Andres R. Schneeberger

Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study

BACKGROUND Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes. METHODS In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data. FINDINGS In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p<0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63). INTERPRETATION Locked doors might not be able to prevent suicide and absconding. FUNDING None.

Cumulative Effects of Stressful Childhood Experiences on Delusions and Hallucinations.

The association between stressful childhood experiences (SCE) and psychotic symptoms is still not clearly understood, and different causal pathways have been proposed. Generalized estimating equation modeling was used to test the dose–response relationship between SCE and delusions and hallucinations at baseline and follow-up periods and the possible confounding effects of dissociation on this relationship. The prevalence of SCE in individuals with psychotic disorders was high, with more co-occurring SCE categories being positively associated with more types of delusions and hallucinations. Each additional SCE was associated with a 1.20 increase in the incidence rate ratio (95% confidence interval [CI; 1.09, 1.32]) for hallucinations and a 1.19 increase (CI [1.09, 1.29]) for delusions, supporting a dose–response association. After we controlled for the mediating effects of dissociative symptoms at follow-up, SCE remained independently associated with delusions. We propose that cumulative SCE can result in complex trauma reactions that present with a broad range of symptomatology, including dissociative, posttraumatic stress disorder, and psychotic symptoms.

Reduction of seclusion on a hospital-wide level: Successful implementation of a less restrictive policy

PURPOSE Change of treatment policy from closed to open ward settings has been shown to reduce coercive measures. The aim of the current study was to examine the effects of the change from closed to open wards on the frequency of seclusion and forced medication in a hospital-wide setting. SUBJECTS AND METHODS 2-year, longitudinal observational study with 2838 inpatient cases. RESULTS On a hospital-wide level, the percentage of patients with at least one seclusion was decreased significantly (χ(2)(1) = 5.8; p = .016), while there was no significant change in forced medication (χ(2)(1) = .08; p = .775). The frequency of seclusions and forced medication decreased significantly on newly opened wards, and there were no significant changes regarding seclusion on permanently closed or open wards, while the number of forced medications increased significantly on closed wards. The decrease in seclusions on newly opened wards remained statistically significant after controlling for diagnoses and severity of illness. DISCUSSION Our results indicate that a reduction of overall seclusion can be successfully attained, and that, in particular, the frequency of seclusion and forced medication on newly opened wards was decreased significantly. These changes were not accompanied by a significant increase in seclusion on other wards. CONCLUSION Open ward treatment was successfully implemented and was associated with a significant decrease of coercive measures in our study. It might therefore provide a good care model, strengthening the patients right to autonomy and leading to a reduction of coercive measures.

Childhood Abuse, Head Injuries, and Use of Medical Emergency Services in People with Severe Mental Illness

People with severe mental illness (SMI) report high rates of traumatic experiences. This study analyzes data collected from 183 people diagnosed with SMI on reports of childhood trauma, head injuries, and emergency room (ER) services. More than half the cohort (56.7%) reported 3 to 7 cooccurring categories of childhood abuse (CAB). People who reported 6 and 7 categories of CAB had a 5-fold risk of experiencing a head injury. If they have used the ER for reasons other than psychiatric illness they endorse more traumatic experiences in their childhood when compared to those who did not. People with SMI and cooccurring CAB experiences might be predisposed to a higher risk of head injuries and more frequent use of the ER.

Use of Psychotropic Medication Groups in People with Severe Mental Illness and Stressful Childhood Experiences

Stressful childhood experiences (SCE) are associated with a variety of health and social problems. In people with severe mental illness (SMI) traumatic childhood experiences have been linked to more severe and treatment refractory forms of psychiatric symptoms, including psychotic symptoms. This study evaluates the use of psychotropic medication groups in a population of people with SMI and SCE, testing the association between SCE and prescription medication in an SMI population. A sample of 183 participants with SMI was divided into 2 exposure groups: high SCE (4 to 7 categories of SCE) and low SCE (0 to 3 categories of SCE). Both groups were compared in regard to prescribed dosing of psychotropic medications (antipsychotics, mood stabilizers, antidepressants, and anxiolytics/hypnotics). Participants who endorsed high SCE received higher doses of antipsychotic medications and mood stabilizers than those with low exposure. The results demonstrate that people with higher SCE categories received a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers.

Stressful Childhood Experiences and Clinical Outcomes in People with Serious Mental Illness: a Gender Comparison in a Clinical Psychiatric Sample

Objective: This study examines stressful childhood experiences (SCE) including childhood abuse and family context in a cohort of 183 people diagnosed with serious mental illness (SMI) and compares gender specific rates of SCE and clinical outcome variables. Methods: 111 men and 72 women with SMI were interviewed regarding SCE and posttraumatic stress disorder (PTSD) symptoms, dissociative symptoms, risk for self-harm, and adult re-victimization. Results: Both genders endorse high rates of SCE. Cumulative SCE (the sum of seven SCE) are linked to increased levels of all four outcome variables after adjusting for demographic factors. Conclusions: The study addresses the need to assess cumulative SCE in a population with SMI and its effects on clinical outcomes in both genders.

Comprehensive trauma training curriculum for psychiatry residents.

Traumatic events in the psychiatric population are prevalent, complex, and often are repeated and ongoing (1–4). As psychiatry residents progress through their training, they have contact with traumatized patients and families from the initial phases of assessment through the recovery process. For example, according to Kessler (5) PTSD is the third most common anxiety disorder in the United States. An increasingly large body of literature about trauma-associated disorders, treatment modalities, and training exists. However, systematic trauma training remains limited and has yet to be incorporated into the core curriculum of graduate training programs, including residency training in psychiatry (2, 3, 6, 7). Trauma training, adapted for psychiatric residents, is of particular importance considering the specific challenges trainees face during the postgraduate years, where a shift from more concrete to more process-oriented thinking can be observed. Also, teaching psychiatry residents is particularly challenging because residents rotate through different services (8). Each service has its own population, culture, and goals and objectives. A comprehensive teaching program for trauma is difficult to integrate into an already-existing complex teaching curriculum, as it must allow for flexibility. Teaching and supervision serve the purpose of enabling residents to reflect on their clinical experiences, along with peer interactions, study groups, and seminars. The Trauma Training Modular Curriculum (TTMC) was created to address the various needs as well as to integrate into ongoing psychiatric training the growing body of literature ranging from assessment of trauma and trauma associated disorders to various treatment interventions. The TTMC is structured in a modular fashion and consists of 16 modules. Each module begins with a preassessment and ends with a post-assessment. Designed to provide a foundation for teaching, each module can focus either on addressing attitudes, conveying knowledge, and/or teaching specific skills. Each module can stand on its own as a single teaching unit. The modular construction of the TTMC allows for flexibility in including one or more modules into an already-existing curriculum. Since learning can be enhanced by the use of different sensory modalities, each module includes visual, auditory, gustatory, and olfactory and/or tactile stimuli. Some modules include the use of the arts and media, such as film excerpts, video clips, music, and interviews. Active participation of the residents is encouraged, using role-play, case discussion, or vignettes. The individual modules begin with a general description of the topic, such as epidemiology, biology, psychology, psychopharmacology, or specific treatment approaches. Many of the modules include the teaching of practical skills of assessing trauma and trauma-related symptoms. Residents practice techniques for interviewing traumatized patients and families. Learning how to develop a treatment alliance with patients who may have attachment difficulties is a cornerstone of the curriculum. Becoming aware of countertransference reactions when exposed to severe affective dysregulation, selfinjurious behavior, and traumatic narratives (9) is an essential feature of many of the modules. Depending on the content of the module, the goals and objectives include discussion of latest research findings and current debates. The efficacy of particular interventions and “best practices” approaches to trauma treatment are highlighted. Included are reading assignments and references. A multisensory, multimedia approach utilizes videos, readings, experiential exercises, and guest speakers. The TTMC takes into consideration the development of a trauma training curriculum that moves from the assessment of traumatic events and related symptomatology to trauma-informed case-formulation and treatment-planning. The impact of trauma on individuals, families, and communities is incorporated into some of the modules. The TTMC is designed to be used as either a single long course or as individual modules, depending on the needs of the training program. As residents progress through training, their level of sophistication increases. The fund of knowledge and skills improves, and the residents’ understanding of clinical material moves from concrete to conceptual. The TTMC includes modules that are targeted to junior residents, such as assessment of trauma and diReceived January 4, 2011; accepted February 1, 2011. From the Dept. of Psychiatry, Albert Einstein College of Medicine, Bronx, NY. Send correspondence to Dr. Muenzenmaier; brmdkmm@omh.state.ny.gov (e-mail). Copyright

Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years

BACKGROUND Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication. METHOD In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models. RESULTS In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; ηp2=0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; ηp2=0.70; odds ratio: 0.90). CONCLUSION This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

Patient Satisfaction and Quality of Life in People with Schizophrenia-Spectrum Disorders in a Rural Area

People suffering from schizophrenia-spectrum disorders often endorse a reduced quality of life (QoL) as compared to the general population. There appears to be a lack of studies for rural catchment areas for this patient population. We conducted a cross-sectional study with 94 people with schizophrenia-spectrum disorders in a mainly rural alpine area. We used multilevel models controlled for covariates to analyze the data. Total service satisfaction was associated with psychological aspects of subjective QoL and physical well-being in our model. Variables characterizing autonomy and empowerment of the person seem crucial concerning the QoL in this population.

Length of Involuntary Hospitalization Related to the Referring Physician’s Psychiatric Emergency Experience

Although involuntary commitment (IC) is a serious intervention in psychiatry and must always be regarded as an emergency measure, the knowledge about influencing factors is limited. Aims were to test the hypothesis that duration of involuntary hospitalization and associated parameters differ for IC’s mandated by physicians with or with less routine experience in psychiatric emergency situations. Duration of involuntary hospitalization and duration until day-passes of 508 patients with IC at the University Hospital of Psychiatry Zurich were analyzed using a generalized linear model. Durations of involuntary hospitalization and time until day-passes were significantly shorter in patients referred by physicians with less routine experience in psychiatric emergency situations than compared to experienced physicians. Shorter hospitalizations following IC by less-experienced physicians suggest that some IC’s might be unnecessary. A specific training or restriction to physicians being capable of conducting IC could decrease the rate of IC.