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Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients’ views of ward care.
Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.
In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect −0·35, 95% CI −0·57 to −0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, −0.01, 95% CI −0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect −0.18 s.d., 95% CI −0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI −£76 to £98, p = 0.774).
Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.
Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.
Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.
PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.
Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.
The Francis report highlights perceptions of care that are affected by
different factors including ward structures.
To assess patient and staff perceptions of psychiatric in-patient wards
Patient and staff perceptions of in-patient psychiatric wards were
assessed over 18 months. We also investigated whether the type of ward or
service structure affected these perceptions. We included triage and
routine care. The goal was to include at least 50% of eligible patients
The most dramatic change was a significant deterioration in all
experiences over the courseof the study. Systems of care or specific
wards did not affect patient experience but staff were more dissatisfied
in the triage system.
This is the first report of deterioration in perceptions of the
therapeutic in-patient environment that has been captured in a rigorous
way. It may reflect contemporaneous experiences across the National
Health Service of budget reductions and increased throughput. The ward
systems we investigated did not improve patient experience and triage may
have been detrimental to staff.
The National Institute of Health and Care Excellence (NICE) in England and Wales recommends the combination of pharmacotherapy and psychotherapy for the treatment of moderate to severe depression. However, the cost-effectiveness analysis on which these recommendations are based has not included psychotherapy as monotherapy as a potential option. For this reason, we aimed to update, augment and refine the existing economic evaluation.
We constructed a decision analytic model with a 27-month time horizon. We compared pharmacotherapy with cognitive–behavioural therapy (CBT) and combination treatment for moderate to severe depression in secondary care from a healthcare service perspective. We reviewed the literature to identify relevant evidence and, where possible, synthesized evidence from clinical trials in a meta-analysis to inform model parameters.
The model suggested that CBT as monotherapy was most likely to be the most cost-effective treatment option above a threshold of £22 000 per quality-adjusted life year (QALY). It dominated combination treatment and had an incremental cost-effectiveness ratio of £20 039 per QALY compared with pharmacotherapy. There was significant decision uncertainty in the probabilistic and deterministic sensitivity analyses.
Contrary to previous NICE guidance, the results indicated that even for those patients for whom pharmacotherapy is acceptable, CBT as monotherapy may be a cost-effective treatment option. However, this conclusion was based on a limited evidence base, particularly for combination treatment. In addition, this evidence cannot easily be transferred to a primary care setting.
Attempts have been made to improve the efficiency of in-patient acute care. A novel method has been the development of a ‘triage system’ in which patients are assessed on admission to develop plans for discharge or transfer to an in-patient ward.
To compare a triage admission system with a traditional system.
Length of stay and readmission data for all admissions in a 1-year period between the two systems were compared using the participating trust's anonymised records.
Despite reduced length of stay on the actual triage ward, the average length of stay was not reduced and the triage system did not lead to a greater number of readmissions. There was no significant difference in costs between the two systems.
Based on our findings we cannot conclude that the triage system reduced length of stay, but we can conclude that it does not increase the number of readmissions as some have feared.
New reimbursement schemes for inpatient mental health care are imminent in the UK and Germany. The shared intention is to reflect cost differences between patients in reimbursement rates. This requires understanding of patient characteristics that influence hospital resource use. The aim of this review was to show which associations between mental health care per diem hospital costs and patient characteristics are supported by current evidence.
A systematic review of the literature published between 1980 and 2012 was carried out. The search strategy included electronic databases and hand-searching. Furthermore, reference lists, citing articles and related publications were screened and experts were contacted.
The search found eight studies. Dispersion in per diem costs was moderate, as was the ability to explain it with patient characteristics. Six patient characteristics were identified as the most relevant variables. These were (1) age, (2) major diagnostic group, (3) risk, (4) legal problems, (5) the ability to perform activities of daily living and (6) presence of psychotic or affective symptoms. Two non-patient-related factors were identified. These were (1) day of stay and (2) treatment site.
Idiosyncrasies of mental health care complicated the prediction of per diem hospital costs. More research is required in European settings since transferability of results is unlikely.
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