Alexander Tulloch

Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register : current status and recent enhancement of an Electronic Mental Health Record-derived data resource.

Purpose The South London and Maudsley National Health Service (NHS) Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register and its Clinical Record Interactive Search (CRIS) application were developed in 2008, generating a research repository of real-time, anonymised, structured and open-text data derived from the electronic health record system used by SLaM, a large mental healthcare provider in southeast London. In this paper, we update this registers descriptive data, and describe the substantial expansion and extension of the data resource since its original development. Participants Descriptive data were generated from the SLaM BRC Case Register on 31 December 2014. Currently, there are over 250 000 patient records accessed through CRIS. Findings to date Since 2008, the most significant developments in the SLaM BRC Case Register have been the introduction of natural language processing to extract structured data from open-text fields, linkages to external sources of data, and the addition of a parallel relational database (Structured Query Language) output. Natural language processing applications to date have brought in new and hitherto inaccessible data on cognitive function, education, social care receipt, smoking, diagnostic statements and pharmacotherapy. In addition, through external data linkages, large volumes of supplementary information have been accessed on mortality, hospital attendances and cancer registrations. Future plans Coupled with robust data security and governance structures, electronic health records provide potentially transformative information on mental disorders and outcomes in routine clinical care. The SLaM BRC Case Register continues to grow as a database, with approximately 20 000 new cases added each year, in addition to extension of follow-up for existing cases. Data linkages and natural language processing present important opportunities to enhance this type of research resource further, achieving both volume and depth of data. However, research projects still need to be carefully tailored, so that they take into account the nature and quality of the source information.

Length of stay of general psychiatric inpatients in the United States: systematic review.

Psychiatric length of stay (LOS) has reduced but is still longer than for physical disorders. Inpatient costs are 16% of total mental health spending. Regression analyses of the determinants of LOS for US adult psychiatric inpatients were systematically reviewed. Most studies predated recent LOS reductions. Psychosis, female gender and larger hospital size were associated with longer LOS, while discharge against medical advice, prospective payment, being married, being detained and either younger or middle age were associated with shorter LOS. Associations appeared consistent, especially where sample size was above 3,000. Updated studies should be adequately powered and include the variables above.

The determinants and outcomes of long-stay psychiatric admissions : A case-control study

BackgroundAcute psychiatric admissions lasting over 6 months (long-stays) continue to occur in England. Previous studies have suggested an association between long-stay and both schizophrenia and challenging behaviour, as well as rehousing or placement difficulties, but no UK study to date has compared such cases with control admissions.MethodsWe performed a case–control study. All long-stay patients present on acute general psychiatric wards serving the London Boroughs of Croydon, Lambeth, Lewisham and Southwark on November 1st 2004 were compared with a group of ‘next admitted’ controls. We followed up long-stay cases 1 year later to determine whether they were still in hospital, and, if not, where they were living.ResultsIn unadjusted comparisons long stay was associated with schizophrenia, non-white ethnicity, admission not due to suicidality, violence, severe illness and need for rehousing. A logistic regression was used to adjust for associations among exposures and only violence, severity of illness and need for rehousing remained associated with long-stay. After 1 year, two-thirds of cases were living out of hospital.ConclusionsCase–control studies may usefully contribute to the study of the complex social phenomenon of long-stay. Further research should address how the combination of individual and socially-determined effects that we found operate together over the course of admission to generate long-stays.

Associations of homelessness and residential mobility with length of stay after acute psychiatric admission

BackgroundA small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures.MethodsCross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression.ResultsResidential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor.ConclusionsHomelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.

Social outcomes in schizophrenia: from description to action

Purpose of review The reality of schizophrenia is not fully expressed by measures of psychopathology and both descriptive research and research into interventions benefit from the investigation of social outcomes. We define these as measures which reflect performance compared to normal social expectations, either of oneself or of another. The studies we reviewed looked at the effects on summary measures, for example, quality of life, as well as simpler, more self-explanatory outcomes such as employment, marital status, financial independence and housing. Recent findings The review contrasts studies which describe the determinants of social outcomes and studies designed to estimate the effects of interventions on these outcomes. Recent descriptive studies demonstrate that social outcomes have both longitudinal and cross-sectional associations with cognitive impairment, preexisting functional impairment and certain symptoms. Studies of both pharmacological and social interventions suggest that, at best, these can affect social outcomes. Summary Simpler social outcomes are reported less frequently than summary measures which can make interpretation more difficult, thus diluting a potential advantage of social outcome measures to researchers and clinicians alike. Social outcomes are underreported compared to measures of psychopathology, particularly in trials of interventions.

Exploring the predictors of early readmission to psychiatric hospital

BACKGROUND Aims of this study are to explore the associations of readmission to psychiatric hospital over time, to develop a statistical model for early readmission to psychiatric hospital and to assess the feasibility of predicting early readmission. METHOD The sample comprised 7891 general psychiatric discharges in South London, taken from a large anonymised repository of electronic patient records. We initially explored time to readmission using Cox regression - this included investigation of time-dependent effects. Subsequently, we used logistic regression to create a predictive model for 90-day readmission. We investigated the effect on readmission of a set of variables that included demographic variables, diagnosis and legal status during the index admission, previous service use, housing variables and individual item scores on the Health of the Nation Outcome Scales (HoNOS) at admission and at discharge. RESULTS Fifteen per cent of those discharged were readmitted within 90 days. Cox regression demonstrated that the estimated baseline hazard of readmission declined steeply after discharge and that the effects of several predictors, especially diagnosis, changed over time - most notably, personality disorder was associated with increased readmission relative to schizophrenia at the time of discharge, but did not significantly differ by 1-year postdischarge. In the logistic regression, increased readmission was associated with personality disorder diagnosis; shorter length of the index admission (excepting zero length admissions); number of discharges in the preceding 2 years; and having a high score at discharge on the HoNOS overactive and aggressive behaviour item, cognitive problems item or hallucinations and delusions items. Detention under Section 3 or a forensic section of the Mental Health Act during the index admission was associated with reduced readmission. The coefficient of discrimination for the logistic regression, which is equivalent to r 2, was 0.04 and the estimated area under the receiver operating curve was 0.65. CONCLUSIONS The association found between early readmission and personality disorder diagnosis merits further investigation, as does the possible trade-off between reduction in length of stay and increased readmission. Other novel findings such as the associations found with HoNOS item scores also merit replication. As with previous studies, we found that the rate of readmission declines steeply after hospital discharge, so that the period immediately subsequent to discharge is a period of comparatively high risk. However, prediction of early readmission within this high-risk group remains challenging - it seems most likely that many unmeasured influences operate subsequent to the time of discharge.

Residential mobility among patients admitted to acute psychiatric wards

Residential mobility among those with mental disorders is consistently associated with hospital admission. We studied 4485 psychiatric admissions in South London, aiming to describe the prevalence, timing and associations of residential moves occurring in association with admission. Moves tended to cluster around discharge; 15% of inpatients moved during admission or up to 28 days after discharge. The strongest associations were with younger age (especially 16-25 years) and homelessness. Unadjusted effects of gender, marital status and previous service use were mediated by homelessness. Possible mechanisms for the associations with homelessness and younger age are discussed.

Khat use among Somali mental health service users in South London

PurposeKhat use has been suggested to be associated with psychosis, but its prevalence and associations among mental health service users have not been described in either traditional use countries or countries with immigrant populations from traditional use countries. We aimed to investigate the clinical and demographic associations of khat use in a sample of Somali users of mental health service users in South London.MethodsWe used an electronic case register of 150,000 mental health patients to investigate the associations of khat use among all 240 Somali patients in the database. We used logistic regression to generate adjusted estimates for a range of exposure variables and used multiple imputation as a principled approach to missing data.ResultsKhat use or non-use was recorded for 172 patients (72% of the total), of whom 80 (47%) were current users. Khat use was very strongly associated with ICD-10 primary diagnosis of schizophrenia, psychosis or drug and alcohol disorder (compared to ICD-10 F43 stress-related disorders and other non-psychotic disorders), male gender, harmful or dependent use of alcohol, and detention under the Mental Health Act.ConclusionsRecording and monitoring of khat use need to be more consistent in clinical settings, and further studies are required to investigate the much higher rates of use among those with psychotic disorders compared to non-psychotic disorders.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services

Aims. 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. Methods. 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. Results. 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. Conclusions. 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.

Assessments of mental capacity in psychiatric inpatients: a retrospective cohort study

BackgroundThe Mental Capacity Act 2005 (MCA) was introduced in 2007 to protect vulnerable individuals who lack capacity to make decisions for themselves and to provide a legal framework for professionals to assess incapacity. The impact of the MCA on clinical practice is not known. This study aims to evaluate how frequently mental capacity is assessed in psychiatric inpatients, whether the criteria for determining capacity set out in the MCA are used in practice, and whether this has increased with the introduction of the MCA.MethodA retrospective cohort study was carried out using a case register of South East London mental health service users. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information on patients admitted to the South London and Maudsley NHS Foundation Trust since 2006. The presence and outcomes of documented mental capacity assessments in psychiatric admissions between May 2006 and February 2010 were identified and demographic information on all admissions was retrieved.ResultsCapacity assessments were documented in 1,732/17,744 admissions (9.8%). There was a significant increase in the frequency of capacity assessments carried out over the study period of 0.3 percentage points per month (95% CI 0.26-0.36, p < 0.00001). In only 14.7% of capacity assessments were the MCA criteria for assessing capacity explicitly used.ConclusionsOver the period of the introduction of the MCA there has been a significant increase in the number of mental capacity assessments carried out on psychiatric inpatients. Although mental health services are considering the issue of capacity more frequently, mental capacity assessments are inconsistently applied and do not make adequate use of MCA criteria.