The long and the short of it: are shorter periods of hospitalisation beneficial?

The politics of shortening hospital stays for people with psychosishas been questioned by a number of studies. Hospital practicein the meantime remains highly variable and the research evidenceincreasingly difficult to interpret given different conceptualisationsof what constitutes effective treatment. In the absence ofclearer guidelines from researchers in this area, decisionsabout duration of hospitalisation risk being driven by economic rather than clinical considerations.

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INTRODUCTION

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INTRODUCTION

A lasting consequence of socio-environmentalist theories ofpsychosis emanating from the 1960s has been the belief thatpatients with psychosis benefit from a rapid return to thecommunity, thus minimising social isolation and the adverseeffects of adopting psychiatric communities as reference groups.Studies of patients returning to the community compared withthose remaining in institutions show not only better qualityof life and larger friendship networks, but also reductionsin dependence on pharmacotherapies and lower mortality rates.¹Enthusiasm for the shortening of hospital stays in the interestof more rapid community reintegration has undoubtedly alsobeen echoed by health economists; the average cost of hospitalstays for people with psychotic disorders being estimated between ${euro}$ 2830.29 and ${euro}$ 3624.95 of which only 3.4% is related to diagnosisand 2.4% to actual treatment.² In almost all Western countriesthe past 40 years has seen a general transition towards a policyof reduced periods of hospitalisation of patients with psychosisand a reduced number of hospital beds.

On the other hand there has been some unsettling evidence tosuggest that shortening hospital stays may not be a generalpanacea. Munk-Jorgensen et al reported that deinstitutionalisationpolicies in Denmark had led to premature discharge and subsequentlya 100% increase in suicide, a doubling of criminal acts committedby patients with psychoses and increases of 80–100% inacute admission rates.³ In a large follow-up study of patientswith psychoses, Desai et al found that hospital stays of lessthan 14 days were significantly associated with increased suicide risk.⁴ Other studies have shown a clear relationship betweenreductions in duration of stay and increases in readmission rates.⁵ These observations have led to speculation that earlydischarge leads to inadequate treatment; an argument that hasbeen further fuelled in France and the UK by highly publicisedhomicides committed by psychiatric in-patients. Others have argued that negative outcomes are attributable to the factthat patients with psychosis, who have drug and alcohol problems,and thus a poorer prognosis, are more likely to seek prematuredischarge and to discontinue treatment.⁶ A Cochrane meta-analysisconducted in 2000 concluded that shorter periods of hospitalisationdid not increase the risk of readmission when the hospitalisationis programmed and planned in advance as a short-term admission.⁷

Short-v. long-term hospitalisation

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Short-v. long-term...

An interesting comparison between three contrasting mental healthcare systems in Holland, Italy and Australia⁸ concluded, not surprisingly,that hospital stays are shortest where community care is moredeveloped, although long-term hospitalisation will always be required for a small number of patients who are severely ill.The general conclusion was that shorter stays work best ifand only if there is high-quality community care that comesinto play immediately on discharge. The central issue appearsto be that the beneficial effects of short stays are modulatedby conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off stayinglonger in order that a structured rehabilitation plan may beput in place. This is clearly a very high-cost strategy.

Thus, unlike most other causes of hospitalisation, durationof in-patient treatment for psychosis is not only determinedby treatment considerations and rate of recovery but also byfactors relating to the personal circumstances of the patientand organisation of the health system. It has been estimatedthat only 50% of hospitalisations over 30 days are medically justified.⁹ Of the remainder, 40% are due to social problemsand 10% are ‘medically unacceptable’.

The evidence presently available suggests that short-term staysmay be preferable for certain patients, but that these staysshould be planned with structured discharge programmes. Thatis all very well, but which patients are best suited to short-termstays? What is ‘short term’ (studies cite periodsvarying from 2 weeks to a year)? Which rehabilitation programmes should be employed? Should rehabilitation planning be a reasonfor extending hospitalisation? Does rehospitalisation constitutea failure of therapy or effective prevention? Perhaps the mostimportant point has been made by Szmukler & Holloway;¹⁰despite the extensive literature on hospital care, we stillcannot define effective in-patient treatment.

Future considerations

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Future considerations

While few patients or clinicians would contest today that areturn to normal community life is preferable to institutionalisation,the adoption of shorter hospital stays was not an evidence-basedpolicy and no adequate evaluation study was ever put in placeto predict the social, clinical and economic consequences ofthis widespread practice. Although duration of hospitalisationis a factor likely to have an enormous impact on the courseof the illness, quality of life, long-term social and professionalreintegration, not to mention the costs to the health sector,we are far from having clear directives on best practice, oreven for that matter consensus on what constitutes a shortstay. Hospital policy in the meantime remains highly variable,determined principally by available resources rather than evidence-basedguidelines. Moreover, as early evidence suggests that psychogeneticscreening for positive treatment response to specific antipsychoticswill in the future be an important means of reducing hospitalisationtime, research in this area now needs to take into account the potential impact of this innovation. As the European Communityworks towards the standardisation of health delivery protocolsin other areas of medicine there is a clear need to reinvestin research of care for patients with psychoses in order todevelop clearer best practice guidelines.

ACKNOWLEDGMENTS

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ACKNOWLEDGMENTS

We thank Professor Graham Thornicroft for his useful commentson this paper.

REFERENCES

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