I was going to ask the same question, effectiveness for what? I think you'd get different answers if the outcomes you were interested in was stabilization or symptom reduction vs. long-term functioning or adjustment. 

Hi Becca

Hope things are good - I have poked around this area a little - and found very little as you might imagine. Here are some papers that lay out some of what I found 

Best

Sean

http://link.springer.com/article/10.1007/s10488-015-0696-z

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079144/

The best argument for their serving a useful societal function is that now we have shut the asylums we find we have to use the prisons instead.

I'm looking to see any evidence comparing hospitalization with other modalities. Outcomes generally would be subjective improvements in mental health and improvements in quality of life. Safety is a large part of it...but do we have data that confirms that hospitalization is the most effective option?

Thank you Sean! Will check out those papers.

Rebecca,

In my PhD-study (1984) hospitalization was not the most effective option in the majority of patients. We have developed admission preventive strategies that significantly reduced the admission rates without reduction in clinical effectiveness.

Some studies have found that admission of suicidal patients is no more effective in preventing death than adequate intense home treatment. Except for psychotic suicidal patients .Also, it has been found that hospital admission doesn't significantly reduce the burden on the family. However, compulsive admission will remain needed for some patients. However, with proper interventions compulsion can be prevented in quite swome cases with specific interventions. Admission prevention can help to  reduce the stigma of psychiatric hospitalization. Please keep in mind that these results strongly depend on the quality of hospital and out-patient care.

Capdevielle D, Ritchie K: The long and the short of it: are shorter periods of hospital- ization beneficial? British Journal of Psychiatry 192:164–165, 2008

As many of the commenters above indicate, the literature pertaining to this question is sparse. The reference above supports the notion that longer hospitalizations  in early phases of schizophrenia may be associated with better outcomes than shorter stays.

Despite the paucity of the literature, very few psychiatrists would argue against the idea that there is a certain subgroup of patients who present to emergency departments and other sites with acute psychosis, severe suicidality, or other forms of severely regressive behavior who require the safety and security of a hospital environment for some period of time.  In fact, in the event of an adverse outcome, failure to recognize the need to hospitalize such a patient is a common litigation issue with hospitals and physicians. 

Thanks Michael, look forward to reading the article.

I wonder about, even in that subgroup of people you identified, if there are other interventions that might be addressed in settings other than hospitals. My concern is we have defaulted to hospitals without necessarily testing and comparing alternatives. Agreed that litigation and liability play a big role.

Thank you, Swapnil and Rebecca, for pointing out the need to look at alternatives to hospitalization for many patients, even for a portion of those that I somewhat arbitrarily highlighted.  We need to be careful that these alternatives are driven by good studies and attention to safety concerns and are not just a response to third party payor demands. As an inpatient psychiatrist at a large university hospital, my personal opinion remains that even with efforts at reduction in hospital utilization and efforts at diversion to other semi-structured settings,  there will be a subset of patients for whom inpatient care is indicated. 

Per APA guidelines and EBR, inpt hospitalization is not recommended, nor is it particularly effective, for those suffering from Borderline Personality Disorders. If it happens for reasons of safety it should be brief and followed up by a robust plan of Partial Hospitalization or outpt tx.

I have seen no evidence of the effectiveness of hospitalization. The use of this tool senses mostly limited to safety concerns - suicide, homocide.But the situations vary, and I think it would be harder than most assume to evaluate the outcomes of hospitalizations. I will watch this question for references. The collaborative study of depression in which about 90% of patients were hospitalized at Rush, Harvard, St. Louis, Iowa, and Columbia had a suicde rate of 3.6% over 10 years, 13.6 % of the follow up sample suicided in the first year of follow-up - showing the oft repeated finding of elevated rates of suicide in the year following hospital discharge. Jan Fawcett,et al, Am J Psychiatry, 1990. Jan Fawcett

This is an important discussion. 

I wonder if the problem is not so much that acute hospitalization is less effective, because it likely is in many cases,  but rather that there are no alternatives.  We frequently house adolescents in our ED for days as respite for their family simply because there are no alternatives.  When we admit a person with dementia (not a condition we are set up to treat in our IP psychiatric unit) they may stay for months for the same reason.  Our state hospital system is unable to support the needs.. It could take months to find a psychiatrist/ nurse practitioner who will take on new patients in the community.   Even if the hospitalization was helpful, there may be no transition of care but only a discharge to their own resources and the cycle continues..

Acute hospitalization may not the best practice in all cases, but it's often the only intervention,   There may be a Mental Health Parity and Addiction Equity Act in the US, but it seems that society and policy leaders continue to support the treatment of medical conditions with more enthusiasm.  Expanding our current knowledge about efficacy of hospitalization with solid research may be a good tool to use in informing reform leaders to explore alternatives.  Sounds like you have an opportunity Rebecca. 

The challenge of creating and then finding evidence is multifactorial: the small amount of research funding on inpatient care, the privacy barriers around mental health treatment, the limited ability to have capacity to consent at admission due to the nature of brain illnesses, the fact that MH services used to be a much larger percent of healthcare spending then they are now even though the prevalence of mental illness has not decreased. So the % of dollars devoted to mental health are lower.

According to SAMHSA, 42% of mental health care dollars went to inpt care in 1986 while only 19% went to inpatient care in 2005. Prescription drugs went from 7% to 27% of the MH budget. Outpatient went from 24 to 33% during the same time period.

Recent attention noted that as the number of inpatient psych beds went from 207 per 100,000 in 1970 to 21 beds per 100,000 in 2000 the rate of suicide in the population has increased. (Yoon J and Bruckner TA Does deinstitutionalization increase suicide? 2009) The number of beds has continued to rapidly decline despite long waiting list times, people being stacked up in emergency departments and shorter lengths of stay. Doris Fuller Chief of Research and Public Affairs at the Treatment Advocacy Center notes evidence of a link between fewer inpt beds, shorter length of stay and higher suicide rates.

The US mental health system is broken.

Fifty years of systematically limiting access to treatment for mental illnesses such as schizophrenia and severe bipolar disorder have left countless individuals and families with nowhere to turn when a loved one needs care.

The system is dysfunctional from top to bottom.

At the federal level, 50 years of treating mentally ill adults separately and unequally have left countless individuals with serious mental illness without access to treatment or hope for recovery.

At the state level, outdated laws too often restrict access to treatment until people become dangerous to themselves or others, while state hospital beds have been eliminated almost to the point of extinction.

At the county level, half the counties in the United States do not have a single mental health professional within them, much less one of the community mental health centers meant to replace the state psychiatric hospitals of the 1950s.

The human and economic cost of this neglect has been catastrophic. People with the most severe psychiatric diseases make up barely 3% of the total population, of the total population, but are vastly more likely to be arrested, incarcerated, homeless or unemployed. Treatment Advocacy Center Fixing the system

Driven by financial pressures, the sole focus of psychiatric inpatient treatment has become safety and crisis stabilization. Data are lacking on outcomes of ultra-shortstay hospitalizations; however, such stays may diminish opportunities for a sustained recovery. In the absence of an evidence base to guide clinicians and  policy makers, mental health professionals have an ethical obligation to promote what they consider to be best practice. This Open Forum focuses on the need to reconsider the current model of inpatient hospitalization in order to maximize positive outcomes and emphasize appropriate transition to the community and less intensive levels of care. A model of care is presented based on rapid formulation of diagnosis, goals, and treatment modalities before treatment begins. Three phases are  described—assessment, implementation, and resolution—with specific principles to guidelength-of-stay decisions and requirements for staffing. (Psychiatric Services 62:206–209, 2011)

Some References:

Centers for Disease Control and Prevention. (April 2016.) Increase in suicide in the United States, 1999-2014.

Fuller DA et al. (June 2016). Going, going, gone: Trends and consequences of eliminating state psychiatric beds, 2016. Treatment Advocacy Center.

Yoon, J. and T. Bruckner. (August 2009). Does deinstitutionalization increase suicide? Health Services Research.

Huntley, DA et al. (1998). Predicting length of stay in an acute psychiatric hospital. Psychiatric Services.

Glick, ID et al. (2011). Inpatient psychiatric care in the 21st century: The need for reform. Psychiatric Services.

Goldacre, M. (1993). Suicide after discharge from psychiatric inpatient care. The Lancet.

Osby U. et al. (August 2000). Time trends in schizophrenia mortality in Stockholm County, Sweden: Cohort study. British Journal of Medicine. 

I tend to think that asking the question as if 'hospitalization' was a thing in itself that is clearly defined and independent of context is problematic. First, the issue of admitting a patient is always situated in a context, and context varies not only between countries but within the same country as well. Second, a lot depends on what happens in the hospital, which depends on the institution's own context, history and traditions, the staff, and the patients. An encounter with a competent healthcare team and the possibility of experiencing benevolent care can make a huge difference, and this, I would argue, whatever the diagnosis is, including "borderline personality disorder" (isn't it ironic that these very patients who are suffering from feeling and being rejected constantly end up in inpatient units where the staff is convinced that they should go away asap?...). And with a bit of luck, one may make very significant encounters with other patients as well. I am late to this conversation, so I have the opportunity to wish you all a happy new year...

"I have seen no evidence of the effectiveness of hospitalization. The use of this tool senses mostly limited to safety concerns - suicide, homicide. But the situations vary"

I think the major criterion of effectiveness should be the opinions of families.   The UK press is always full of stories of families and patients begging admission to places of safety, only to be refused with tragic consequences.  I think there should be an absolute right to request inpatient admission for the mentally ill. 

Normally, I would always rely on empirical research over subjective experience in psychiatry.  However, the facts of this case (and many other similar ones) speak for themselves  (Why was he let out, ask family of mental patient killed by train? Evening Standard Jan 4th 2017 p29):

"... he was hearing voices and was considering jumping in front of a train.  He was said to have been assessed as 'high risk' and admitted for care.  But on the [next]...morning he told staff he was feeling better and was granted leave.  He returned briefly to the unit that evening and maintained he was feeling fine.  It was agreed he would return for a review with a consultant in the morning.  He did not return and was found dead at the station."

**********************************************************

Comment: The reason he was let out is clear, it was because he asked to be. It was assumed his judgement was not impaired by his psychosis.  Is there not a case for "approved" relatives to have an absolute right to insist on temporary institutional admission?  

Yes. I recommend this article from JAMA for a good evidence-based answer (attached)

Evidence of interventions depends on their goals. What is the target? Selfdestruction and suicide need protective interventions. These may be given outsife as well as inside hospitals. This measn that only in some cases, but not all, hospitalization may be effective. Its effectiveness depends on means, ward climate, and specialized staff. If these are sub-optimal hospitalization may increase suicide-risk.

Civil commitment may be needed to protect others. However, not all cases do need psychiatric hospitalisation. Calculating the effectiveness of this intervention is problematic because of the base rate expectancy and the definitions of mental illness as well as dangerousnessdue to mental illness.

Given an adequate organisation of out-side care most treatment interventions if not all can beproperly given ouside as good as inside hospitals. Comparing their out-patient psychiatric care need for hospitalisation will be more in the USA than in The Netherlands. Sufficient personnel trained in psycho-socual interventions such as CBT, HIT or ACT may decrease the need for hospitalisation. In cases of trained staff hospitalisation may be seen as forms of neglect.

Let me finish with a case I have written inmy book on directive problemsolving therapies as the queen of the ward. This patiënt was hospitalized once to twice a year because depressive and suicidal symptoms. She always demanded and got a single room. When admitted she refused any treatment to the despaire of staff. Due to ilness of her psychiatrist she was referred to my outpatient facility. During the psychiatric examination her symptoms increased. For this interesting phenomenon I decided to start a hypercongruent approach. I excuses myself for not having given sufficient attention to her complaints and offered her an admission in an olsfashioned hospital with following advances in her special case.(1) Akthough most patients regret that single rooms are absent and the food is overcooked in your case this may be seen as an advantage. (2)The department had at least six beds per ward hence other patients could alarm staff if needed an staff was absent. (3) Although the food quality is far from perfect in your case this a minor problem because as you mentioned your appetite have gone (her BM! was >30). After few time she started to convince me that her symptoms were far less than I though, that she could take good care of herself. I was persuaded under the condition that she called me daily to inform me about her daily activities and suicide intention. These improved daily. One may conclude that desolation and loneliness fitted her symptoms better than depression and suicide. Hence, an intensive outpatient programme was started and hospitalization was no more needed till she died because of age. Hospitalisation in this case had induced a wrong selective reinforcement cycle that improved her need for hospitalization.

Conclusion: At present, the question cannot be scientifically answered. In the absence of context variables research results are questionable

Best Rebecca,

I fully agree with Humberto - this is a most interesting question!

I have tried to find studies made in Sweden on the experienced effect of in-care and coercive psychiatric care in my homecountry Sweden and found that NOTHING is done in this matter.

This theme will therefore form one of the themes of my post doc studies at Karolinska Institutet.

Maybe we could do something together?

Best regards,

Pontus Höglund

I think it is essential to control for people with and without anosognosia about their illness. Those who have anosognosia end up with compulsory treatment in most instances I am familiar with. The group of people who know they are ill are much more amenable to treatment then those with the neurological impairments preventing such insight. If one studies only those who have insight into being ill and the effects of their illness on their life even when ill, the results will not likely be generalizable in any way to the group with anosognosia.

There are many studies and descriptions but here is one.

Lehrer DS, Lorenz J. Anosognosia in Schizophrenia: Hidden in Plain Sight. Innovations in Clinical Neuroscience. 2014;11(5-6):10-17.

This is one of those areas where, one's clinical experience is much influenced by where one treats people. When one works at a state mental hospital in the US it is a very different group of patients then one sees in a suburban or urban outpatient clinic...

Perhaps the way to look at this is to ask: What happens when asylums and inpatient facilities are shut down? One only has to wander the streets of London to see the unfortunate results of this.

Such thoughtful and varied answers - thank you to all who responded. I am still thinking on this question and tend to agree with Michael Polacek regarding the lack of alternatives making the question truly hard to answer in any empirical kind of way.

I am interested in the idea raised about people saying they feel ok and being released, then coming to harm either via themselves or otherwise. I worry that focusing on these few instances as representative can be utilized to take away rights from those who might really be ok...and thinking about the lack of intermediate options --- hospital ----> living alone is a huge jump and if there could be flexible supports (live in companion, respite, etc), perhaps a person would feel more comfortable, and the continuum would support better timed transitions, as opposed to people feeling oppressed in hospitals, desperate to get out and regain some freedom even if they are not totally ready psychologically.

Very much appreciate the thoughts people contributed and hope to hear more.

Jack Jenner - would love to see your dissertation, could you add the reference to this thread? I will also backchannel you.

Maureen Nash - thank you for bringing up the question of anosognosia. I struggle with that term and the concept of insight. I work in public mental health and with people who conceptualize their experiences differently than an illness. I'm not sure that the right question is "insight or no insight", but think of it more from a disability stance of "what accommodations can we work on to help this person live the life they want?". Sidestepping the question can reframe the issue and sometimes seems to help think differently about what interventions/support is needed or helpful. I would be curious what your thoughts are on this.

Any data on reduced suicide rates in patients hospitalized for ' x " weeks vs those with equal severity of depression not hospitalizedave not been able to find such a study.I

Helton - just rereading the article you posted and wwondered about correlation vs causation. I wondervwhat other social factors would contribute to this increase in rates of suicide like breakdiwn of social an community support poverty and unemployment etc.

If you read people's open-ended answers in our paper, at least some people think there is a great advantage with treatment in hospitals:

Beatrice -thank you for posting the paper, very interesting findings. It is interesting to see what the lay public thinks about the need for hospitalization and an increase in hospital beds. I suggest though that there is a lack of alternatives that are 1. available in a widespread way and 2. that the public is familiar with.

Reasking the question - is there any recent research out there that points to evidence for inpatient hospitalization?

I think you will find that the answer is no. As others have pointed out you are only likely to find that for some groups it makes things worse. So hospitalisation is the great non-evidence based and expensive behemoth. I have always found it intriguing when people assert that a person needs hospitalisation. No they don't... It isn't on Maslow's hierarchy. A better question might be framed as 'What and whose needs are met through hospitalisation?'. There may be an immediate need for safety, shelter etc... And the social system might need a break or wish to satisfy it's need for safety through deference to authority etc etc. The other epistemological issue is that hospitalisation is not treatment... never was... never will be. As it isn't, it is not going to be researched and evaluated like treatments... One could also say the same thing about referral to different health professionals... Is there any evidence that seeing a psychiatrist improves outcomes? No... not that I'm aware of. Hospital might be a conduit to treatment... sadly rarely. It is expensive. A day or two in hospital could easily pay for months of psychotherapy which people are rarely offered. Indeed one might argue that we spend an absurd amount of money hospitalising people rather that providing treatments. I totally agree with you Rebecca... we do need alternatives... See Mosher's work on Soteria. The outcomes were better than hospitalisation but evidence does not drive public policy.

My article in Advances in Medical Sociology reviews relevant research, in historical context. Hope you find it of value.

You may want to consider the following:

a. Quality of Inpatient Psychiatric Care and Consumers’ Trust in the Mental Health Care System

Morgan C. Shields, M.Sc., Christina P. C. Borba, Ph.D., M.P.H., and Nhi-Ha T. Trinh, M.D., M.P.H.Published Online:1 Jun 2017 https://doi.org/10.1176/appi.ps.201600508

b. Rose, D. Participatory research: real or imagined. Soc Psychiatry Psychiatr Epidemiol 53, 765–771 (2018). https://doi.org/10.1007/s00127-018-1549-3

Hi Rebecca,

If you haven't already seen these...

In-patient rehabilitation: clinical outcomes and cost implications

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/2C0B7D6D3E7EB5DC48B87BE7E7398BD4/S2056469400001376a.pdf/inpatient_rehabilitation_clinical_outcomes_and_cost_implications.pdf

Evaluating outcomes in an adult inpatient psychiatric rehabilitation unit

Article Evaluating outcomes in an adult inpatient psychiatric rehabi...