© 2002 The Royal College of Psychiatrists
Correspondence |
Hospitalisation in first-episode psychosis
Salford Primary Care NHS Trust, Salford, UK
Meadowbrook, Department of Psychological Medicine, Stott Lane, Salford M6 8HG, UK
Salford Primary Care NHS Trust, Salford, UK
The paper by Sipos et al (2001) was discussed with great enthusiasm in our evidence-based journal club. We learnt that 80% of patients with first-episode psychosis were hospitalised within 3 years of first contact with specialist services. Patients with manic symptoms at presentation were admitted rapidly; those with negative symptoms and longer duration of untreated illness were admitted later. The paper concluded that community-oriented psychiatric services might only delay, rather than prevent, admission of patients with a first-episode of psychosis.
At the end of the journal club we realised that the findings from this paper cannot be generalised to our patient group without the knowledge of certain other key issues not mentioned in the paper.
- Availability of in-patient beds: studies have shown that the utilisation of
in-patient care is determined by the supply of available beds
(Saarento et al,
1996).
- Availability of assertive community psychiatric services: an assertive
community treatment programme has shown to be effective in reducing
hospitalisation compared with clinical case management programmes
(Ziguras & Stuart,
2000).
- A study by Lang et al
(1999) demonstrates that
improvement in social support predicted decline in hospitalisation.
- History of suicidal behaviour carries a greater risk of admission in
first-episode psychosis and higher readmission rates over 2-year follow-up
(Verdoux et al,
2001).
- In clinical practice a patient's willingness to accept treatment as an
out-patient would be a factor in deciding about in-patient treatment.
In our opinion hospitalisation in first-episode psychosis would be greatly affected by the above issues and without knowledge of these issues, the findings from Sipos et al's study cannot be generalised to patient groups in other areas/services.
REFERENCES
- Lang, M. A., Davidson, L., Bailey, P., et al
(1999) Clinicians' and clients' perspectives on the impact of
assertive community treatment. Psychiatric Services,
50,
1331-1340.
[Abstract/Free Full Text] - Saarento, O., Hanson, L., Sandlund, M., et al (1996) The Nordic Comparative Study on Sectorized Psychiatry. Utilisation of psychiatric hospital care related to amount and allocation of resources to psychiatric services. Social Psychiatry and Psychiatric Epidemiology, 31, 327-335.[CrossRef][Medline]
- Sipos, A., Harrison, G., Gunnell, D., et al
(2001) Patterns and predictors of hospitalisation in
first-episode psychosis: prospective cohort study. British Journal
of Psychiatry, 178,
518-523.
[Abstract/Free Full Text] - Verdoux H., Liraud, F., Gonzales, B., et al (2001) Predictors and outcome characteristics associated with suicidal behaviour in early psychosis: a two-year follow-up of first-admitted subjects. Acta Psychiatrica Scandinavica, 103, 347-354.[CrossRef][Medline]
- Ziguras, S.J. & Stuart, G.W. (2000) A meta
analysis of the effectiveness of mental health case-management over 20 years.
Psychiatric Services,
51,
1410-1421.
[Abstract/Free Full Text]
Authors' reply
Division of Psychiatry, University of Bristol, 41 St Michael's Hill, Bristol BS2 8DZ, UK
Division of Psychiatry, University of Bristol, Bristol, UK
Department of Social Medicine, University of Bristol, Bristol, UK
Trafford General Hospital, Manchester, UK
Queen's Medical Centre, Nottingham, UK
We were delighted to read that our paper was so enthusiastically discussed by Sridharan et al at their evidence-based journal club. They have spotted the main limitation to the study, which was included in our own list of limitations — namely, that our findings were "based upon only one service model and may have limited generalisability" (Sipos et al, 2001). In our paper, we cited previous work from Nottingham (Harrison et al, 1991), showing how the development of multi-disciplinary teams had coincided with a reduction in the proportion of patients with first-episode psychosis requiring hospitalisation at initial contact. In Sipos et al (2001) we went on to show that, although there is clearly a reduction in hospitalisation at first contact, the risk of admission at some point in the first 3 years after first onset has actually remained the same. Indeed, there are striking differences between those patients admitted early in the course of the disorder and those admitted later.
On reflection, we agree that the paper would have benefited from a slightly more detailed specification of service changes in Nottingham, although these have been described elsewhere and we would refer readers to Beck et al (1997). We would caution, however, against attempts to draw causal inferences from the presence, or absence, of particular ‘community’ services because our paper reported an observational study rather than a controlled one. The research community has barely begun to understand the interplay between different components of ‘community-oriented’ services and patient outcomes. The parameters mentioned by Sridharan et al are certainly pointers in the right direction but we have some way to go in describing (and measuring) factors such as the amount of ‘social support’ available, let alone evaluating their impact on outcomes.
REFERENCES
- Beck, A., Croudace, T.J., Singh, S., et al
(1997) The Nottingham Acute Bed Study: alternatives to acute
psychiatric care. British Journal of Psychiatry,
170,
247-252.
[Abstract/Free Full Text] - Harrison, G., Cooper, J. E. & Gancarczyk, R.
(1991) Changes in the administrative incidence of
schizophrenia. British Journal of Psychiatry,
159,
811-816.
[Abstract/Free Full Text] - Sipos, A., Harrison, G., Gunnell, D., et al (2001) Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study. British Journal of Psychiatry, 178, 518-523.
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