Service use and costs: impact of hospital triage, drug use disorders in psychosis and childhood behavioural problems
Three papers in the Journal this month examine the impact on service use of particular service developments and patient/illness characteristics. Williams et al (pp.) compared patterns of service use, including hospital admission rates, before and after the introduction of a triage admission system in one large innercity mental health organisation. Overall, little difference was found between the two conditions - in terms of average length of total hospital stay, number of readmissions or cost - even though length of stay on the actual triage wards was reduced for many patients. The authors comment on the possibility that transfer from triage wards for those who cannot be rapidly discharged may actually prolong admission for that group.
Focusing on patient/illness characteristics, Sara et al (pp.) utilised mental health service use data to examine the impact of cannabis and stimulant disorders on outcomes for those with first-episode psychosis. Over the 2-year follow-up period, readmission was not found to be predicted by the presence of baseline substance use disorders, although both the presence of a stimulant disorder diagnosis made prior to the index admission with psychosis and ongoing problem drug use did predict readmission. The authors comment on the need to identify substance use disorders for those with first-episode psychosis since intervention leading to discontinuation may be associated with the best outcomes for this group. D’Amico et al (pp.) undertook a long-term follow-up study of service use and associated costs for a sample of young adults with a childhood history of hyperactivity/conduct problems. The authors found an association between high levels of childhood conduct problems and early adulthood service costs, particularly driven by involvement with the criminal justice system. Interestingly, across all baseline groups in the sample, high levels of A&E and general hospital contact were found in young adulthood while use of mental health services was comparatively lower.
Three randomised controlled trials: focused on benzodiazepine use, self-harm and dementia
Two papers in the Journal this month test the efficacy of relatively simple interventions delivered in non-psychiatric settings. Vicens et al (pp.) detail the results of a cluster randomised controlled trial (RCT) in primary care comparing two interventions to discontinue long-term benzodiazepine use in three regions of Spain. Both active interventions (structured interventions with either follow-up visits or written instructions) were found to be effective in reducing benzodiazepine use. The structured intervention with written instructions was found to be less time-consuming but as effective as the intervention with follow-up visits. In Pakistan, Husain et al (pp.) examined the efficacy of a brief psychological intervention (culturally adapted manual-assisted problem-solving training) delivered after an episode of self-harm leading to admission to a medical unit. The primary outcome, a reduction in suicidal ideation at 3 months, was found to be associated with the intervention compared with treatment-as-usual, as were improvements in the Beck Hopelessness Inventory score and a reduction in symptoms of depression.
Cognitive stimulation has been shown to be of short-term benefit, including with regard to cognitive functioning, for people with dementia, but the longer-term effects are unknown. In a single-blind, multicentre pragmatic RCT of maintenance cognitive stimulation therapy, involving individuals with dementia recruited from care homes and community services in England, Orrell et al (pp.) report that at 6 months, the intervention group demonstrated significant improvements in quality of life (self-rated) but no evidence of cognitive benefit was found. However, for the subgroup of patients taking acetylcholinesterase inhibitors, cognitive benefits were seen at 3 and 6 months. The authors comment on the need for replicative research testing maintenance cognitive stimulation therapy in different groups and different settings, and highlight the importance of measuring quality of life as a key outcome indicator in dementia interventions studies as well as more traditional disease- or symptom-specific measures.
Impact of additional risk factors on survival for those with psychiatric illness: socioeconomic disadvantage and physical illness
In a study by Chen et al (pp.) of people with dementia and late-life depression in China, rural living was found to be associated with a greater risk of mortality over a 5.6-year follow-up period. When educational, occupational and income disadvantage were considered, no impact on mortality was found for those with dementia but disadvantage was associated non-significantly with risk of mortality for those with depression. The authors call for a particular focus on rural mental health provision for adults with dementia and depression to address apparent mental health inequalities.
In a Danish national register study, Qin et al (pp.) found that suicide risk in those with physical illness varies by the presence of psychiatric comorbidity and is particularly influenced by the relative timing of illness onset. Suicide risk was elevated when onsets of illness, physical and psychiatric, occurred close in time to each other. Suicide risk was also particularly elevated among those with physical illness who developed psychiatric disorder some time later. The authors highlight the importance of considering physical as well as psychiatric illness in evaluation of suicide risk and call for a greater integration of healthcare services and clinicians dealing with those who experience such comorbidity.
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