Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

Abstract

Background:

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

Aims:

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

Method:

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

Results:

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

Conclusions:

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients’ admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Keywords

Hospital admissions involuntary admissions mobile mental health units rural areas schizophrenia

Introduction

In contemporary clinical practice and health policy, the treatment of the severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services (Thornicroft et al., 2010). The efficacy of community interventions for these disabling disorders is supported by several studies (Armijo et al., 2013; Asher et al., 2017). However, evidence is still lacking for most countries in the European region, with the exception of some high-income countries (Semrau et al., 2011). For instance, the impact of generic community mental health teams (CMHTs) on the care of the severely mentally ill patients has not been studied systematically. There is only one previous meta-analysis (Simmonds et al., 2001), two decades ago, which suggested that treatment by CMHTs may reduce hospitalizations and costs of care. This study analyzed data from 5 randomized studies, which were all conducted in urban settings. There are no data regarding rural settings. This dearth of studies regarding the efficacy of the generic CMHTs is probably due to that the more specialized Assertive Community Treatment (ACT) has emerged as the most widely used practice for the treatment of people with severe mental illness in the community. This model of care has been implemented for several decades in high income Western countries and has been studied extensively. There is evidence that ACT can reduce hospitalizations and symptom severity in patients with psychotic disorders, and improve functioning and well-being (Coldwell & Bender, 2007; Nordén et al., 2012; Vijverberg et al., 2017). However, the evidence regarding the effectiveness of this model has been criticized (Burns, 2009; Shetty, 2010). No advantage of ACT in reducing admissions and bed usage was found when CMHTs were active comparators rather than treatment as usual (Killaspy et al., 2009). Accordingly, it has been suggested that care by CMHTs may be equally effective to that by ACT at much lower cost (Burns, 2010).

The delivery of mental health services in rural and remote areas is still challenging. This is the case of rural areas in Eastern-Europe countries, which do not receive adequate mental health care due to socioeconomic and geographical reasons, and distant facilities (Thornicroft et al., 2011). Similarly, rural areas in Greece were mostly uncovered by mental health care facilities, according to previous reports (Madianos et al., 1999). To address the unmet mental health care needs in rural areas, the Greek state has launched several mobile CMHTs, namely the Mobile Mental Health Units (MMHUs) over the last decades, that deliver generic mental health services in remote areas of the mainland and in the numerous Greek islands (Peritogiannis & Mavreas, 2014; Stylianidis et al., 2016). These services operate according to the principles of social and community psychiatry, yet there are some differences among the services, in terms of staffing and patients’ diagnoses (Peritogiannis, 2019). The objective of the present study was to assess the changes in hospitalization rates in patients with schizophrenia spectrum disorders that receive treatment by a MMHU in a defined rural catchment area in Greece.

Methods

The treatment setting

The MMHU of the prefectures of Ioannina and Thesprotia (MMHU I-T) delivers services in a rural area of 5,000 km² with a population grossly estimated at 100,000 in Epirus, northwest Greece, which is one of the poorer regions in the European Union (Eurostat, 2019). This area is mostly mountainous, with dispersed settlement structure. There are no other mental health facilities in the rural area, and patients have to travel long distances to be examined by a mental health professional. The MMHU I-T is a multidisciplinary team that provides evidence-based treatment for all mental health disorders, although patients with psychotic disorders are a priority for the team (Peritogiannis et al., 2011, 2017). The MMHU I-T works with primary health care staff, social services and local community authorities and the patients’ families to gather information and coordinate care.

Study design

Data were obtained for patients with schizophrenia spectrum disorders (F20-F29, according to the International Classification of Diseases-10th revision) who were engaged to treatment with the MMHU I-T in the year 2017. Treatment engagement was defined when patients regularly attended scheduled follow-up appointments, according to individual treatment plan. Those patients were exclusively treated by the MMHU I-T. Patients with co-morbid severe mental retardation or organic brain disorder were excluded from the study. Data on hospitalizations and length of stay were retrieved from the patients’ charts.

For the evaluation of hospital admissions before and after treatment engagement of patients with the MMHU I-T we used a pre-post-mirror comparison design, which has been used in recent research (Schöttle et al., 2019). For each patient comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T. All the procedures of the study were approved by the institutional board and the ethics committee of the Democritus University of Thrace.

Statistical analysis

Data were analyzed using the SPSS version 25.0 (IBM Corporation, Armonk, NY, US). Categorical variables were presented in frequencies and percentages. Whereas the continuous variable of before and after scores were expressed as mean ±SD, the paired sample t-test/Wilcoxon signed ranked test was applied to determine the mean and median significant differences between of outcomes before and after the intervention. p-value < .05 was considered statistically significant.

Results

A total of 78 patients with schizophrenia spectrum disorders were engaged to treatment with the MMHU I-T in the year 2017. Two patients met the exclusion criteria, and data of 76 patients were processed. The average age of patients was 56 years (SD = 14.3) and more than two-thirds (67.1%) were male. Most were single (61.8%), but the majority lived with a caregiver (67.1%), usually an elderly parent. In a substantial proportion of cases (21%), all family members were severely mentally ill. The majority of patients received a disability pension. The mean illness duration was 28 years (SD = 14.9), whereas the mean patients’ follow-up duration by the MMHU I-T was 5.3 years (SD = 38.6). The mean number of hospitalizations of the patients over the course of their illness was 2.4 (SD = 2.3). Patients’ characteristics are presented in Table 1. The treatment regimen of the patients is presented in Table 2. Most received an atypical antipsychotic, whereas in several cases the treatment regimen comprised an antidepressant and/or a benzodiazepine. More than one fifth of patients were in treatment with a long-acting injectable antipsychotic compound.

Table 1.

Patients’ demographic and clinical characteristics.

	N = 76
Demographic characteristics
Gender (male)	51 (67.1%)
Age (mean, (SD), years)	56 (14.4)
Marital status	Married/cohabited	18 (23.7%)
	Not married	47 (61.8%)
	Widowed/divorced	11 (14.5%)
Caregiver	Living with a caregiver	51 (67.2%)
	Living alone	9 (11.8%)
	Living with other family members with SMI	16 (21%)
Education	Primary	44 (57.9%)
	Secondary	28 (36.9%)
	Tertiary	3 (3.9%)
	Illiterate	1 (1.3%)
Employment	Employed	4 (5.3%)
	Unemployed	6 (7.9%)
	Disability pension	59 (77.6%)
	Pension due to aging	7 (9.2%)
Clinical characteristics
Illness duration (mean (SD), years)	28 (14.9)
Duration of follow-up by the MMHU I-T (mean, (SD), years)	5.3 (38.6)
History of alcohol/substance abuse	14 (18.4%)

SD: standard deviation; SMI: severe mental illness; MMHU I-T: Mobile Mental Health Unit of the prefectures of Ioannina and Thesprotia.

Table 2.

Patients’ treatment regimen.

Treatment regimen	N (%)
Atypical antipsychotic	54 (71)
Conventional antipsychotic	4 (5.2)
Antipsychotic combination	13 (17.1)
Antidepressant	14 (18.4)
Benzodiazepine	28 (36.8)
Long acting injectable antipsychotic	17 (22.4)
Clozapine	5 (6.6)

A Wilcoxon Signed-ranks test indicated that

Number of hospitalizations per year were less in post-engagement measurements than in pre-engagement measurements (Z = 4.379, p < .001).

Days of hospitalization per year were less in post-engagement measurements than in pre-engagement measurements (Z = 3.395, p = .001).

Number of involuntary hospitalizations per year were less in post-engagement measurements than in pre-engagement measurements (Z = 2.905, p = .004).

Differences in the number of hospitalizations, number of involuntary admissions and length of hospital stay after treatment engagement of patients with the MMHU I-T, are shown in Figures 1 and 2.

Figure 1.

Differences in the number of total and involuntary admissions in patients with schizophrenia spectrum disorders prior and after treatment engagement with the MMHU I-T.

Figure 2.

Differences in duration of hospitalization in patients with schizophrenia spectrum disorders prior and after treatment engagement with the MMHU I-T.

Discussion

A significant decrease in hospitalizations in chronic patients with schizophrenia spectrum disorders, after engagement to treatment with the MMHU I-T was observed in this study. Over the 5.3-year follow-up period, the mean number of admissions was dropped to less than one-fifth. For patients that needed hospitalization over the follow-up period, length of hospital stay was significantly less as well, and was reduced 2.6-fold. Given that patients did not receive any other mental health treatment, these observations are better understood as the effect of the treatment by the MMHU I-T. The multidisciplinary team delivers comprehensive treatment that goes beyond evidence-based pharmacotherapy. MMHUs work closely with the community for coordination of care and can provide a broad range of psychosocial interventions that may increase the patients’ treatment adherence and hence reduce hospitalizations. When the hospitalization of a patient is unavoidable, their discharge is facilitated by the close cooperation with the psychiatric ward and this probably reduces length of hospital stay.

It should be noted that the average annual cost of ambulatory care plus hospitalization of patients with schizophrenia in Greece has been estimated to be 3.2-fold higher than the cost of outpatient treatment (Geitona et al., 2007). It might be argued that the treatment delivered by the MMHU I-T for patients with psychotic disorders could result in saving of costs and resources; however, this study is not a cost-effectiveness study thus such conclusions cannot be drawn. Future research with cost-effectiveness studies could address this issue.

Continuity of care is considered essential in the effective management of long-term mental disorders (Burns et al., 2009). Recent research has shown that the decline in continuing of mental health care over the years was associated with worse clinical outcomes in patients with schizophrenia (Macdonald et al., 2019). The MMHU I-T is efficient in engaging patients with schizophrenia-spectrum disorders to treatment, as demonstrated by a previous study. Over a 5-year period, as many as 67.2% of the referred patients were engaged to treatment (Peritogiannis et al., 2013). In another study, we have shown that older adult patients with schizophrenia spectrum disorders were more likely to receive treatment with regular domiciliary visits (Peritogiannis et al., 2016). The MMHU I-T has the potential to trace and treat homebound older adult patients with such disorders, who would otherwise remain untreated. This practice may facilitate continuity of care with subsequent reduction of psychiatric hospitalizations.

It should be noted that in several cases patients were referred to the MMHU I-T after an, often involuntary, hospitalization. In a recent large study, which examined 491,094 hospital discharges for 250,091 patients across a public mental health hospital system for 30 years, it was found that 50% of all observed readmissions occurred within less than 8 months. Diagnosis of schizophrenia was one of the major predictors of readmission (Shafer, 2019). Importantly, in the present study, the mean follow-up duration of patients was 5.3 years. It seems that in the case of the MMHU I-T the engagement of patients to community treatment after discharge accounted for the reduction of the re-hospitalizations. This is further supported by a recent nationwide retrospective cohort study in Japan that suggested that timely follow-up visits after discharge reduced the readmission risk in patients with severe mental disorders, such as schizophrenia and bipolar disorder (Okumura et al., 2018).

The reduction of involuntary admissions was also significant in the present study. After treatment engagement with the MMHU I-T involuntary admissions were reduced almost sixfold. This finding is important, given the detrimental effects of involuntary admissions to patients (Rusch et al., 2014). Notably, there is recent evidence that compulsory assessments and involuntary admissions have raised dramatically over the last years in Greece (Skokou et al., 2016). This notion makes the findings of this study even more relevant. A plausible explanation for this reduction is that with regular monitoring of a patient’s clinical condition, and the co-operation with family and local services, it would be possible to avoid admission. In cases that admission cannot be avoided, the MMHU I-T could refer the patient timely for voluntary hospitalization, before the aggravation of his or her condition that would require involuntary admission. This is further supported by a recent study in Athens, the capital of Greece, that suggested that previous contact with community mental health services yielded a protective effect against involuntary hospitalization (Stylianidis et al., 2017). Notably, a recent study in Germany assessed the effect of an ACT model on reducing involuntary admissions in patients with schizophrenia spectrum disorders attending an urban setting. Over the 4-year follow-up the rates of involuntary admissions decreased significantly (Schöttle et al., 2019).

The results of the present study are in line with a few previous reports in Greece. A previous study on the impact of a community mental health center on psychiatric hospitalizations in two areas in Athens showed a significant reduction in the number and days of hospitalization and a reduction in compulsory admissions. The authors suggested that medication monitoring, outreach, domiciliary care for patients in crisis, and day care were effective and robust principles of mental health services (Madianos & Economou, 1999). Such components of community mental health care are included in the comprehensive treatment by the MMHU I-T, and this probably accounts for the observed reduction of hospitalizations and length of hospital stay.

In the present study, there was a significant reduction of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders that were treated by the MMHU I-T. Community interventions for severe mental disorders may minimize the number of admissions, but it is rather unlikely to eliminate hospitalizations. The course of schizophrenia spectrum disorders is heterogeneous, and the outcome is rather poor for many patients (Jääskeläinen et al., 2015). Several patients may need to be acutely admitted in a psychiatric ward for the optimal management of a relapse thus community care cannot fully replace short-term inpatient care. This is in accordance with the balanced care model, which indicates that a comprehensive mental health system should include both community- and hospital-based components of care (Thornicroft & Tansella, 2013).

Strengths and limitations

This study involved patients with schizophrenia spectrum disorders that received care by a community mental health service in a rural setting. It adds to a very limited literature involving such settings. The sample of patients may be representative, as most patients referred to the MMHU I-T were engaged to treatment. Due to the long follow-up period, it was possible to assess the long-term effects of continuous treatment on patients’ hospitalization rates. The comparison of the number and days of hospitalizations in patients prior and after treatment engagement with the MMHU I-T presumably measures the treatment effects. However, the study has some limitations and the results should be interpreted with caution. A major limitation of the study is the lack of a control group of patients that receive other care. Therefore, a direct causal effect of the treatment on the reduction of hospitalizations cannot be established. Furthermore, some patients may have not engaged to treatment or may have not been referred to the MMHU I-T at all. Several cases of those ‘difficult to engage’ patients may have been repeatedly hospitalized. Indeed, such patients are eligible for ACT. It is known that CMHTs such as the MMHUs may not efficiently engage all psychotic patients, and that is the main argument for the introduction of the more specialized and intense ACT (Bonsack et al., 2005). Finally, the measurement of other aspects of patients’ outcome, such as psychopathology and functioning, were beyond the scope of this study. These issues have been recently addressed by other research by our team and results were encouraging (Peritogiannis et al., 2019; Peritogiannis & Nikolaou, 2020).

Implications for care

The implications of the MMHUs model of care should be discussed in the context of the rural setting. It is known that patients living in rural and remote areas may have limited access to mental health care due to lack of facilities and socioeconomic reasons (Thornicroft et al., 2011). MMHUs may overcome these barriers and may promote continuity of care due to their accessibility and their potential to perform domiciliary visits when needed. A potential limitation is that working in rural areas has several adversities for health professionals (Moore et al., 2010) and probably is a less favorable option for them, and this could result in inadequate staffing of rural mental health services.

The implications of such care should be also discussed in the context of the available funding and resources. The consequences of the financial crisis and austerity in Greece still affect the mental health system and impede psychiatric reform (Giannakopoulos & Anagnostopoulos, 2016). However, MMHUs in rural areas are low-cost services, because they deliver generic mental health services and they use the infrastructures and resources of the well-established primary health care system in those areas (Peritogiannis & Mavreas, 2014). Generic mental health services currently receive little research attention in most Western countries where research has been focused on highly resourced specialized care, such as the ACT. However, there is a controversy over the actual effectiveness of specialized mental health services, and there are arguments that the effectiveness of generic CMHTs may be comparable to the more specialized and highly-resourced ACT at much lower cost (Burns, 2010) Service cost and funding are currently important issues even in high-income Western countries (Docherty & Thornicroft, 2015), and certainly in Greece. This report points out the utility of generic mental health care delivery for patients with schizophrenia spectrum disorders as an alternative to more specialized care in cases of under-resourced rural settings.

Notably, in the COPSI study in India the collaborative community-based care plus facility-based care intervention was found to be modestly more effective than facility-based care for reducing disability and symptoms of psychosis. Importantly, the results showed that the study intervention was best implemented in settings where services are scarce, such as in rural areas (Chatterjee et al., 2014).

Conclusion

This study suggests that treatment of schizophrenia spectrum disorders in rural residents may be effective and feasible through the MMHUs. This model of mental health care delivery may contribute to the reduction of hospital admissions and length of hospital stay. The Greek state should ensure adequate funding and other resources for the MMHUs and even expand this care to most underserved areas.

Footnotes

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Vaios Peritogiannis

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