Evaluation of a Pathway team for homeless mental health in-patients.

AIMS AND METHOD: The Pathway model is an enhanced care coordination model for homeless people in hospital. We aimed to evaluate the first attempt to apply it on psychiatric wards, which started in 2015 in South London. We developed a logic model which expressed how the Pathway approach might work. Two predictions from this model were tested, using propensity scores and regression to estimate the effect of the intervention among people who were eligible for it. RESULTS: The Pathway team theorised that their interventions would reduce length of stay, improve housing outcomes and optimise the use of primary care - and, more tentatively, reduce readmission and emergency presentations. We were able to estimate effects on length of stay (-20.3 days; 95% CI -32.5 to -8.1; P = 0.0012) and readmission (a non-significant reduction). CLINICAL IMPLICATIONS: The marked reduction in length of stay, explicable in terms of the logic model, constitutes preliminary support for the Pathway model in mental health services.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units.

AIMS: The aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint. BACKGROUND: One of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied. DESIGN: The study applied a cross-sectional design. METHODS: Data were collected from 207 staff at eight hospital sites in England between 2013 - 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision-making in relation to the need for manual restraint of an aggressive patient. RESULTS: In service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation. CONCLUSION: Tolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.

Utility of the Health of the Nation Outcome Scales (HoNOS) in Predicting Mental Health Service Costs for Patients with Common Mental Health Problems: Historical Cohort Study.

BACKGROUND: Few countries have made much progress in implementing transparent and efficient systems for the allocation of mental health care resources. In England there are ongoing efforts by the National Health Service (NHS) to develop mental health 'payment by results' (PbR). The system depends on the ability of patient 'clusters' derived from the Health of the Nation Outcome Scales (HoNOS) to predict costs. We therefore investigated the associations of individual HoNOS items and the Total HoNOS score at baseline with mental health service costs at one year follow-up. METHODS: An historical cohort study using secondary care patient records from the UK financial year 2012-2013. Included were 1,343 patients with 'common mental health problems', represented by ICD-10 disorders between F32-48. Costs were based on patient contacts with community-based and hospital-based mental health services. The costs outcome was transformed into 'high costs' vs 'regular costs' in main analyses. RESULTS: After adjustment for covariates, 11 HoNOS items were not associated with costs. The exception was 'self-injury' with an odds ratio of 1.41 (95% CI 1.10-2.99). Population attributable fractions (PAFs) for the contribution of HoNOS items to high costs ranged from 0.6% (physical illness) to 22.4% (self-injury). After adjustment, the Total HoNOS score was not associated with costs (OR 1.03, 95% CI 0.99-1.07). However, the PAF (33.3%) demonstrated that it might account for a modest proportion of the incidence of high costs. CONCLUSIONS: Our findings provide limited support for the utility of the self-injury item and Total HoNOS score in predicting costs. However, the absence of associations for the remaining HoNOS items indicates that current PbR clusters have minimal ability to predict costs, so potentially contributing to a misallocation of NHS resources across England. The findings may inform the development of mental health payment systems internationally, especially since the vast majority of countries have not progressed past the early stages of this development. Discrepancies between our findings with those from Australia and New Zealand point to the need for further international investigations.

Clinical outcomes and mortality associated with weekend admission to psychiatric hospital.

BACKGROUND: Studies indicate that risk of mortality is higher for patients admitted to acute hospitals at the weekend. However, less is known about clinical outcomes among patients admitted to psychiatric hospitals. AIMS: To investigate whether weekend admission to a psychiatric hospital is associated with worse clinical outcomes. METHOD: Data were obtained from 45 264 consecutive psychiatric hospital admissions. The association of weekend admission with in-patient mortality, duration of hospital admission and risk of readmission was investigated using multivariable regression analyses. Secondary analyses were performed to investigate the distribution of admissions, discharges, in-patient mortality, episodes of seclusion and violent incidents on different days of the week. RESULTS: There were 7303 weekend admissions (16.1%). Patients who were aged between 26 and 35 years, female or from a minority ethnic group were more likely to be admitted at the weekend. Patients admitted at the weekend were more likely to present via acute hospital services, other psychiatric hospitals and the criminal justice system than to be admitted directly from their own home. Weekend admission was associated with a shorter duration of admission (B coefficient -21.1 days, 95% CI -24.6 to -17.6, P<0.001) and an increased risk of readmission in the 12 months following index admission (incidence rate ratio 1.13, 95% CI 1.08 to 1.18, P<0.001), but in-patient mortality (odds ratio (OR) = 0.79, 95% CI 0.51 to 1.23, P = 0.30) was not greater than for weekday admission. Fewer episodes of seclusion occurred at the weekend but there was no significant variation in deaths during hospital admission or violent incidents on different days of the week. CONCLUSIONS: Being admitted at the weekend was not associated with an increased risk of in-patient mortality. However, patients admitted at the weekend had shorter admissions and were more likely to be readmitted, suggesting that they may represent a different clinical population to those admitted during the week. This is an important consideration if mental healthcare services are to be implemented across a 7-day week.

Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register: current status and recent enhancement of an Electronic Mental Health Record-derived data resource.

PURPOSE: The South London and Maudsley National Health Service (NHS) Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register and its Clinical Record Interactive Search (CRIS) application were developed in 2008, generating a research repository of real-time, anonymised, structured and open-text data derived from the electronic health record system used by SLaM, a large mental healthcare provider in southeast London. In this paper, we update this register's descriptive data, and describe the substantial expansion and extension of the data resource since its original development. PARTICIPANTS: Descriptive data were generated from the SLaM BRC Case Register on 31 December 2014. Currently, there are over 250,000 patient records accessed through CRIS. FINDINGS TO DATE: Since 2008, the most significant developments in the SLaM BRC Case Register have been the introduction of natural language processing to extract structured data from open-text fields, linkages to external sources of data, and the addition of a parallel relational database (Structured Query Language) output. Natural language processing applications to date have brought in new and hitherto inaccessible data on cognitive function, education, social care receipt, smoking, diagnostic statements and pharmacotherapy. In addition, through external data linkages, large volumes of supplementary information have been accessed on mortality, hospital attendances and cancer registrations. FUTURE PLANS: Coupled with robust data security and governance structures, electronic health records provide potentially transformative information on mental disorders and outcomes in routine clinical care. The SLaM BRC Case Register continues to grow as a database, with approximately 20,000 new cases added each year, in addition to extension of follow-up for existing cases. Data linkages and natural language processing present important opportunities to enhance this type of research resource further, achieving both volume and depth of data. However, research projects still need to be carefully tailored, so that they take into account the nature and quality of the source information.

Assessments of mental capacity in psychiatric inpatients: a retrospective cohort study.

BACKGROUND: The Mental Capacity Act 2005 (MCA) was introduced in 2007 to protect vulnerable individuals who lack capacity to make decisions for themselves and to provide a legal framework for professionals to assess incapacity. The impact of the MCA on clinical practice is not known. This study aims to evaluate how frequently mental capacity is assessed in psychiatric inpatients, whether the criteria for determining capacity set out in the MCA are used in practice, and whether this has increased with the introduction of the MCA. METHOD: A retrospective cohort study was carried out using a case register of South East London mental health service users. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information on patients admitted to the South London and Maudsley NHS Foundation Trust since 2006. The presence and outcomes of documented mental capacity assessments in psychiatric admissions between May 2006 and February 2010 were identified and demographic information on all admissions was retrieved. RESULTS: Capacity assessments were documented in 1,732/17,744 admissions (9.8%). There was a significant increase in the frequency of capacity assessments carried out over the study period of 0.3 percentage points per month (95% CI 0.26-0.36, p < 0.00001). In only 14.7% of capacity assessments were the MCA criteria for assessing capacity explicitly used. CONCLUSIONS: Over the period of the introduction of the MCA there has been a significant increase in the number of mental capacity assessments carried out on psychiatric inpatients. Although mental health services are considering the issue of capacity more frequently, mental capacity assessments are inconsistently applied and do not make adequate use of MCA criteria.

Associations of homelessness and residential mobility with length of stay after acute psychiatric admission.

BACKGROUND: A small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures. METHODS: Cross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression. RESULTS: Residential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor. CONCLUSIONS: Homelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.

Khat use among Somali mental health service users in South London.

PURPOSE: Khat use has been suggested to be associated with psychosis, but its prevalence and associations among mental health service users have not been described in either traditional use countries or countries with immigrant populations from traditional use countries. We aimed to investigate the clinical and demographic associations of khat use in a sample of Somali users of mental health service users in South London. METHODS: We used an electronic case register of 150,000 mental health patients to investigate the associations of khat use among all 240 Somali patients in the database. We used logistic regression to generate adjusted estimates for a range of exposure variables and used multiple imputation as a principled approach to missing data. RESULTS: Khat use or non-use was recorded for 172 patients (72% of the total), of whom 80 (47%) were current users. Khat use was very strongly associated with ICD-10 primary diagnosis of schizophrenia, psychosis or drug and alcohol disorder (compared to ICD-10 F43 stress-related disorders and other non-psychotic disorders), male gender, harmful or dependent use of alcohol, and detention under the Mental Health Act. CONCLUSIONS: Recording and monitoring of khat use need to be more consistent in clinical settings, and further studies are required to investigate the much higher rates of use among those with psychotic disorders compared to non-psychotic disorders.

Timing, prevalence, determinants and outcomes of homelessness among patients admitted to acute psychiatric wards.

PURPOSE: To document the prevalence, timing, associations and short-term housing outcomes of homelessness among acute psychiatric inpatients. METHODS: Cross-sectional study of 4,386 acute psychiatric admissions discharged from a single NHS Trust in 2008-2009. RESULTS: Homelessness occurred in 16%. Most homelessness (70%) was either recorded as present at admission or started within 1 week. It was associated with younger age; male gender; ethnicity other than White British or Black African/Caribbean; being single, divorced, separated or widowed; diagnosis of drug and alcohol disorder; detention under a forensic section of the Mental Health Act; having no previous admission or alternatively having a longer previous admission; having a low score on the depressed mood or hallucinations and delusions items of the Health of the Nation Outcome Scales (HoNOS); and having a high score on the HoNOS relationship difficulties and occupation and activities items. Of those who were followed-up for 28 days after discharge, 53% had a new address recorded; of those who were not, only 22% did. CONCLUSIONS: Homelessness affects a substantial minority of psychiatric admissions in the UK. Housing outcomes are uncertain, and it is possible that more than half continue to be homeless or living in very transient situations. Demographic and diagnostic associations with homelessness were consistent with US studies; associations with HoNOS item scores and having had no admission in the preceding 2 years suggest that, in many cases, social adversity predominates over active psychopathology at the time of admission.

Residential mobility among patients admitted to acute psychiatric wards.

Residential mobility among those with mental disorders is consistently associated with hospital admission. We studied 4485 psychiatric admissions in South London, aiming to describe the prevalence, timing and associations of residential moves occurring in association with admission. Moves tended to cluster around discharge; 15% of inpatients moved during admission or up to 28 days after discharge. The strongest associations were with younger age (especially 16-25 years) and homelessness. Unadjusted effects of gender, marital status and previous service use were mediated by homelessness. Possible mechanisms for the associations with homelessness and younger age are discussed.

Length of stay of general psychiatric inpatients in the United States: systematic review.

Psychiatric length of stay (LOS) has reduced but is still longer than for physical disorders. Inpatient costs are 16% of total mental health spending. Regression analyses of the determinants of LOS for US adult psychiatric inpatients were systematically reviewed. Most studies predated recent LOS reductions. Psychosis, female gender and larger hospital size were associated with longer LOS, while discharge against medical advice, prospective payment, being married, being detained and either younger or middle age were associated with shorter LOS. Associations appeared consistent, especially where sample size was above 3,000. Updated studies should be adequately powered and include the variables above.

Residential mobility among individuals with severe mental illness: cohort study of UK700 participants.

BACKGROUND: There is limited research concerning residential mobility among people with severe mental illness. AIM: To investigate residential mobility over 2 years among participants in the UK700 trial of intensive case management in severe mental illness. METHODS: Cohort study. RESULTS: Over 60% of participants had recently wanted to move or improve their accommodation but this was not associated with mobility. Mobility was strongly associated with younger age and drug and alcohol misuse and weakly associated with being unmarried and needs relating to a benefit claim. Among those likely to have been living in supported housing, mobility was also associated with being able to look after the home. Among those living independently, mobility was also associated with being an inpatient at randomisation. DISCUSSION: Wanting to move did not predict mobility. This contrasts with findings in the general population. Several of the associations found are possibly due to forced mobility. The association with younger age is likely to represent voluntary mobility as in the general population. CONCLUSIONS: Future studies of residential mobility in severe mental illness should make use of a wider range of methods and should draw on the general population literature.

The determinants and outcomes of long-stay psychiatric admissions: a case-control study.

BACKGROUND: Acute psychiatric admissions lasting over 6 months (long-stays) continue to occur in England. Previous studies have suggested an association between long-stay and both schizophrenia and challenging behaviour, as well as rehousing or placement difficulties, but no UK study to date has compared such cases with control admissions. METHODS: We performed a case-control study. All long-stay patients present on acute general psychiatric wards serving the London Boroughs of Croydon, Lambeth, Lewisham and Southwark on November 1st 2004 were compared with a group of 'next admitted' controls. We followed up long-stay cases 1 year later to determine whether they were still in hospital, and, if not, where they were living. RESULTS: In unadjusted comparisons long stay was associated with schizophrenia, non-white ethnicity, admission not due to suicidality, violence, severe illness and need for rehousing. A logistic regression was used to adjust for associations among exposures and only violence, severity of illness and need for rehousing remained associated with long-stay. After 1 year, two-thirds of cases were living out of hospital. CONCLUSIONS: Case-control studies may usefully contribute to the study of the complex social phenomenon of long-stay. Further research should address how the combination of individual and socially-determined effects that we found operate together over the course of admission to generate long-stays.

Social outcomes in schizophrenia: from description to action.

PURPOSE OF REVIEW: The reality of schizophrenia is not fully expressed by measures of psychopathology and both descriptive research and research into interventions benefit from the investigation of social outcomes. We define these as measures which reflect performance compared to normal social expectations, either of oneself or of another. The studies we reviewed looked at the effects on summary measures, for example, quality of life, as well as simpler, more self-explanatory outcomes such as employment, marital status, financial independence and housing. RECENT FINDINGS: The review contrasts studies which describe the determinants of social outcomes and studies designed to estimate the effects of interventions on these outcomes. Recent descriptive studies demonstrate that social outcomes have both longitudinal and cross-sectional associations with cognitive impairment, preexisting functional impairment and certain symptoms. Studies of both pharmacological and social interventions suggest that, at best, these can affect social outcomes. SUMMARY: Simpler social outcomes are reported less frequently than summary measures which can make interpretation more difficult, thus diluting a potential advantage of social outcome measures to researchers and clinicians alike. Social outcomes are underreported compared to measures of psychopathology, particularly in trials of interventions.