forensic information from the forensic and medical records of revolving-door and non revolving-door patients. RESULTS. In the period 1999-2000, 183 revolving-door patients accounted for 771 (37.8%, 4.2 admissions per patient) and 1056 non revolving-door patients accounted for 1264 (62.5%, 1.2 admissions per patient) of the 2035 admissions to our hospital. Involuntary hospitalizations accounted for 23.9% of revolving-door and 76.0% of non revolving-door admissions. Revolving-door patients had significantly shorter mean interval between hospitalizations, showed less violence, and were usually discharged contrary to medical advice. We found no differences in sex, marital status, age, ethnicity, diagnoses, illegal drug and alcohol use, or previous suicide-attempts between the groups. CONCLUSIONS. Revolving-door patients are not necessarily hospitalized for longer time periods and do not have more involuntarily admissions. The main difference between revolving-door and non revolving-door patients is greater self-management of the hospitalization process by shortening the time between voluntary re-admission and discharge against medical advice.

P.3.a.003 The revolving door patients – are they different?

P.3.a.003 The revolving door patients – are they different?

The revolving door phenomenon in psychiatry: comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing country

Deinstitutionalization has led to a dramatic reduction of inpatient beds and subsequent increase in pressure on available beds. Another consequence of deinstitutionalization has been the phenomenon of the revolving door patient; high-frequency users (HFUs) admitted to hospital repeatedly, remaining well for only short periods of time. The purpose of the study was to determine factors that contribute to HFU of inpatient psychiatric services by schizophrenia and schizo-affective disorder subjects in a developing country with a view to understanding this phenomenon better. Subjects were divided into HFU and low-frequency user (LFUs) groups for comparison with regard to selected variables. HFUs had higher PANSS scores (p < 0.01), were more likely to admit to lifetime substance use (p = 0.01), be on mood stabilizers (p < 0.01) and also to have been crisis (premature) discharges (p < 0.01). LFUs were more likely to have been treated with depot medication (p < 0.01). Multivariate analysis showed crisis discharge (p = 0.03) and depot use (p = 0.03) to be the only remaining significant predictors of HFU versus LFU status. Our findings suggest HFUs' characteristics to be similar across different settings, with under-utilization of depot antipsychotics and early discharge from hospital as particular contributors to high-frequency use of services in our sample. Results seem to indicate that HFU-specific interventions are vital to addressing these issues.

Last episode psychosis

Last Episode Psychosis 1 1 First time the first author was introduced to the concept Last Episode Psychosis was in the autumn of 2008 at a telephone conversation with Michael Schmidt, MD, Copenhagen, Denmark which in practice is schizophrenia could be defined as every psychotic episode which is not first episode. This definition is not very operational, but could be refined later for, e.g. research purposes. In Fig. 1, we present the number of first ever schizophrenia admissions to Danish psychiatric departments in the years 1996 to 2007, a few hundred per year. The figure also shows the number of last episode psychosis, around 6000 to 7000 per year (P. Munk-Jørgensen, personal communication). Last Episode Psychosis is not last ever episode psychosis, but it is last episode psychosis –for the time being. If the person is discharged, he or she may have last episode psychosis also next year and the following year, called revolving door patients 20 years ago. First ever contact and readmitted (in- and out-patient) with schizophrenia in Denmark, ICD-10 F20. Figure 2 shows the average life expectancy for male and female schizophrenia patients from 1997 to 2006 compared to the average life expectancy for the general Danish population (J. Nielsen, personal communication). Average life expectancy. The data in Fig. 1 is absolute numbers and Fig. 2 presents crude rates not standardized. The figures are calculated from The Danish Nationwide Psychiatric Research Register (Fig. 1) and the Danish Causes of Death Register (Fig. 2). Several more arguments but the numerical for focusing Last Episode Psychosis is urgent: Eleven percentage of homeless people are suffering from schizophrenia which is much higher than the background population (1), the effects of antipsychotic drugs in chronic patients are more limited compared to the first episode patients (2), the risk of myocardial infarction in patients with chronic schizophrenia is twice the background population (3), and they have an up to eight times increased risk for cardiovascular mortality (4). Patients with schizophrenia have a double risk for diabetes (4), half of them have increased body weight (4) and they are three times as often smokers as the background population (4). Patients with schizophrenia have a decreased compliance (5, 6) which increases the risk for readmission (7), extended hospitalization period (7) and increased suicide risk (8). Populations of patients with schizophrenia have high prevalence of substance use disorder comorbidity (9). Patients with schizophrenia have an increased physical morbidity in general (10), they have more frequently complications in connections with operations (11). Furthermore, patients with schizophrenia are less likely to receive proper preventive medical care (10). The antipsychotic treatment of the chronic patients with schizophrenia is more often poly-pharmaceutical though a change to monotherapy might be possible (12) and antipsychotic treatment further increases the weight gain (13, 14). Patients with schizophrenia have an increased SMR compared to the background population (15-17). Furthermore, patients with chronic schizophrenia have lowered cognitive performance compared to other psychiatric disorders which interferes with social interaction (18) and compromised quality of life (19). It is the authors’ hope that an increased focus on the Last Episode Psychosis could improve the general care for patients with schizophrenia through increased focus in the clinical practice, increased research and increased political attention.

Clinical case management of revolving door patients – a semi‐randomized study

To assess the effectiveness of psychiatric clinical case management. Subjects with at least three admissions in the previous 2 years were randomized into a clinical case management group (CMG; n = 122) and a standard care group (SCG; n = 95). Individuals who refused or were not located were included in a third, non-randomized no-treatment group (NTG; n = 153). Parameters assessed included utilization of in-patient services and psychosocial functioning. We found no difference between the CMG and the SCG in psychosocial functioning as evaluated by interviewers, and no difference between the three groups in hospitalization. In subjects' self-ratings, the CMG showed slight improvement in psychosocial functioning. Clinical case management did not prove itself superior to standard care in a revolving door population.