Does short inpatient care make a significant difference? Mental Health care professionals and treatment team staff here at Western State Hospital (WSH) ponder this question daily. Patients at WSH are admitted every day due to major psychopathology yet are discharged at increasing rates within 72 hours of admission. Recidivism rates worldwide are staggering and should be examined. Therefore, the undersigned decided to explore overseas into Italy’s mental health system seeking answers to the above mentioned question.
Over the past decade and beyond in the United States, acute psychiatric admissions have declined. In their article, “Do patients improve after short psychiatric admission? A cohort study in Italy,” Barbato, Parabiaghi, Panicali, Battino, D’Avanzo, De Girolamo, Rucci, & Santone, (2011) mentioned that approximately three weeks of hospitalization was defined as a “brief” admission. The authors further examined additional sources and found that a two week admission was considered an extended admission. Here one can already get a sense of the problem and the decrease in length of acute admissions. Not surprisingly, Barbato, et al mentioned that this decline was not only problematic in the United States of America, but overseas as well including Canada (seventeen days); England (eighteen days); Australia (eleven days); and Italy (twelve days). Given this scenario, one may estimate, with confidence, that brief admissions (i.e., acute levels or otherwise), especially patients presenting severe symptomatology, can face increased suicidal ideation or unnecessary readmission. Of course there are additional reasons to consider as causal factors for patient recidivism, such as medication non-adherence, lack of follow-up to aftercare therapy, and unstable social environment, just to name a few. However, in this article, the author’s intent was to estimate the level of percentage change in symptoms at discharge. In others words, the authors assessed patients (n=206) utilizing the standardized Italian version of the Brief Psychiatric Rating Scale (BPRS) pre/post admission and again when transferred on an acute unit (pre/post) prior to discharge. The BPRS item scores ranged from one to seven and the total score ranged from 24 to 168 (Barbato, et al, 2011, p. 252). The BPRS factors positive symptoms of mania/disorganization, depression/anxiety and negative symptoms as well. The authors felt that the BPRS would identify patient outcome and could be used to guide effective treatment.
In comparison to the United States, inpatient care in Italy is distributed among public and private interests. In 2003, there were over 300 public facilities and over 50 private facilities responsible for the mental health needs of patients. The authors gathered information on acute inpatient care by conducting surveys over two-phases that was accepted by the local Ethical Appraisal Panel of the National Health Institute. The research was sponsored by the Ministry of Health over a four year period in all regions except Sicily. Phase I explored the number of patients versus the average length of hospitalization plus resources, such as bed availability. Phase II involved indentifying a representative random sample of patients from both public and private facilities.
Statistical analysis:
The Mann–Whitney test was utilized for continuous variables and the X² test for categorical variables to compare between independent groups. The significance level of .05 was used and tests were two-tailed. The effect size was calculated by Cohen’s d, as the difference between the mean BPRS score at admission and discharge divided by the pooled standard deviation.
Results:
Out of 206 patients, clinical improvements were found in about one in seven patients after a brief admission. Improvements were noted in the total and factor scores of the BPRS, with moderate to large effect sizes. Statistical measures were conducted to record and track psychopathology at the group and individual levels. BPRS scores were captured at admission: Leucht et al. (2006) reviewed the clinical implications of BPRS scores and revealed that patients were indentified on average as moderately ill at admission with a mean score of 2.22, and as “mildly ill” at discharge (on the admissions unit), with a mean score of 1.73, which represented a 22% drop in BPRS score thus considered minimal improvement in approximately a one week period. Once discharged from admissions to an acute unit, the BPRS was again assessed. Varner et al. (2000) assessed the outcomes of acute inpatient care that utilized an 18-item BPRS. Varner et al. found that patients admitted to an acute unit scored 2.0 at baseline and 1.8, 1.5 and 1.4 on days 2, 7 and 14, respectively. The authors concluded that a minimum of seven days of hospitalization were needed to show improvement, which was based on patients that already showed marked improvement since day two.
Limitations:
1. The authors mentioned that diagnoses at admittance were not based on a comprehensive clinical interview, but rather based on observation and the BPRS was felt to be more effective and accurate. While the undersign believe that clinical observation cannot be discounted during the assessment process (one can collect valuable information through collateral resources, such as nursing staff, social workers, and psychiatrists), conducting a clinical interview, in my opinion, yields greater information than observation alone and an assessment tool.
2. There was not a consistent sample of patients drawn for one facility, but from approximately three different facilities that increased the generalizability in treatment strategies that could not be accurately captured in statistical formulation.
Outcome assessment of short psychiatric hospitalization:
A study by Svindseth, et al. (2010) of acute inpatients revealed similar BPRS scores at admission (53.8 vs. 53.2), but noted that patient length of stay was longer (13 days vs. 5 – 7). BPRS scores were helpful during the admissions process to identify mild to moderately ill patients. A great number of patients were identified as mildly impaired and therefore did not require acute hospitalization. The authors identified mildly impaired patients as those having mild levels of depression/anxiety, impairment in work and/or social functioning, social withdrawal, or family conflict. Those individuals were immediately discharged and recommended for outpatient clinical services.
In conclusion, there is a global urgency that exists for the continuity of care for mental health patients. Outpatient treatment is a critical and necessary component of the mental health community. While the authors have pointed to decreases in percentage and symptomatology on the inpatient admissions unit, time-limited acute care, although producing symptom improvement, is still considered too short to yield significant improvement.
References
Barbato, A., Parabiaghi, A., Panicali, F., Battino, N., D’Avanzo, B., De Girolamo, G., Rucci, P., & Santone, G. (2011). Do patients improve after short psychiatric admission? A cohort study in Italy [on behalf of the PROGRESS-Acute Group]. Nordic Journal of Psychiatry, 65:251–258.
Leucht, S., Kane, J.M., Etschel, E., Kissling,W., Hamann, J., & Engel, R. R. (2006). Linking the PANSS, BPRS, and CGI: Clinical implications. Neuropsychopharmacology, 31:2318 – 2325.
Varner, R.V., Chen, Y.R., Swann, A.C., & Moeller, F.G. (2000). The Brief Psychiatric Rating Scale as an acute inpatient outcome measurement tool: A pilot study. Journal of Clinica Psychiatry, 61:418 – 21.
Svindseth, M. F., Nottestad, J.A., & Dahl, A.A (2010). A study of outcome in patients treated at a psychiatry emergency unit. Nordic Journal of Psychiatry, DOI:Â Â Â Â Â Â Â 10.3109/08039481003690273.
David J. Wright, MA., MSW
WKPIC Doctoral Intern