Inpatient and outpatient care

What is inpatient and outpatient care?

Treatment that is provided to patients in a home environment, community or outpatient mental health facility are more commonly provided for patients in chronic or stable phases of the disorder. Treatments are integrated as part of a comprehensive program in conjunction with ongoing medication. Patients in a more acute phase of illness are usually treated through psychiatric inpatient hospital services.

 

What is the evidence for inpatient care and outpatient care?

Moderate to low quality evidence suggests improved overall symptoms and social adjustment with home-based crisis intervention by 20 months, reduced unsociable behaviour, agitation, and disorientation by 4-6 months, and reduced family burden and disruption by 3 months (but not 6 months). Patients and their relatives also report greater satisfaction with treatment with home-based crisis intervention compared to hospitalisation.

Moderate to low quality evidence suggests community care involving assertive community treatment, intensive case management, or educational support, may provide some benefit over standard care or case management for treatment adherence. Community care plus family interventions may reduce the rate of transition to psychosis in the short term (< 1 year), but not the longer term (> 1 year) in people at an ultra-high risk of psychosis. There is some benefit of community based mental health programs in low and middle income countries for improving symptoms, and reducing relapse rates and disability.

Moderate quality evidence suggests day hospitals may have short-term benefit for global functioning and employment rates compared to outpatient care. Moderate to low quality evidence suggests there is longer duration of treatment in day hospitals compared to inpatient care.

Moderate to low quality evidence suggests inpatients who abscond from hospital are often young men in the first three weeks following admission. Absconding may occur in up to 34% of admissions, and up to 80% of absconders return within 24 hours. A large proportion of absconders indicate intent to leave, and most commonly abscond directly from the ward. There is insufficient evidence regarding interventions for preventing absconding.

Moderate quality evidence suggests some benefit of cognitive behavioural therapy provided in hospital settings for reducing symptom severity in patients with acute recent-onset psychosis. Moderate to low quality evidence suggests pre- and post-discharge transitional programs may reduce psychiatric hospital readmissions by 1 – 2 years after discharge, particularly transitioning programs that involve a psychoeducation component and that provide transition managers who start their relationship with the patient pre-discharge and follow through until the patient is settled in the community. Moderate to high quality evidence suggests patients with hospital stays between 1 week and 1 month are more likely to be unemployed by 1 to 2 years after hospitalisation than patients with hospital stays over 2 months.

 

April 2016

Physical restraint

What is physical restraint? 

The management of acutely disturbed patients poses a challenge for mental health services. Some patients may be suicidal while others may pose a danger to staff or other patients. The challenge is to maintain the safety of all patients and staff, while providing a therapeutic environment. Management techniques for dealing with patients who become excessively agitated, aggressive, or violent may include the use of physical restraint, seclusion or containment.

What is the evidence for physical restraint ?

Moderate to low quality evidence suggests prevalence rates of restraint vary across countries, from 3.8% of patient admissions in Finland to 20% in Japan. Slovenia had a prevalence rate of 5%, Switzerland 6.6%, Germany 7% to 10.4%, United States 8% to 13.6%, Australia 9.4% to 12.5%, and Norway, Israel and Poland all had rates between 14.1% and 15.7%. Factors associated with the use of restraint are male sex, young adult age, foreign ethnicity, schizophrenia diagnosis, involuntary admission, aggression or trying to abscond, and the presence of male staff. Review authors conclude that staff require training on the use of alternatives to physical restraint in order to reduce any risks associated with restraint.

 

April 2016