Chase Farm Hospital, Enfield
Institute of Psychiatry, London, UK
Correspondence: Professor Julian Leff, Head of Social Psychiatry Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK
Funding from the Department of Health, North Thames Regional Health Authority, and the Sainsbury Family Trusts.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To study the long-term outcome of a group of 72 long-stay psychiatric inpatients, regarded as unsuitable for community placement.
Method A prospective cohort study with follow-ups at 1 year and 5 years.
Results The patients' mental state remained unchanged after 1 year and 5 years. The level of functioning and social behaviour showed minimal change after 1 year, but then improved over the next 4 years. The profile of problematic behaviours changed significantly over 5 years, with a reduction of 50% in their frequency. Physical aggression practically disappeared. The improvements in behaviour enabled 29 patients (40% of the study group) finally to be resettled in various care homes, gaining better access to community amenities and living more independently.
Conclusions A high proportion of patients with severe disabilities, designated as difficult to place in the community, could benefit from slow-stream rehabilitation within specialised facilities, enabling them to move into ordinary community homes.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aim
The reprovision programme for Friern hospital, a large psychiatric
institution in north London, provided an opportunity to study this issue on a
long-term basis. When the majority of the hospital long-stay population moved
into the community, a residual group of patients emerged as too disturbed or
too disturbing to be considered for community placement
(Trieman & Leff,
1996a). This difficult-to-place group was relocated in
four designated facilities, three of which were hospital based
(Trieman & Leff,
1996b). The patients were allocated to the different
facilities on the basis of their catchment areas and not on the basis of any
clinical criteria. The cost of those highly staffed facilities impacted
significantly on the overall expenditure of the reprovision programme
(Hallam, 1996). The aim of this
study was to evaluate the efficacy of such facilities by monitoring the
long-term outcome for their residents.
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Setting B was a hospital hostel, comprising three purpose-built houses located in the grounds of a small psychiatric hospital, close to a busy neighbourhood. The houses were homely, well designed and had no locked doors. There were 28 places, a staff:patient ratio of 1.7:1, and an environmental index of 10, equal to that in sheltered houses in the community.
Setting C was a special needs unit which was part of the psychiatry department of a district general hospital. It provided intensive rehabilitation within a structured milieu. It had 12 places, a staff:patient ratio of 1.3:1, and an environmental index of 30.
Setting D was a continuing care ward situated close to C. It contained a group of very withdrawn patients within a traditional institutional setting. There were 24 places, a staff:patient ratio of 1:1, and an environmental index of 22.
The care policies implemented in these facilities varied considerably with regard to the intensity and quality of the therapeutic input. The care environment was meant to be safe but as non-restrictive as possible. However, apart from setting B, these facilities were quite restrictive in their management policy. In general, the staff applied a slow-stream rehabilitation programme aiming to modify inappropriate social behaviour, to improve performance of basic living tasks and to expose the residents to the local community in a graduated manner. In practice, care programmes were not fully individualised, being applied neither consistently nor equitably. One of the facilities, D, offered very little active rehabilitation.
Sample
The study group consisted of 72 patients, all fulfilling the inclusion
criteria applied to the long-stay population of Friern hospital by the Team
for the Assessment of Psychiatric Services (TAPS)
(O'Driscoll & Leff, 1993).
Designated by the hospital staff as difficult to place, these residual
patients were transferred to the specialised facilities in early 1993, as
Friern hospital closed. Among the 72 patients were 8 catchment-area patients
who were residing at that time in other hospitals, and were incorporated into
the Friern reprovision programme.
Assessments
Assessments were carried out at baseline in Friern and other hospitals,
shortly before the patients were relocated in 1993, and subsequently after 1
year (1994) and 5 years (1998). The patients were individually assessed by
four schedules previously used in the TAPS study
(O'Driscoll & Leff, 1993).
The Present State Examination (PSE; Wing
et al, 1974) and the Social Network Schedule (SNS;
Leff et al, 1990) are
both structured interviews administered to the patient by a trained
researcher. The Social Behaviour Schedule (SBS;
Sturt & Wykes, 1986) and
the Basic Everyday Living Skills (BELS;
Leff et al, 1996)
schedule obtain information about the patient from senior care staff.
A new schedule, developed as part of this research, was the Special Problems Rating Scale (SPRS; Leff & Szmidla, 2002). Its design stemmed from a pilot study in which a series of behavioural problems likely to impede placement in the community was compiled (Trieman & Leff, 1996a). It has proved to have a high interrater reliability. Any reported problem was confirmed by medical records and rated positive if severe and persistent over a 3-month period (Trieman & Leff, 1996b). New problems emerging during the follow-up period were rated using the SPRS. Environmental features of the care facilities were formally assessed by the environmental index (O'Driscoll & Leff, 1993), which measures the number of restrictions imposed on residents in their living environment.
Basic demographic data, psychiatric history and data pertaining to mortality, residential mobility, criminal offences and medication were obtained from members of staff, ward records and case notes.
Data analysis
The schedules generated both continuous and categorical data. Nine
variables, derived from the PSE, BELS, SBS and SNS, were selected
prospectively as representative of the major clinical and functional
parameters, based on previous analysis of data from the total long-stay
population (Leff et al,
1996). For each variable the distribution of continuous data was
tested for normality. For variables with skewed distribution, normality was
induced by means of a logarithmic transformation. The mean scores were
calculated together with the mean differences between the baseline assessment
and the 1-year and 5-year follow-ups and 95% confidence intervals of these
differences. In the case of categorical variables with dichotomous responses,
the proportions were compared between the three points of time together with
95% confidence intervals. The analysis discarded cases for whom data were
missing at one or more of the time points.
The total number of problems rated as positive on the SPRS, and the frequency of specific problems, were compared between baseline and the two follow-ups for the whole group.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Administrative outcomes: mortality, vagrancy and crime
Over the 5 years, none of the patients was lost to follow-up or drifted out
of contact with mental health services. Over that period 11 patients died, of
whom 1 committed suicide (a crude death rate of 30 per 1000 person-years).
Incidents of a disruptive nature provoked by the patients were mostly confined to the premises, being generally well contained by the staff. Inappropriate behaviour in the neighbourhood was relatively uncommon, including a few cases of petty shoplifting, disrobing, urinating in the street and the like. Police were most commonly involved in returning to the facilities patients who absconded. Over 100 informal contacts with police were recorded over the 5-year follow-up, mostly associated with 8 patients presenting recidivistic behaviour. Two-thirds of the sample had not been in contact with the police. Serious assaults numbered 4, of which 2 were targeted at fellow residents and 2 at staff members. Legal charges were dropped in all cases, but the 2 perpetrators involved in these incidents (both from setting B) were transferred to secure wards.
Clinical outcome
The following data pertain to the 61 patients who were still alive at the
5-year follow-up.
Psychiatric state (PSE data)
As shown in Table 1, there
were no significant changes in the total PSE scores between baseline and the
1-year and 5-year follow-ups. Active psychotic symptoms (delusions and
hallucinations sub-score) also remained remarkably stable. However, negative
symptoms increased significantly between baseline and the 5-year
follow-up.
|
Social behaviour problems (SBS data)
There was a significant change in the total SBS score between baseline and
the 5-year follow-up (mean difference -1.00, 95% CI -1.9 to -0.09),
representing an average reduction of 1 behavioural problem over that period of
time. No change was detected at the 1-year follow-up.
Special problems (SPRS data)
Thirteen types of challenging behaviour were rated as present at baseline
among members of the difficult-to-place group. By far the most frequent of
these was aggression (Trieman & Leff,
1996a). Cumulative data, pertaining to 61 members of the
group for whom data were available at the three time points, showed that the
total number of 130 problem behaviours recorded at baseline remained
quantitatively unchanged after 1 year. However, the total fell to 60 by the
end of the 5-year follow-up. A very significant change was detected in
physical aggression: the proportion of those exhibiting this behaviour fell
from 47% at baseline to 7% at the 5-year follow-up (McNemar test,
2=12.5, d.f.=1, P<0.001).
Basic everyday living skills (BELS data)
Significant changes in each of the four BELS sub-scores were recorded over
the 5-year follow-up, indicating improved performance in all domains,
including self-care, domestic chores, activity within the community and social
relations. No such changes were apparent at the 1-year follow-up.
Social networks (SNS data)
There was no change in the size of the patients' social networks throughout
the 5-year follow-up. On average, each patient had only 5 persons who could be
named as acquaintances. Data were obtainable at each assessment for no more
than half the sample, while data from all three consecutive assessments were
available for only a third of the sample. The likelihood that those refusing
interviews were the most socially withdrawn patients
(Leff et al, 1990) implies that the results might not be representative of the whole sample.
Movement between settings
As a result of the improvements in patients' behaviour and skills, by the
5-year follow-up 29 patients had been discharged to a variety of community
settings: 24 went to residential care homes, 3 to nursing homes for elderly
people with mental health care needs, 1 to an independent flat and 1 to live
with family. There was no significant difference between the various
facilities in the proportions of patients discharged.
Comparison between discharged and non-discharged patients
It was of interest to identify features that distinguished patients who
were able to move to community homes from those who remained in the
specialised facilities. A comparison of movers and
stayers, excluding the 11 patients who died during the 5 years,
is shown in Table 2.
|
It is evident that those who were discharged showed significantly fewer
behavioural problems and had acquired significantly more skills than those who
remained. The two groups did not differ in any clinical measure, in gender
distribution or in the size of social network. The proportion of each group
prescribed novel antipsychotics (movers 48%,
stayers 25%) did not differ significantly
(2=3.57, d.f.=1, P>0.05).
Environmental Index
While at Friern hospital, members of the difficult-to-place group lived in
a highly restrictive institutional environment (mean environmental index score
24, s.d.=6.6). Overall, the alternative facilities offered a more permissive
environment (mean environmental index score 19 at 1 year, s.d.=8.5). At 5
years, when a high proportion of the former difficult-to-place patients were
living in residential homes, the group was subjected to an even lower level of
restrictiveness in comparison with that prevailing in Friern hospital
(difference in mean environmental index=9; 95% CI -6 to -12).
Medication
In 1993, while still at Friern hospital, only 6 patients were treated with
novel antipsychotic medication. At 5-year follow-up, more than 40% of the
remaining group were prescribed clozapine, risperidone or olanzapine. The use
of polypharmacy and high-dose regimes, which was common practice at Friern,
altered to only a modest degree.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Improvements in behaviour and skills
There was a significant reduction in the mean number of severe behaviour
problems of the difficult-to-place patients, each patient on average losing 1
severe problem. It is highly unlikely that this could have been a response to
changes in medication. Although there was a marked increase in the number of
patients on novel antipsychotics, the lack of change in delusions and
hallucinations combined with the increase in negative symptoms argues against
their contribution to the behavioural improvements noted. The highly
significant acquisition of skills across all areas of the BELS points to the
efficacy of the rehabilitation programmes in the facilities, to which the
reduction in severe problems is most plausibly attributable. As with the main
group of long-stay patients, difficult-to-place patients were reluctant to
complete the SNS: data from all three assessment points were available for
only one-third of this sample. These data did not suggest any significant
alteration in the quantity or quality of the social networks. Possibly the
findings are biased towards a positive view, because patients who do not
complete the SNS are more socially restricted than those who do
(Leff et al,
1990).
Factors leading to discharge
The improvement in patients' behaviour and skills enabled many of them to
be discharged to sheltered accommodation in the community. At the end of 5
years, 29 (40%) were living in community homes. It is of clinical importance
to be able to identify the changes that facilitated these moves. Hence, we
compared the patients who were discharged with those who remained in the
specialised facilities. It is not surprising that those who were able to leave
were significantly more skilled in every area than those who remained, and
exhibited fewer problematic behaviours. However, the two groups did not differ
on any measure of mental state, in either positive or negative symptoms.
Furthermore, there was no difference between the two groups in the proportion
prescribed novel antipsychotics. This suggests that psychotic symptoms that
are resistant to medication are no impediment to achieving clinically
meaningful improvements in patients' behaviour and skills.
The need for rehabilitation facilities
Difficult-to-place patients will not disappear with the closure of the
psychiatric hospitals, since a high proportion of them are new long-stay
patients (Trieman et al,
1998). They continue to arise from the population of patients
recently diagnosed as suffering from psychosis, and block the beds on
admission wards because they need long-term specialised care. The profile of
our sample, two-thirds of which were new long-stay, is similar to that of
long-stay patients currently accumulating in admission wards in general
hospitals. One of the reasons for this accumulation is the scarcity of
rehabilitation facilities.
This study has shown that slow-stream rehabilitation in specialised facilities, even if not consistently applied, can produce sufficient improvement in 40% of difficult-to-place patients over 5 years to enable them to move to community homes. The consequent saving of money in the long term justifies the investment in such rehabilitation units (Hallam & Trieman, 2001). However, it is our belief that faster progress in preparing such patients for discharge could be made by introducing individualised cognitivebehavioural programmes, and special training for the care staff (Willetts & Leff, 1997). We report on an endeavour of this kind in another paper (Leff & Szmidla, 2002).
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Hallam, A. (1996) Costs and outcomes for people with special psychiatric needs. PSSRU/CEMH Mental Health Research Review, 3, 10-13.
Hallam, A. & Trieman, N. (2001) The cost effectiveness of specialised facilities for service users with persistent challenging behaviours. Health and Social Care in the Community, 9, 429-435.[Medline]
Leff, J. & Trieman, N. (2000) Long-stay
patients discharged from psychiatric hospitals. Social and clinical outcomes
after five years in the community. The TAPS Project 46. British
Journal of Psychiatry, 176,
217-223.
Leff, J. & Szmidla, A. (2002) Evaluation of a special rehabilitation programme for patients who are difficult to place. Social Psychiatry and Psychiatric Epidemiology, in press.
Leff, J., O'Driscoll, C., Dayson, D., et al (1990) The TAPS Project. 5. The structure of social-network data obtained from long-stay patients. British Journal of Psychiatry, 157, 848-852.[Abstract]
Leff, J., Thornicroft, G., Coxhead, N., et al (1994) The TAPS Project. 22. A five-year follow-up of long-stay psychiatric patients discharged to the community. British Journal of Psychiatry, 165 (suppl. 25), 13-17.[Abstract]
Leff, J., Trieman, N. & Gooch, C. (1996) The TAPS Project 33: A prospective follow-up study of long-stay patients discharged from two psychiatric hospitals. American Journal of Psychiatry, 153, 1318-1324.[Abstract]
Lelliott, P. & Wing, J. (1994) A national audit of new long-stay psychiatric patients. II: impact on services. British Journal of Psychiatry, 165, 170-178.[Abstract]
O'Driscoll, C. & Leff, J. (1993) The TAPS Project 8: Design of the research study on the long-stay patients. British Journal of Psychiatry, 162 (suppl. 19), 18-24.
Sturt, E. & Wykes, T. (1986) The Social Behaviour Schedule: a validity and reliability study. British Journal of Psychiatry, 148, 1-11.[Abstract]
Trieman, N. & Leff, J. (1996a) The difficult to place patients in a psychiatric hospital closure programme. The TAPS Project 24. Psychological Medicine, 26, 765-774.[Medline]
Trieman, N. & Leff, J. (1996b) The TAPS Project. 36. The most difficult to place long-stay psychiatric patients. Outcome one year after relocation. British Journal of Psychiatry, 169, 289-292.[Abstract]
Trieman, N., Hughes, J. & Leff, J. (1998) The TAPS Project 42: the last to leave hospital: profile of residual long-stay populations and plans for their resettlement. Acta Psychiatrica Scandinavica, 98, 354-359.[Medline]
Willetts, L. E. & Leff, J. (1997) Expressed emotion and schizophrenia: the efficacy of a staff training programme. Journal of Advanced Nursing, 26, 1125-1133.[Medline]
Wing, J. K., Cooper, J. E. & Sartorius, N. (1974) Description and Classification of Psychiatric Symptoms. London: Cambridge University Press.
Received for publication October 15, 2001. Revision received May 23, 2002. Accepted for publication June 26, 2002.
Related articles in BJP:
HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |