Are long-term psychiatric patients causing more crisis consultations outside office hours in mental health care?

Abstract

Background:

As well as an improvement in community services, the de-institutionalization of patients receiving long-term psychiatric care can lead to marginally staffed mental health services, more homelessness, rising admission rates and more people in prison cells. It is assumed that an imbalance between community and hospital care for chronic patients puts pressure on crisis services.

Aims:

In this study, the central question is whether patients receiving long-term psychiatric care in Amsterdam do indeed put pressure on the city’s emergency mental health services. We compare the pressure exerted by this group with the pressure resulting from the use of these services by all registered patients.

Methods:

Data were taken from the client registration systems of three mental health organizations in Amsterdam in the period from 2000 to 2004. Inclusion criteria for long-term psychiatric patients were age above 19 years and uninterrupted receipt of mental health care for a minimum of two successive years.

Results:

Annually, 6%–8% of all non-long-term patients experienced a crisis outside office hours in the period under investigation; this was 4%–6% for long-term patients. The non-long-term patients accounted for 83% of crisis contacts outside office hours over the entire study period, with long-term patients accounting for 17%.

Conclusions:

The assumption that crises are more prevalent in long-term patients in the community seems to be an example of stigmatization rather than an observation based on fact.

Keywords

Long-term psychiatric care de-institutionalization crisis services psychiatry

Introduction

The de-institutionalization of care for chronic psychiatric patients has not only led to better community services for many patients (Thornicroft & Bebbington, 1989), it has also resulted in a rise in admissions (voluntary or involuntary), marginal staffing, more patients in prison cells and more homelessness (Priebe et al., 2008). De-institutionalization has also contributed to some extent to increased pressure on acute inpatient services in the UK (Ford, Durcan, Warner, Hardy, & Muijen, 1998). In fact, Marshall (1997) proclaimed a crisis in mental health services in London (partly caused by a shortage of acute beds and partly by de-institutionalization). Faced with major urban problems (such as unemployment, social deprivation and homelessness), the inner-city admission wards have had to battle with severe overcrowding, as well as with more psychotic disorders and increased coercion (Audini, Duffett, Lelliot, Pearce, & Ayres, 1999). Some have suggested that this pressure on admission beds was more a response to a change in population needs than a consequence of de-institutionalization (Fitzpatrick et al., 2003). Others have looked to different thresholds for admission as the factor explaining the differences in bed occupancy (Thompson et al., 2004). A lowered threshold has been found to be a particularly important factor in the case of ethnic minorities (Bhui et al., 2003; Jarvis, Kirmayer, Jarvis, & Whitley, 2005; Singh, Greenwood, White, & Churchill, 2007). However, variations in the availability of community services also influence the pressure on acute psychiatric beds (Bartlett, Holloway, Evans, Owen, & Harrison, 2001).

Amsterdam has encountered the same problems. Over the past decade, psychiatric hospitals have had to cope with an increase in admissions (voluntary and involuntary), as well as with over-occupancy of admission beds (Mulder, Dekker, & Gijsbers van Wijk, 2005; van der Post et al., 2010). In the early years of this millennium, the Dutch media reported a rise in problems on the streets involving people clearly suffering from psychiatric disorders, and an imbalance between community and hospital care, resulting in undue pressure on the city’s crisis services (Peen, Theunissen, Duurkoop, Kikkert, & Dekker, 2011; Theunissen et al., 2008). Public opinion and policy makers thought that the old and new long-term patients in Amsterdam were particularly responsible for the ongoing high pressure on the city’s psychiatric crisis services. The main goal of this study was to determine whether long-term patients were indeed responsible for the pressure on crisis services. We therefore looked at the extent to which long-term psychiatric patients used the crisis services in Amsterdam in the first five years of this millennium compared to non-long-term patients.

Methods

Data

The reported data are based on the client registration systems of the three main mental health institutions (MHIs) in Amsterdam between 2000 and 2004. These three mental health care organizations (Mentrum, Meren and GGZ-Buitenamstel) provided care for 95% of the chronic patients in Amsterdam. These MHIs all used the same registration system. The three databases of these systems were linked with an encrypted code based on gender, date of birth and the first two letters of the family name. This link allowed us to deduce for unique clients total care consumption expressed as days and contacts. The data used for this study were gender, diagnosis, age, type of contact (a crisis contact or a non-crisis contact), duration of care and total number of care contacts.

We were quite optimistic about the reliability and completeness of the data on consumption of care. The MHIs’ income depended on the reliable registration of use of care and this data can therefore be expected to be accurate. To check the reliability of the officially registered psychiatric diagnoses in the databases of the three MHIs, we looked at 50 medical files to see whether the diagnosis in the database was concurrent with the diagnosis as noted by the psychiatrist in the treatment plan. In 98%, these diagnoses were the same – a reassuring finding.

Exclusion criteria

We included all patients registered at the three MHIs with the following exclusions. We excluded patients from the departments of child psychiatry and geriatric psychiatry. Specialized services with a supra-regional function were also excluded; these were the departments for clinical psychotherapy, forensic psychiatry and specialist care of the academic centres. Apart from the forensic clinic (about 70 beds), none of these clinics provided long-term care (in other words, care lasting more than two years).

Patients in care

The study population consisted of patients older than 19 years of age and registered in one of the three MHIs. All patients who had received uninterrupted care (residential or outpatient care) for at least two successive years were qualified as long-term patients. All MHI patients receiving care for a period of less than two years were classified as non-long-term patients.

We distinguished between subgroups of long-term patients over the five-year study period (corresponding with the definitions of chronicity in the study of a Dutch national case register by Dieperink and colleagues (Dieperink, Pijl, & Driessen, 2006; Dieperink, Pijl, Mulder, van Os, & Drukker, 2008) as follows:

Long-term inpatients: patients who had stayed in one or more psychiatric hospitals for at least two successive years (for the whole period of two years).

Long-term in- and outpatients: patients receiving in- and outpatient care for at least two consecutive years (including ‘revolving-door’ patients). A patient with a history of, for example, 14 months of inpatient care followed by 10 months of outpatient care over the last two years would come into this category.

Long-term outpatients: patients who had received no inpatient care in the last two years but only uninterrupted outpatient care for at least two successive years. The care period was considered to be uninterrupted if the period between contacts did not exceed 90 days.

We used the annual numbers for all these four groups to calculate the prevalence rates per 100,000 inhabitants. Amsterdam had a population of about 760,000 during the years in question. In 2004, the three MHIs had about 680 beds, that is about 90 beds per 100,000 inhabitants. As well as these beds in psychiatric hospitals, there were about 750 places for sheltered living.

We compared our study results with the national study by Dieperink et al. (2008). Their study comprised the data from three case registers in the Netherlands covering almost 3.5 million inhabitants (16% of the Dutch population). In this study, Dieperink et al. distinguished between different levels of urbanization (based on the ‘density of addresses’, a criterion for the degree of human activity) (Dekker, Peen, Gardien, de Jonghe, & Wijdenes, 1997; den Dulk, van den Stadt, & Vliegen, 1992). Amsterdam is one of the most urbanized cities in the Netherlands, and so we compared our prevalence rates not only with the prevalence rates in the national study but also with the rates in the most urbanized areas in the national study. Dieperink et al. (2008) also included patients in sheltered housing in the group of long-term inpatients. In his first study (Dieperink et al., 2006), the prevalence rate for patients in sheltered housing was about 3.8 per 1,000 inhabitants in 1998 (one third of the total group of long-term inpatients). However, in our study, all these patients were registered as long-term outpatients, and not examined separately because all received their psychiatric care from the psychiatrists of one of the three MHIs. In our study, then, these patients were included in the group of long-term outpatients.

Identification of patients in crisis

Emergency public mental health care in Amsterdam was delivered in the study period by three crisis teams from the three mental health organizations (van der Post, Mulder, Bernardt, & Schoevers, 2009). These teams were responsible outside office hours for all acute psychiatric assessments (with outreach activities such as home visits) at the request of police, general practitioners, hospitals, and so on. They had also the sole mandate for emergency admissions to all of the Amsterdam psychiatric intensive care units (PICU) outside office hours. These teams worked together closely outside office hours and so crisis management outside office hours in Amsterdam was standardized in terms of procedures, registration and protocols. They defined a crisis as a patient who required care within 24 hours and when there was a risk of unpredictable events such as the possibility of suicide, serious behavioural problems, problems with law and order and safety, the sudden loss of social support, and involuntary admission.

In this study, we looked only at crises outside office hours. We did not examine the crises inside office hours as these were usually processed by the regular psychiatrists, psychologists or psychiatric nurses. In addition, all these people could have used different procedures during office hours, resulting in limited comparability.

Results

Numbers of long-term patients per 1,000 inhabitants

Table 1 shows the types of long-term psychiatric patients and non-long-term psychiatric patients per 1,000 inhabitants in Amsterdam from 2000 until 2004 and in three case register regions of the Netherlands in 2004.

Table 1.

Types of long-term psychiatric patients and non-long-term psychiatric patients per 1,000 inhabitants in Amsterdam and in a representative part of the Netherlands.

	Amsterdam (> 19 years)					Case register for regions of the Netherlands
Year	2000	2001	2002	2003	2004	2004All regions	2004Very highly urbanized regions
Number inhabitants (> 19 years)	581,464	583,066	582,198	581,288	582,614	2,636,662	719,436
Patients
Long-term inpatients	0.63	0.59	0.55	0.54	0.57	1.20	1.20
Long-term in- and outpatients	2.36	2.21	2.41	2.77	2.96	1.30	1.80
Long-term outpatients	6.15	5.81	5.96	6.70	6.75	3.50	4.20
Subtotal	9.15	8.61	8.93	10.01	10.28	5.90	7.10
Non-long-term patients	39.43	38.81	37.29	35.84	39.55	42.30	50.80
Total patients	48.58	47.41	46.22	45.85	49.83	48.20	57.90
N Long-term patients	4,698	4,244	4,532	5,043	5,236	15,556	5,108
N Total	28,245	27,645	26,909	26,651	29,032	127,087	41,655

The first striking finding (by contrast with the national study) is that the vast majority of long-term patients were treated in outpatient care (6.75/10.28 =) 66% in 2004. Only a small percentage was treated in long-stay clinics (0.57/10.28 =) 6% in 2004. In the three regions of the Netherlands, these percentages were 59% and 20%, respectively, and about 60% and 17% in the very highly urbanized parts of these regions.

A second interesting finding is that the number of non-long-term patients in Amsterdam during the study period was around 39 per 1,000, whereas it was markedly higher at about 51 per 1,000 in comparable highly urbanized regions in the Netherlands.

The third remarkable finding in the Amsterdam data is the fluctuations in total numbers of treated patients. In 2000 to 2001 there was a decrease in the number of long-term patients, followed by an increase in 2002 to 2004. In 2000 to 2003 there was a continuous decrease in non-long-term patients, with numbers increasing for the first time in 2004. The rise in long-term patients was partly related to the fall in non-long-term patients in these years (see Discussion).

Characteristics of long-term patients

The long-term inpatients in Amsterdam were mostly males (59%) in the age groups 35–44 (24%) and 45–64 (46%). Most suffered from schizophrenia (83%), psychotic disorder not otherwise specified (NOS) (4%) or depression (4%).

Long-term in- and outpatients were mostly females (54%) in the age groups 35–44 (31%) and 45–64 (32%). Most suffered from schizophrenia (51%), psychotic disorder NOS (9%), depressive disorder (13%) or bipolar disorder (14%).

Most of the long-term outpatients were females (61%) in the age groups 35–44 (31%) and 45–64 (32%). This group had a wider range of diagnostic categories: schizophrenia (17%), psychotic disorder NOS (5%), depressive disorder (28%), bipolar disorder (5%) or anxiety disorder (14%).

Crisis contacts in long-term patients

The total number of outpatient treatment contacts for all patients rose to 322,244 in 2000 and 425,898 in 2004, an increase of around 32%. In 2000, there were 2,968 contacts with after-hours crisis services, rising to 4,832 in 2004 (an increase of about 60%). Annually, 4%–6% of all long-term patients experienced a crisis outside office hours in the period 2000 to 2004. In the case of non-long-term patients, the after-hours crisis rate was 6%–8%. The crisis rates in these two groups were therefore more or less comparable.

Because the number of non-long-term patients is six times that of long-term patients, this group accounted for the majority (83%) of after-hours crisis contacts throughout the entire study period, with long-term patients accounting for only 17% of all crisis contacts after office hours in these four years. Figure 1 lists the percentages for the four groups over these years.

Figure 1.

Percentages of crisis contacts after office hours.

Most of the crisis contacts involving long-term patients came from the long-term in- and outpatient groups. The long-stay inpatients were almost not at risk for using crisis services during their hospitalization (understandable because of the round-the-clock care). The percentage of long-term outpatients in the total number of crisis contacts varied between 2% and 4% on an annual basis. Further analysis of the group of non-long-term patients with crises outside office hours in 2004 revealed that 26% of this group involved foreign tourists or Dutch residents from outside Amsterdam; 46% involved known non-long-term care patients (had received or were receiving any help from the three MHIs in the last five years); and 26% involved patients who had not received any help from the three MHIs over the previous five years (in accordance with a later cohort study in Amsterdam (van der Post et al., 2011)).

Discussion

There were a number of remarkable findings. First, the stigmatizing public image of the long-term outpatient in crisis as a troublemaker is not borne out by the facts. The prevailing idea among the public and the claim made by policy makers in the early years of the 1990s that the de-institutionalization of new and old long-term psychiatric patients (Dekker & van den Langeberg, 1994) was responsible for most of the problems in Amsterdam and for the high number of crisis contacts is not supported by the facts. On the contrary, on an annual basis most of the psychiatric crises outside office hours were crises with patients who had been in care for less than two years and with new patients. This is a remarkable finding that justifies further investigation in terms of preventing these crises.

In addition, it is noteworthy that Amsterdam has de-institutionalized more long-term patients than the rest of the Netherlands. In Amsterdam, most of the long-term patients were in/outpatients or outpatients – about 94% compared to the 80% in representative similar regions in the Netherlands. There is an ongoing debate about the optimal balance between community and hospital care. The Netherlands is one of the countries in Europe with the highest number of psychiatric beds per 100,000 inhabitants (Priebe et al., 2008), suggesting that there is no severe imbalance in this country between community and hospital care. In Amsterdam, that balance tends more towards community care than in the rest of the Netherlands, but it is still different from other European countries. The number of conventional psychiatric inpatient beds in the Netherlands in 2006 was about 136 beds per 100,000 (Priebe et al., 2008). The number of conventional psychiatric inpatient beds in Amsterdam in 2005 was about 90 per 100,000. This is admittedly fewer than in other parts of the Netherlands but still almost twice as many as in Austria, Denmark and England.

A third remarkable result was the fluctuation in the numbers of treated patients (Table 1). The most plausible explanation for the rise in treated long-term patients is that policy makers in the MHIs focused more on severely ill patients in the study period. For example, the three crisis service teams were required to work more closely together in handling crises (especially through the city council) than they had been used to, with more clear agreements with the police about identifying the patients with severe mental illness. In short-term outpatient clinics there was a change in policy towards assigning practitioners more to the severely ill patients and less to people with common mental health disorders (Peen et al., 2011). This meant that they had more long-term patients in their caseloads, fewer regular outpatients with common mental health disorders (like depression, anxiety, etc.) and longer waiting lists. So the increase in long-term patients was partly related to the decrease in non-long-term patients in these years. The increase in 2004 in non-long-term patients resulted from an increase in treatment capacity as the government put in extra funds to reduce these waiting lists.

The high number of long-term patients in Amsterdam is probably partly a consequence of the more explicit focus on severely ill patients. In Amsterdam in 2004, there were about 75% more long-term patients (per 100,000 inhabitants) than in a large part of the Netherlands (Dieperink et al., 2008). Compared to a group of other highly urbanized Dutch municipalities (which included Rotterdam, Groningen, Maastricht and Leeuwarden), Amsterdam still had 45% more long-term patients. As well as the increased focus on chronic patients, it is also possible that Amsterdam attracts more long-term patients from outside the city region than the other highly urbanized municipalities in the national study of Dieperink et al. Alternatively, living in the capital may be an extra stress factor because of high rates of unemployment, immigration and crime figures, all of which are related to risk of chronicity (Peen & Dekker, 2004).

Limitations

One limitation of this study is that the research population is limited to patients with chronic psychiatric problems receiving uninterrupted care (residential or outpatient care) for at least two successive years from mental health care services. Little is known about the size and characteristics of the group of chronic psychiatric patients not receiving care or receiving interrupted care who might be responsible for the presumed nuisance. Kroon, Theunissen, van Busschbach, Raven and Wiersma (1998) have calculated that, for any two long-term patients in mental health care, there will be one who does not receive mental health care or any care at all. These study results can therefore only be generalized to probably adequately treated patients. Another concern is that we saw an increase in the number of registered contacts in the study period, while the total number of treated patients first decreased and then increased (being almost the same at the end as in the beginning). The most plausible explanation for the increase in contacts is that, in recent years, conglomeration, merging and financial pressures and extra funding from the government (for cutting waiting lists) have led to a significant increase in the number of patient contacts in the MHIs in the Netherlands (Dieperink, Pijl, & Driessen, 2007). Taking into account the incompleteness of the MHIs’ registrations systems, we in Amsterdam saw fewer non-long-term patients (39 per 1,000) than our colleagues in the other highly urbanized regions in the national study (51 per 1,000). One explanation for this lower number may be that only patients in MHI care were included. Alongside these MHIs, Amsterdam has more psychotherapists and psychiatrists with their own practice per 1,000 inhabitants than the other big cities (Heijnen & Projectgroep Onderzoek GGZ Amsterdam, 2006). The patients of these practitioners were not involved in either this study or the national study. In 2004, these practitioners in Amsterdam treated about 20,000 outpatients (95% of whom had probably been receiving treatment for less than two years) (Heijnen & Projectgroep Onderzoek GGZ Amsterdam, 2006). This makes the number of non-long-term patients in Amsterdam about 64 per 1,000 inhabitants, which is a higher number than in the national study and more in accordance with generally reported higher levels of care in large cities (Peen, Schoevers, Beekman, & Dekker, 2010).

Conclusions

The idea that chronic psychiatric patients in the community account for most of the crisis consultations outside office hours could not be confirmed. On the contrary, many more new and non-long-term patients were in crisis outside office hours. We hope this finding will be helpful in counteracting the stigmatization of chronic psychiatric patients living in the community.

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