Original Research ❚ Psychiatric rehabilitation
Evaluating outcomes in an adult
inpatient psychiatric rehabilitation unit
Marlene Kelbrick MBChB, MRCPsych, PGCert (diabetes), MRes (translational research management),
Suheib Abu-Kmeil MBChB, FRCPsych, Marco Picchioni MBBS, MRCP, FRCPsych PhD
Patients with severe and enduring mental illness often require recovery-focused inpatient
rehabilitation in order to improve functional impairment and successfully reintegrate
into the community. Here, the authors describe a case note audit of patients admitted
to a rehabilitation unit over a two-year period to establish how many patients were
successfully discharged back into the community and what the vocational reintegration
outcomes were. The study highlights the crucial need for evaluating these outcomes in
order to guide future practice and improve care quality.
P
sychiatric rehabilitation services aim to reduce functional
impairment in those with complex
and enduring mental illness by
enabling the development of emotional, social and vocational skills,
improving illness management,
and enhancing personal autonomy and independence, in order
to maximise quality of life. 1–4
Rehabilitation services typically
employ multidimensional interventions, are patient-centered and
recovery-focused, with the ultimate goal of achieving successful
reintegration into the community
in a setting and societal role chosen by the individual.5,6
Patients in UK psychiatric rehabilitation settings include those
with severe and enduring mental
illnesses, both psychotic and
non-psychotic disorders. They
represent a ‘low volume, high
needs, high cost’ group with
difficult-­to-treat illness and frequent comorbidity, who often
require longer admissions and
ongoing specialist mental health
support to successfully live in the
community after discharge.2,3,7
Patients are often referred to
rehabilitation services when their
complex mental health needs
mean they cannot be successfully
discharged from an acute ward
18
Guidance for commissioners
of rehabilitation services for
people with complex mental
health needs (2013)
1. Number of readmissions to the acute
inpatient unit following discharge
(For audit purposes to include a
12-month period post-discharge)
Clinical outcomes in mental
health rehabilitation services
(2013)
2. Number of patients who achieve
successful (sustained) ‘move-on’ to more
independent settings (‘discharge down
care pathway’)
• Independent living with or without
support
• Supported accommodation
(Sustained ‘move-on’ defined as at the
time of audit)
3. Number of patients participating
in work (voluntary/paid) or education
following discharge
4. Length of hospital stay
Table 1. Standards for measuring rehabilitation outcomes
while further progress seems
unlikely, at least in the time frame
that these services operate to. They
are typically unable to progress in
their recovery and require intensive support, often in a structured
environment, to overcome their
disabilities, or are transitioning
from a more- to a less-supportive
environment. 7 This often also
includes the repatriation of ‘out-ofarea’ placements to local services
that are usually less restrictive and
more independent.8
UK Government policy high-
Progress in Neurology and Psychiatry September/October 2016
lights the need for accountability
and transparency in healthcare
delivery with a focus on outcomes
that are meaningful to both the
patient and the clinician. 9–11
Although there is still some
debate as to what would be a
‘meaningful outcome’ in psychiatric rehabilitation, symptom
reduction, improved cognitive
and functional measures, personal goal attainment and
reduced service utilisation, as well
as improved physical health, are
likely key domains.1,3,11
www.progressnp.com
Psychiatric rehabilitation ❚
Aims
We aimed to identify and describe
the demographic, clinical and
legal characteristics, including
the risk profile, of patients admitted to an adult open psychiatric
rehabilitation inpatient unit, and
to evaluate rehabilitation outcome-­
related factors.
Method
Northamptonshire is a large
county in the East Midlands region
of the United Kingdom with a population of 701 000. 12 The adult
inpatient psychiatric rehabilitation
service was based in the south of
the county in Northampton.
Between 2012 and 2014 the service
consisted of a seven-bedded
female community inpatient unit,
and an eight-bedded male hospital-based inpatient unit.
The population audited consisted of all patients admitted over
a two-year period to the female
rehabilitation unit, from its inception in May 2012 to May 2014, and
all patients admitted to the male
rehabilitation unit from its inception in August 2012 to August
2014. The audit was conducted in
November 2014.
Patients were identified from
electronic patient records obtained
from the hospital Trust Performance Team, and data extracted
from the electronic patient notes
after approval by the Northamptonshire Healthcare Foundation
NHS Trust Audit committee. Data
were pseudononymised.
Rehabilitation outcome-related
factors were based on national
guidelines (see Table 1).3,13
Demographic, clinical and
legal characteristics
Twenty three female and thirty
male patients were admitted to the
inpatient rehabilitation service
across the two units during the
audit periods (Table 2). The majority (68%) were admitted from the
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acute psychiatric inpatient unit. A
minority, three (13%) female and
seven (23%) male patients were
repatriated from out-of-area placements. Other referral sources
included ‘step down’ from forensic
inpatient rehabilitation units and
‘step up’ from the community.
Most patients were Caucasian
(83%), women were older (mean
age: female, 36 years; male, 31
years). Of the 19 female and 25
male patients who were discharged
by the time of the audit (to either
acute inpatient or community setting), median length of stay was 128
days (range 38–469) for female and
164 days (range 3–482) for male
patients. The most common primary psychiatric diagnosis was
schizophrenia and related psychoses (58%). More female than male
patients (35% versus 10%) had a
Original Research
primary diagnosis of personality
disorder (see Table 3). Substance
misuse was not formally coded as a
diagnosis, but included in the risk
profile (see below section).
Thirteen of 23 (57%) female
and 12 of 30 (40%) male patients
had a history of three or more previous acute psychiatric admissions.
For 3 of 23 (13%) female and 9 of
30 (30%) male patients the period
of rehabilitation formed part of
their first admission. Just over a
third (39.1%) of female and half
(50.0%) of male patients were
detained under the Mental Health
Act (1983).
Prescribing patterns
At the points of admission and
discharge the majority of patients
were prescribed two or more psychotropic medicines, indeed
Male rehab
unit – number
of patients (N)
Female rehab
unit – number
of patients (N)
Total – number of
patients (N)
Admissions
30
23
53
Aug 2012–Aug 2013 males;
May 2012–May 2013 females
(one year)
16
11
27
Aug 2013–Aug 2014 males;
May 2013–May 2014 females
(one year)
14
12
26
Aug 2012–Aug 2013 males;
May 2012–May 2013 females
(one year)
11
6
17
Aug 2013–Aug 2013 males;
May 2013–May 2014 females
(one year)
14
13
27
Still an inpatient
5
3
8
Deceased
0
1
1
Referral source
N (%)
N (%)
N (%)
Acute
20 (67)
16 (70)
36 (68)
Out-of-area placement
7 (23)
3 (13)
10 (19)
Forensic services
3 (10)
0
3 (6)
Community
0
4 (17)
4 (7)
Discharges
Table 2. Admissions, discharges and referral sources
Progress in Neurology and Psychiatry September/October 2016
19
Original Research ❚ Psychiatric rehabilitation
polypharmacy rates increased over
the admission period (admission:
62%, discharge: 66%). Anti­
psychotic polypharmacy was more
common in male compared with
female patients (see Table 4).
Five of the nine (56%) female,
and 14 of 21 (67%) male patients
with schizophrenia met the criteria
for treatment resistance, defined as
‘failure to respond adequately to
treatment despite sequential use of
adequate doses of two or more
antipsychotic drugs’ (NICE 2014),
and were eligible for clozapine use.
Of the female patients with
treatment-­resistant schizophrenia,
three (33%) were prescribed clozapine (two initiated during the admission). For those who had not been
prescribed clozapine no clear reasons were documented. In addition,
clozapine was prescribed for a further three female patients (two initiated during the admission) with
difficult-to-treat emotionally unstable
personality disorder. Of the male
patients with treatment-resistant
schizophrenia, eight (57%) were prescribed clozapine (two initiated during the admission).
For those who had not been
prescribed clozapine, four (29%)
Admissions: Male from Aug 2012–Aug 2014;
Female May 2012–May 2014 (2-year period)
Male rehab unit
Female rehab unit
Total
Number of patients (N)
30
23
53
Age in years
Mean (SD)
Mean (SD)
Mean (SD)
31 (12)
36 (14)
33 (13)
Ethnicity
N (%)
N (%)
N (%)
White British
Other white
Other black
Asian
Mixed
Other
23 (77)
2 (7)
1 (3)
1 (3)
2 (7)
1 (3)
21 (91)
0
0
1 (4)
1 (4)
0
44 (83)
2 (4)
1 (2)
2 (4)
3 (6)
1 (2)
Number of patients (N)
25*
19**
44***
Length of stay in days
Median (range)
Median (range)
Median (range)
164 (3–482)
128 (38–469)
140 (3–482)
Number of patients (N)
30
23
53
Legal status
N (%)
N (%)
N (%)
Informal
Section 3 MHA (1983)
Section 37 MHA (1983)
15 (50)
14 (47)
1 (3)
14 (61)
9 (39)
0
29 (55)
23 (43)
1 (2)
21 (70)
1 (3)
3 (10)
0
3 (10)
1 (3)
1 (3)
9 (39)
3 (13)
2 (9)
1 (4)
8 (35)
0
0
31 (58)
4 (8)
5 (9)
1 (2)
10 (19)
1 (2)
1 (2)
1 (3)
0
1 (3)
4 (13)
1 (4)
1 (4)
0
0
2 (4)
1 (2)
1 (2)
4 (8)
Primary ICD10 diagnosis
F20-29 Schizophrenia and related psychoses
F30-31 Bipolar affective disorder
F32-34 Depressive disorder (recurrent)
F40-48 Anxiety and stress-related disorder
F60-61 Personality disorder
F70-79 Mental retardation
F84 Pervasive developmental disorder (ASD)
Secondary ICD10 diagnosis
F40-48 Anxiety and stress-related disorder
F60-61 Personality disorder
F70-79 Mental retardation
F90 Hyperkinetic disorder (ADHD)
* Excluding 5 still rehabilitation inpatients ** Excluding 3 still rehabilitation inpatients, and 1 deceased
*** Excluding 8 still rehabilitation inpatients and 1 deceased
Table 3. Demographic, clinical and legal characteristics
20
Progress in Neurology and Psychiatry September/October 2016
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Psychiatric rehabilitation ❚
Original Research
Male rehab unit
Number of
patients (%)
Female rehab unit
Number of
patients (%)
Total
Number of
patients (%)
At the time of admission
30 (100)
23 (100)
53 (100)
One
Two or more
15 (50)
15 (50)
5 (22)
18 (78)
20 (38)
33 (62)
At the time of discharge (excluding those still
inpatients/deceased)
N = 25
N = 19
N = 44
One
Two or more
12 (48)
13 (52)
3 (16)
16 (84)
15 (34)
29 (66)
At the time of admission
N = 30
N = 23
N = 53
One
Two or more
18 (60)
6 (20)
17 (74)
4 (17)
35 (66)
10 (19)
At the time of discharge (excluding those still
inpatients/deceased)
N = 25
N = 19
N = 44
One
Two or more
14 (56)
6 (24)
16 (84)
1 (5)
30 (68)
7 (16)
N = 30
N = 23
N = 53
2 (7)
0
8 (27)
2 (9)
1 (4)
6 (26)
4 (7)
1 (2)
14 (26)
6 (20)
3 (13)
9 (17)
Psychotropic medication
Antipsychotic medication
Clozapine initiated during admission
Depot preparation initiated during admission
Patients on clozapine during admission period
Number of patients on depot antipsychotic during
admission period
Table 4. Prescribing patterns (admission and discharge)
patients had documented reasons
of refusal and/or poor compliance.
Depot antipsychotic medication was prescribed for three
female patients (two with a diagnosis of schizophrenia and related
psychoses and one with bipolar affective disorder), and six male patients
with diagnoses of schizophrenia and
related psychoses. Documented reasons for depot antipsychotic prescription were poor compliance with
oral medication.
Risk profile
The most common documented
historical risk types for female
patients were aggression (78%), followed by self-harm (65%), self-neglect (61%), medication
non-concordance (52%), substance
misuse (52%), and vulnerability to
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exploitation by others (44%). For
male patients, the most common
identified historical risk types were
violence to others (83%), followed
by medication non-concordance
(63.3%), substance misuse (60%),
self-neglect (57%), and self-harm
(50%). Active risk behaviours
included mainly self-neglect, selfharm, illicit drug seeking behaviour
and medication non-concordance.
Outcome-related factors
Discharge placement
At the time of audit 35 of 53 (66%)
patients had been discharged from
the inpatient service to the community. Of these, 20 (57%) patients
were discharged to a supported
accommodation setting, and 15
(42%) discharged to independent
living arrangements (mainly with
additional support). Fifteen of 53
(15%) patients were transferred
back to the acute psychiatric inpatient unit during their inpatient
admission to the rehabilitation service due to an increase in their risk
that could not be managed safely
within the rehabilitation ward setting, one (2%) patient was transferred to a locked rehabilitation
unit, and one (2%) female patient
died during the audit period (see
Table 5).
Readmissions
Of the patients discharged to the
community during the audit period
(15 female and 20 male), 12 (80%)
female and 15 (75%) male patients
had no further psychiatric admissions. Of those patients readmitted
to a psychiatric hospital following
Progress in Neurology and Psychiatry September/October 2016
21
Original Research ❚ Psychiatric rehabilitation
Discharge placement or
transfer from the rehab
unit
Number of
male rehab unit
patients (%)
Number of
female rehab unit
patients (%)
Total
number of
patients (%)
30
23
53
Independent living with or
without support
7 (23)
8 (35)
15 (28)
Supported accommodation
13 (43)
7 (30)
20 (38)
Transfer back to the acute
inpatient unit
5 (17)
3 (13)
8 (15)
Transfer to higher level of
security (ie locked rehabilitation)
0
1 (4)
1 (2)
Still a rehabilitation inpatient
5 (17)
3 (13)
8 (15)
Deceased
0
1 (4)
1 (2)
Table 5. Discharge placements
discharge from the rehabilitation
service, median time to readmission was 174 days (range 120–360
days) for female, and 301 days
(range 10–474 days) for male
patients.
Readmission rate
Of patients discharged to the community, three (20%) female and
three (15%) male patients had had
one or more readmission to a psychiatric hospital within 12 months.
Vocational rehabilitation
Of patients discharged to the community, only two (13%) female,
and three (15%) male patients
were engaged in voluntary work or
education. Four (20%) discharged
male patients who were unemployed at the time of audit were
documented to be actively applying for paid employment.
Discussion
Evaluating psychiatric rehabil­
itation service outcomes is
complicated by a multitude of
factors that include illness heterogeneity and the diversity of treatments employed in the
rehabilitation process,1 as well as
current attempts to achieve
individual­­i sed recovery targets
22
that will, by definition, differ from
patient to patient. Disentangling
what single or combination of
interventions makes a difference
remains a challenge.
Quite apart from the focus on
the needs of the individual, an
inevitable purpose of recovery is to
reduce service utilisation.1 The
majority of our patients were successfully discharged to a less supported community-based setting
during the audit period with only
a minority readmitted to an acute
psychiatric inpatient unit. However, limitations of the audit
included the lack of a comparison
group, the small sample size,
under-­r epresentation of ethnic
minority patients, and modest
length of follow-up.
Factors that cause, or are markers of, a less favourable outcome in
psychiatric rehabilitation patients
include medication nonadherence
(linked frequently with lack of
insight or denial of illness),14 challenging behaviour such as aggression and self-harm, treatment with
high-dose antipsychotic medication, antipsychotic poly­pharmacy,
and previous care in forensic psychiatric services, reflecting the
complexity and treatment-resistant
nature of this patient group15 –
Progress in Neurology and Psychiatry September/October 2016
features that were seen in our
patient population.
Polypharmacy was common
amongst our audited population,
and similar to national UK figures.16–19 The use of combined
antipsychotic treatment is strongly
discouraged (except for short
changeover periods) due to an
increased side-effect burden and a
general lack of evidence for efficacy
(although there is some evidence
suggesting a modest benefit in certain exceptional clinical circumstances). 17,20,21 Reasons for
combined antipsychotic medication
use frequently include incomplete
medication changeover due to
symptom improvement, the addition of a second antipsychotic to
long-term maintenance treatment
in the context of acute relapse, and
as a measure to reduce side-effects
by using lower doses whilst achieving therapeutic benefit.22
New clozapine use in eligible
patients included in this audit was
low. Clozapine has superior efficacy
compared with other antipsychotic
medication in treatment-resistant
schizophrenia and can significantly
improve functioning and quality
of life.23 Despite this, underutilisation and delayed initiation of clozapine in this patient population
remains a problem.16,24 Possible
reasons for this include clinician-­
related (negative attitudes/beliefs
and lack of experience), and
patient-related factors (poor compliance and refusal).24,25
In contrast to less favourable outcome predictors, predictors of a positive outcome include psychiatric
rehabilitation admission within the
first 10 years of psychotic illness that
suggests that earlier engagement, or
the patient who is willing to engage
early, is likely to have a more positive
outcome.14,15 A proportion of our
patients (13% female and 30%
male) were in their first episode of
illness, a factor that may have contributed positively to outcomes in
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Psychiatric rehabilitation ❚
terms of successful ‘move on’ to the
community.
Outcomes for vocational reintegration were less favourable,
with only a minority of patients
engaged in voluntary work or education, and no patients engaged in
paid employment. Recovery is
likely to increase a patient’s
chances of securing employment,
while employment is associated
with a positive effect on mental
health, promoting the process of
recovery through fostering pride
and self-esteem, giving meaning
and purpose and a sense of
achievement, and providing structure to daily living.26,27 However,
unemployment rates amongst
those with long-term mental
health disabilities remain high.28
Premorbid factors such as education and employment history,
illness-related factors such as negative symptoms, comorbidity and
the need for frequent hospitalisation, social factors such as stigma
and poor interpersonal skills, and
environment-­related factors such as
low expectations, underestimation
and/or underutilisation of skills,
and restricted work project opportunities, are all likely to play a
role.27–34 Vocational support programmes that include inter­agency
collaboration and adhere to the
individual placement and support
(IPS) model with the use of an integrated community employment
specialist, have been shown to be
most effective in helping those with
mental health disabilities gain and
sustain employment, and should
form part of any psychiatric rehabilitation service.35
Conclusion
Ongoing investment in local psychiatric rehabilitation services is
needed to reduce the need for
prolonged hospital inpatient stays
and out-of-area placements in
those with complex mental health
needs. A failure to invest in
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and provide these can have a negative impact on both patients and
clinical organisations.36 There is a
crucial need to identify nationally
agreed meaningful service and
patient-centred outcome measures
that also involve carers, as well as to
evaluate the impact of various rehabilitative interventions in order to
guide future practice and service
design and improve quality of care.
In our own service, at the time
of audit, we were reviewing our
rehabilitation pathway and discharge planning process with input
from patients and carers, and
started to introduce Royal College
of Psychiatrists’ recommended outcome measures. 10,13,37 We were
also working closely with the local
Trust funding panel to effectively
identify cases for repatriation, and
were working with the acute inpatient service to improve early identification of patients requiring
rehabilitation in order to reduce
delayed discharges.
Dr Kelbrick is a Specialty Registrar,
General Adult Psychiatry,
Leicestershire Partnership NHS
Trust; Dr Abu-Kmeil is a Consultant
Psychiatrist, Northamptonshire
Healthcare Foundation NHS Trust,
and Senior Lecturer, and Dr Picchioni
is an Honorary Consultant Forensic
Psychiatrist, St Andrew’s Academic
Department, Department of Forensic
and Neurodevelopmental Science,
Institute of Psychiatry, Psychology
and Neuroscience, Northampton.
Declaration of interests
Marlene Kelbrick owns shares in
GSK.
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POEMs
ACP chronic insomnia guideline: CBT before drugs
Clinical question
How should chronic insomnia be managed?
Reference
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Study design: Practice guideline Funding source:
Self-funded or unfunded Setting: Various (guide-
line)
Synopsis
This guideline addresses the treatment of
chronic insomnia, defined as a sleep disorder
that causes significant functional distress or
impairment at least three nights a week for
three months.
The recommendations are based on a systematic review of treatment options. Based on
moderate-quality evidence, cognitive behavioral
therapy aimed at insomnia improved remission,
treatment response, time to sleep, waking after
sleep onset, and sleep quality. Treatment can
be delivered as individual or group therapy, by
telephone, web-based, or via self-help books.
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Harm with therapy may occur but has not been
reported in studies.
Cognitive behavioral therapy for insomnia
consists of: (1) Cognitive therapy aimed at dysfunctional beliefs and attitudes toward sleep
and insomnia; (2) stimulus control: avoiding
nonsleep activities in the bedroom; (3) sleep
restriction: limiting time in bed to match perceived sleep duration to assure that more than
85% of time spent in bed was spent sleeping;
(4) sleep hygiene: typical measures of alcohol,
caffeine, and nicotine intake and sleep scheduling; and (5) relaxation techniques: meditation,
mindfulness, and so forth.
Drug therapy using newer hypnotics—eszopiclone (Lunesta), zolpidem (Ambien), and
suvorexant (Belsomra)—improves some aspects
of sleep, though most studies of these drugs
were of low quality. Benzodiazepine hypnotics
have not been studied for long-term use.
Doxepin, in a low-quality study, was shown to
improve total sleep time and waking after sleep
onset, but other older medicines, such as
diphenhydramine and trazodone, have not
been studied.
Drug treatment was judged to be secondline therapy because of its cost and harms. This
group suggests using medicine for no longer
than 4 to 5 weeks, if possible.
Progress in Neurology and Psychiatry September/October 2016
www.progressnp.com