17.What is the place of psychiatric inpatient care in the 21st century? Lessons from research on hospital alternatives.

I wrote this article for the April 2011 issue of ” Community Psychiatrist”: the newsletter of the American Association of Community Psychiatrists. It highlights the role of intensive home treatment and how I think this model fits with the two other hospital alternatives; acute day hospitals and crisis residences.

Lessons from research on hospital alternatives to Inpatient care:  what’s its place in the 21stcentury? 

David S. Heath FRCPC

This article is a brief summary of research on an essential component of any recovery oriented mental health system, the adequate provision of community-based alternatives to hospitalization (1).

This summary reviews three alternatives, all of which share several characteristics.  First, they represent services that are specifically designed for the sole purpose of replacing hospital treatment.  Second, they are facilities to which a patient, if determined to need hospital admission, can be quickly referred instead.  And third, they have been compared with hospital treatment in either a randomized or non-randomized trial.

When reviewing these less than flawless studies, one needs to keep in mind that  what these services purport to replace – inpatient care – is a historically derived service for which there is almost no effectiveness research (2).

The first alternative, called residential alternatives (RA), is impossible to summarize neatly.  A systematic review identified fifteen relevant studies, eleven from the US and six of which were considered of moderate quality.  All found outcomes that were equal or superior to standard hospital care.  Of the four that assessed patient satisfaction, three found greater satisfaction in the alternative.  In addition, three of the four assessing cost found the alternative to be cheaper (3).  An English multi-site study of five RAs, comparing their patients with patients in local hospitals, found no significant difference in risk of intentional or unintentional self-harm, recent self-harm, social functioning, and social problems.  RA patients were also less likely to be psychotic and less likely to be perceived as a risk to others.  Some patients were involuntarily detained under mental health legislation (4).

The second alternative – day hospitals – can reduce regular hospital admissions by 23%, according to a systematic review of randomized controlled trials (5) and a European multi-centre (five countries) randomized control trial (6).  The review showed clinical outcomes were equal to the hospital controls.

The third alternative – intensive home treatment (IHT) – is now the front runner, as it is the most versatile and flexible alternative and also the least stigmatizing and intrusive.

In the following IHT studies, clinical outcomes were equal to the hospital controls.

A Cochrane review of five randomized studies showed a mean reduction in admissions of 55%.  However, all the experimental services differed from the IHT service offering typical of today, in that they continued to follow patients once the acute phase was over (7).

Non-randomized studies, while somewhat flawed in ensuring equivalence of populations, have the advantage of no exclusions.  Four such English studies showed reduction in admissions ranged from 22%-72% (8, 9, 10, 11).

The most superior and most recent randomized trial was the N. Islington study, in inner London.  Located in a socially deprived area with a very community oriented   control hospital service, this was an unusually stringent test.  Nevertheless, there was still a reduction in admissions of 37%.  The NNT to avoid one admission was 2.65 (12).  Cost savings over six months were $4,000 (13).

Research on the effect of IHT teams throughout England found a mean reduction in admissions of 23% in areas that had IHT services with 24-hour coverage (14). England’s independent government audit of IHT teams found wide variations in such factors as staffing, availability of consultant psychiatrists, and adherence to the model.  A survey of ward managers concluded that an additional 20% of admissions could have been avoided with adherence to the model.  IHT also led to the early discharge of 40% of admitted patients (15).  Economic modelling showed cost savings of $980 per episode (16).

Since the mandated creation of IHT teams throughout England after 2000, two naturalistic studies showed reductions in admissions of 37.5% (17) and 45% (18), respectively.

A second type of research on hospital alternatives is known as “alternative projections research” (19).  This research utilizes a “bottom up” approach, whereby clinicians decide on a given day which of the current in-patients – including newly admitted patients – could be treated in one or more of the alternative services, even if those alternatives were not available.  For example, a 2002 study of a psychiatric hospital in Montreal found that, on a given day, only 29% of a sample of acute care patients was unsuitable for a hospital alternative.  71% could have been treated by “packages” of the three alternatives (20).

The picture emerging from this research is that a triad of alternatives can be provided in a crisis, either singly, sequentially, or in combination.  Behavioural health administrators, from the national level to the local level, should advocate for the systematic provision of these alternatives as the default disposition for all patients in a crisis. Hospitalization should be used only when an alternative is not feasible, and then only for the shortest time necessary.

References

  1. Slade, M. (2009) Personal recovery and mental illness. A guide for mental health professionals. Cambridge University Press.
  2. Szmukler, G & Holloway, F. ( 2001) In-patient treatment. In Thornicroft, G. & Szmukler, G. Textbook of community psychiatry (pp 321-337). Oxford University Press.
  3. Lloyd-Evans, B. Slade, M. Jagielska, D and Johnson, S. (2009). Residential alternatives to acute psychiatric hospital admission: a systematic review. British Journal of Psychiatry, 195, 109-117.
  4. Johnson,S., Lloyd-Evans, B., Morant, N., Gilburt,H., Shepherd, G.Slade, M. et al. ( 2010) Alternatives to standard acute in-patient care in England: roles and populations served. British Journal of Psychiatry,197,s 6-13
  5. Marshall, M., Crowther, R., Almaraz-Serrano,A., Creed, F., Sledge,W.Kluiter, W. et al. (2001) Systematic reviews of the effectiveness of day care for people with severe mental disorders; (1) Acute day hospital versus admission. Health Technology Assessment, 5,1-25
  6. Kallert,T.W., Priebe, S., McCabe, R., Kiejna,A., Rymaszewska, J.Nawka, P. et al.( 2007) Are day hospitals effective for acutely ill patients? A European multicentre randomized controlled trial. Journal of Clinical Psychiatry, 68, 278-287
  7. Joy,C.B., Adams,C.E. & Rice, K.( 2006) Crisis intervention for people with severe mental illness, Cochrance Database of Systematic Reviews Issue 4
  8. Dean,C.& Gadd,E.M. ( 1990) Home treatment for acute psychiatric illness. British Medical Journal,301,1021-1023
  9. Dean,C. Phillips,J., Gadd,E.M., Joseph,M. & England,S. ( 1993) Comparison of community based service with hospital based service for people with acute severe psychiatric illness. British Medical Journal,307.473-476
  • Minghella, E.,Ford,R., FreemanT., Hoult,J., McGlynn,P.,& O’Halloran,P.( 1998) Open all hours: 24-hour response for people with mental emergencies. London: The Sainsbury Centre for Mental Health
  • Johnson,S., Nolan,F., Hoult,J., White,I.R., Bebbington,P., Sandor,A. et al. (2005) Outcomes of crises before and after introduction of a crisis resolution team. British Journal of Psychiatry, 187,68-75
  • Johnson,S., Nolan,F., Pilling,S., Sandor,A., Hoult,J., McKenzie,N. et al.(2005) Randomized trial of acute mental health care by a crisis resolution team: the north Islington crisis study. British Medical Journal,331,586-587
  • McCrone,P., Johnson,S., Nolan,F.,Pilling,S,.Sandor,A.,Hoult,J. et al. (2009) Economic evaluation of a crisis resolution service: a randomised controlled trial.Epidemiologia e Psichiatria Sociale ,16,54-58
  • Glover,G., Arts,G., & Babu, K.S.( 2006) Crisis resolution/home treatment teams and psychiatric admission rates in England. British Journal of Psychiatry ,189,441-445
  • National Audit Office (2007) Helping people through mental health crisis: The role of crisis resolution and home treatment services HC Session 2007-2008 7 December 2007. Retrieved June 6 2010 from http://www.nao.org.uk/publications/0708/helping_people_through_mental.aspx
  • Mc Crone,P., Knapp,M. & Hudson, J. ( 2007) Model to assess the economic impact of integrating CRHT and inpatient services. National Audit Office. Retrieved 6 June 2010 fromhttp://www.nao.org.uk/publications/0708/helping_people_through_mental.aspx

  • Jethwa,K., Gallapathie, N., & Hewson,P. ( 2007) Effects of a crisis resolution and home treatment team on in-patient admissions. Psychiatric Bulletin,31, 170-172
  • Keown,P., Tacchi,M.J., Niemic,S., & Huges,J. ( 2007) Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatric Bulletin, 31,288-292

19.Bartlett,C., Holloway,J., Evans,M & Harrison,G. ( 1999) Projection of alternatives to acute psychiatric beds: Review of an emerging service assessment method .Journal of Mental Health, 8 555-568

20Lesage,A.D., Bonsack,C., Clerc,D., Vanier,C., Charron,M.,Sasseville,M. et al ( 2002) Alternatives to acute hospital psychiatric care in east-end Montreal. Canadian Journal of Psychiatry, 47,51-57

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