High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: −0.45%/week, 95% confidence interval [CI] = −0.78%, −0.12%; Urban: −0.49%/week, 95% CI = −0.73%, −0.25%); PDU implementation in each was associated with an estimated 35–38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (−20.4%, CI = −29.7%, −10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (−16.6%, 95% CI = −23.9%, −8.5%) but no significant (long-term) trend change (−0.20%/week, 95% CI = −0.74%, 0.34%) and no short- (−2.8%, 95% CI = −19.3%, 17.0%) or long-term (0.08%/week, 95% CI = −0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Telemedicine has been at the heart of healthcare system’s strategic response to the COVID-19 pandemic. Within psychiatry, there has been a surge of research and guidelines into the use of video-teleconferencing to replace face to face consultations across clinical settings. Clinical ward rounds are central to inpatient psychiatric care yet little guidance is available on how best to integrate telemedicine into the multidisciplinary work of inpatient psychiatry.

We report on the introduction of video teleconferencing for psychiatric ward rounds on our acute inner-London psychiatric unit during the outbreak of COVID-19.

In undertaking the rapid transition to tele-ward rounds, we had to reconcile the multiple functions of psychiatric ward rounds with the technological resources available to us.

Tele-ward rounds helped simplify care delivery, facilitate multidisciplinary collaboration and improve accessibility for patients and relatives in a time of crisis. The transition to tele-ward rounds also brought about technical, operational and communication issues that may impact on the patient experience and quality of care including governance challenges, contextual dissonance and technological limitations.

The routine use of newer technology in psychiatry ward rounds is unlikely to succeed on the basis of improvisation, particularly given the stream of technical innovations in telemedicine, and the multifarious quality of social interactions in our clinical setting. Staff training and the development of an adapted etiquette and code of communication are both essential. Patient participation in future developments will also help ensure tele-ward rounds continue to meet the standards of high quality inpatient psychiatric care beyond the COVID-19 pandemic.

No significant relationships.

People diagnosed with a severe mental illness (SMI) are at elevated risk of dying prematurely compared to the general population. We aimed to understand the additional risk among people with SMI after discharge from inpatient psychiatric care, when many patients experience an acute phase of their illness.

In the Clinical Practice Research Datalink (CPRD) GOLD and Aurum datasets, adults aged 18 years and older who were discharged from psychiatric inpatient care in England between 2001 and 2018 with primary diagnoses of SMI (schizophrenia, bipolar disorder, other psychoses) were matched by age and gender with up to five individuals with SMI and without recent hospital stays. Using survival analysis approaches, cumulative incidence and adjusted hazard ratios were estimated for all-cause mortality, external and natural causes of death, and suicide. All analyses were stratified by younger, middle and older ages and also by gender.

In the year after their discharge, the risk of dying by all causes examined was higher than among individuals with SMI who had not received inpatient psychiatric care recently. Suicide risk was 11.6 times (95% CI 6.4–20.9) higher in the first 3 months and remained greater at 2–5 years after discharge (HR 2.3, 1.7–3.2). This risk elevation remained after adjustment for self-harm in the 6 months prior to the discharge date. The relative risk of dying by natural causes was raised in the first 3 months (HR 1.6, 1.3–1.9), with no evidence of elevation during the second year following discharge.

There is an additional risk of death by suicide and natural causes for people with SMI who have been recently discharged from inpatient care over and above the general risk among people with the same diagnosis who have not recently been treated as an inpatient. This mortality gap shows the importance of continued focus, following discharge, on individuals who require inpatient care.

Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a narrow therapeutic range and high interpatient variability in the dose-response relationship. Serum clozapine levels are essential both for therapeutic dosing and to monitor adherence. Use of venepuncture and prolonged result turnaround times with standard laboratory based methods for drug monitoring together contribute to the suboptimal use of clozapine.

A novel portable point-of-care (POC) device has been developed to measure whole blood clozapine concentrations using an automated homogenous immunoassay. It is as accurate and reliable as standard laboratory methods but only requires a drop of blood obtained by finger prick and can produce a result in minutes. We pioneered clozapine POC testing in the acute inpatient setting during the outbreak of the COVID-19 pandemic.

We report on the use of POC clozapine testing in the management of 4 acutely psychotic patients with treatment resistant schizophrenia.

POC testing offered a more practical, less invasive and quicker alternative to conventional methods for monitoring of clozapine levels. Near immediate availability of clozapine levels expedited clinical decisions and helped ensure safe clozapine prescribing to severely unwell patients in a time of crisis. By facilitating patients’ early safe discharge from hospital, clozapine point of care testing also reduced length of hospitalisation.

Point of care monitoring of other psychotropic medications in addition to clozapine brings about the prospect of personalised precision medicine for patients with severe mental illness, both in the acute setting and in the community.

The number of mental hospital beds per population varies widely across countries, and the reasons for this variation are not fully understood. Given that differences in disease prevalence do not explain variation in inpatient mental health care availability, we examined the relationship between mental hospital beds and national income, education and longevity as measured by the Human Development Index (HDI).

We used an international dataset of social, economic and structural measures to conduct a mixed-effects longitudinal regression of predictors of the number of mental hospital beds per 100 000 in the overall population for 86 countries for years 2005–2015.

Our initial dataset contained 1881 observations consisting of 11 years of potential measurements across 171 countries. After eliminations based on missing data and subsequent imputation, the dataset for the final regression model included 946 observations over 86 countries. The primary predictors of a country's number of mental hospital beds were year, HDI and GINI coefficient, the latter being a measure of income disparity. Holding all other factors constant, the number of beds decreased 8% per year, reflecting the ongoing international trend of deinstitutionalisation. As hypothesised, higher HDI predicted more mental hospital beds. Every 0.1 increase in HDI (0–1.0) was associated with a 126% increase in the number of hospital beds at the sample's mean GINI index score of 38 (0–100). However, a strong interaction between HDI and the GINI coefficient indicated that a high level of income disparity attenuated the positive association between HDI and mental hospital beds. At a GINI index score of 48, every 0.1 increase in HDI was associated with a 71% increase in the number of hospital beds.

As countries reduce the number of hospital beds over time, higher levels of economic disparity are associated with a reduction in the strength of the association between national prosperity and investment in mental hospitals. As power becomes increasingly concentrated, perhaps those with the least are more easily forgotten.

Although shared decision-making (SDM) has the potential to improve health outcomes, psychiatrists often exclude patients with more severe mental illnesses or more acute conditions from participation in treatment decisions. This study examines whether SDM is facilitated by an approach which is specifically adapted to the needs of acutely ill patients (SDM-PLUS).

The study is a multi-centre, cluster-randomised, non-blinded, controlled trial of SDM-PLUS in 12 acute psychiatric wards of five psychiatric hospitals addressing inpatients with schizophrenia or schizoaffective disorder. All patients fulfilling the inclusion criteria were consecutively recruited for the trial at the time of their admission to the ward. Treatment teams of intervention wards were trained in the SDM-PLUS approach through participation in two half-day workshops. Patients on intervention wards received group training in SDM. Staff (and patients) of the control wards acted under ‘treatment as usual’ conditions. The primary outcome parameter was the patients' perceived involvement in decision-making at 3 weeks after study enrolment, analysed using a random-effects linear regression model.

In total, 161 participants each were recruited in the intervention and control group. SDM-PLUS led to higher perceived involvement in decision-making (primary outcome, analysed patients n = 257, mean group difference 16.5, 95% CI 9.0–24.0, p = 0.002, adjusted for baseline differences: β 17.3, 95% CI 10.8–23.6, p = 0.0004). In addition, intervention group patients exhibited better therapeutic alliance, treatment satisfaction and self-rated medication compliance during inpatient stay. There were, however, no significant improvements in adherence and rehospitalisation rates in the 6- and 12-month follow-up.

Despite limitations in patient recruitment, the SDM-PLUS trial has shown that the adoption of behavioural approaches (e.g. motivational interviewing) for SDM may yield a successful application to mental health. The authors recommend strategies to ensure effects are not lost at the interface between in- and outpatient treatment.

Trial registration: The trial was registered at Deutsches Register Klinischer Studien (DRKS00010880).

Studies on the frequency of caregiver involvement in representative inpatient samples are scarce. The aim of our study was to conduct a representative survey on caregiver involvement in routine inpatient care involving all three parties (patients, caregivers, psychiatrists). Therefore, we performed face-to-face interviews consisting of open-ended questions to gain a deeper understanding of when and how caregivers are involved in care treatment and to identify which topics are mainly discussed.

This cross-sectional survey included inpatients from 55 acute psychiatric wards across ten psychiatric hospitals, their treating psychiatrists and, when possible, their caregivers. In total, we performed semi-structured face-to-face interviews with 247 patients, their treating psychiatrists and 94 informal caregivers. Each psychiatrist named the next two to three patients to be discharged. After a patient had given informed consent, the interview was performed by a researcher. In addition, the psychiatrist and, when possible, the primary caregiver identified by the patient, were also interviewed.

It was perceived by both patients and psychiatrists that contact between caregiver and psychiatrist had taken place in one-third of the patient cases. Predictors for psychiatrist-caregiver-contact were revealed in the patient's diagnosis (schizophrenia), a lower history of inpatient stays, and the respective hospital. According to psychiatrists the most frequent subjects of discussion with caregivers involved therapeutic issues and organisational and social-psychiatric topics (e.g. work, living and social support). Patients and caregivers stated that psychiatric treatment and the diagnostic classification of the mental illness were the most frequent topics of conversation. For all three groups, the most often cited reason for missed caregiver involvement was the subjective perception that a caregiver was not in fact needed.

Whether or not caregivers were contacted and involved during an inpatient stay strongly depended on the individual hospital. The frequency of involvement of caregivers can certainly be increased by changing processes and structures in hospitals. All three parties (patients, caregivers and psychiatrists) most often stated that the caregiver was not involved in the treatment because they thought it was unnecessary. Evidence demonstrates the positive effect of caregivers' involvement on the therapeutic process but also on the well-being of the caregiver, therefore it is necessary to increase awareness of this evidence among all three interest groups.

The current study sought to examine the relationship between documented social media use and suicidality and self-injurious behaviors in adolescents at the time of psychiatric hospitalization.

We retrospectively identified adolescents (aged 12-17 years) hospitalized on an inpatient psychiatric unit during 1 year. Abstracted information included documented social media use, demographic variables, documented self-injurious behaviors, the Patient Health Questionnaire-9, and the Suicide Status Form-II. Logistic regression was implemented to examine the effect of social media use on the risk of self-injurious behaviors and suicidality.

Fifty-six adolescents who used social media were identified and matched with 56 non-social media users. Those with reported social media use had significantly greater odds of self-injurious behaviors at admission (odds ratio, 2.55; 95% confidence intervals, 1.17-5.71; P = .02) vs youth without reported social media use. Adolescents with reported social media use also had greater odds of increased suicidal ideation and suicide risk than those with no reported use, but these relationships were not statistically significant.

Social media use in adolescents with a psychiatric admission may be associated with the risk of self-injurious behaviors and could be a marker of impulsivity. Further work should guide the assessment of social media use as part of a routine adolescent psychiatric history.

Children of parents with psychiatric disorders are at risk of poor outcomes. However, there is limited evidence regarding the relationship between parental psychiatric disorders and child school readiness, which is linked to later academic achievement. This study aims to investigate these relationships and broaden the evidence underlying the rationale for family-focused interventions for parental psychiatric disorders.

This study used linked administrative data. Children's school readiness in multiple developmental domains (physical, social, emotional, communicative, cognitive) was measured by the Australian Early Development Census (AEDC) for 19 071 Western Australian children (mean age 5.5 years). Children scoring in the bottom 25% on any AEDC domain were considered developmentally vulnerable, or at risk of vulnerability, on that domain. Biological child–parent pairs were identified using birth records. Parents with psychiatric disorders were identified from hospital records, which included information on diagnosis and frequency/duration of psychiatric admissions. Logistic regressions, adjusted for parent age, mother's marital status, child Aboriginality, child English language status, local community remoteness and socioeconomic index, estimated the odds of children being vulnerable/at-risk on each of the AEDC domains.

A total of 719 mothers and 417 fathers had a psychiatric hospitalisation during the study period (12 months prior to the child's birth, up to the end of 2009). Children whose parents had psychiatric disorders had increased odds of being classified as vulnerable/at-risk for school readiness. This increase in odds was evident for both maternal (adjusted odds ratio, aOR 1.37– 1.51) and paternal psychiatric disorders (aOR 1.38–1.50); and for a single admission of one day (aOR 1.32–1.59), a single admission of multiple days (aOR 1.30–1.47), and multiple admissions (aOR 1.35–1.63). Some variability in child outcome was found depending on the parents’ psychiatric diagnosis (mood, anxiety, substance abuse or comorbid disorder).

Children of parents who have been hospitalised with psychiatric disorders are at risk for poor school readiness. These findings add support to recommendations that mental health professionals consider dependent children in discharge and treatment planning for adult psychiatric inpatients. It is also important to ensure that the impact of psychiatric illness in fathers is not overlooked in assessment and intervention. Family-based approaches to adult psychiatric care could meet the dual needs of intervention for parents and preventative measures for children. These findings can inform policy regarding the importance of integrating and coordinating services to meet the needs of families.

The World Health Organization (WHO)’s Mental Health Atlas series has established itself as the single most comprehensive and most widely used source of information on the global mental health situation. The data derived from the latest Mental Health Atlas survey carried out in 2014 describes the availability and delivery of mental health services in the WHO's Member States, focussing on differences by country's income level.

The data contained in this paper are mainly derived from questions relating to mental health service availability and uptake, as well as on financial and human resources for mental health. Results are presented as median values and analysed by World Bank income group. Interquartile ranges are also provided as measures of statistical dispersion.

In total, 171 out of WHO's 194 Member States were able to at least partially complete the Atlas questionnaire. The results highlight a wide gap between high and low-medium income countries in a number of areas: for example, high-income countries have 20 times more beds in community-based inpatient units and 30 times more admissions; the rate of patients cared by outpatient facilities is 40 times higher; and there are 66 times more community outpatient contacts and 15 times more mental health staff at outpatient level. Overall resources for mental health are not distributed efficiently: globally about 60% of financial resources and over two-thirds of all available mental health staff are concentrated in mental hospitals, which serve only a small proportion of patients. Results indicate that outpatient care is the only effective means of increasing the coverage for mental disorders and is expanding, but it is strongly influenced by country income level. Two elements of the network of mental health facilities are particularly scarce in low- and middle-income countries: day treatment facilities and community residential facilities.

The WHO Mental Health Atlas 2014 survey provides basic mental health information at the level of WHO's Member States, concerning mental health resources and activities. Atlas promotes the use of information, usually underestimated not only in low- and middle-income countries but also in high-income countries. Information is needed not only for monitoring the scaling up of the mental health system at country level, but also for improving transparency and accountability for users, families and the public.

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

A meta-analysis of cohort and case–control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43–3.87) in affective disorder populations to 8.00 (95% CI 5.46–11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74–2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10–0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

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.

Patient emotion, behaviour, and symptoms may explain avoidance of the daily programming on an acute psychiatric inpatient treatment milieu. We compared changes of emotion, behaviour, and symptoms among acutely ill psychiatric inpatients assigned to Behavioural Activation Communication (BAC), a newly designed milieu program, and those assigned to a unit representing treatment as usual (TAU).

Participants included 144 adult inpatients treated between January 2011 and July 2011 at two similar psychiatric units at a medical centre. Psychiatric patients were assigned to either the BAC or the TAU unit based bed availability. At admission and discharge, patients completed the Brief Symptom Inventory, Positive Affect and Negative Affect Scale, and the Checklist of Unit Behaviors.

A comparison of BAC and TAU patients showed greater relative change on positive affect and of behavioural activation with the daily programming.

The BAC program is associated with a significant increase of positive emotion and activation of inpatients.