Use of Benzodiazepines and Antipsychotic Drugs Are Inversely Associated With Acute Readmission Risk in Schizophrenia.

PURPOSE: Little is known about the impact of different psychotropic drugs on acute readmission risk, when used concomitantly in a real-life setting. We aimed to investigate the association between acute readmission risk and use of antipsychotic drugs, antidepressants, mood stabilizers, and benzodiazepines in patients with schizophrenia. METHODS: A cohort study included all patients diagnosed with schizophrenia admitted to a psychiatric acute unit at Haukeland University Hospital in Bergen, Norway, during a 10-year period (N = 663). Patients were followed from discharge until first readmission or censoring. Cox multiple regression analyses were conducted using antipsychotic drugs, antidepressants, mood stabilizers, and benzodiazepines as time-dependent variables, and periods of use and nonuse were compared within individual patients. Adjustments were made for sex, age at index admission, and excessive use of alcohol and illicit substances. RESULTS: A total of 410 patients (61.8%) were readmitted during follow-up, and the mean and median times in days to readmission were 709 and 575, respectively. Compared with nonuse, the use of antipsychotic drugs was associated with reduced risk of readmission (adjusted hazards ratio, 0.20; P < 0.01; confidence interval, 0.16-0.24), and the use of benzodiazepines was associated with increased risk of readmission (adjusted hazards ratio, 1.51; P < 0.01; confidence interval, 1.13-2.02). However, no relation to readmission risk was found for the use of antidepressants and mood stabilizers. CONCLUSIONS: We found that use of benzodiazepines and antipsychotic drugs are inversely associated with acute readmission risk in schizophrenia.

Mortality and non-use of antipsychotic drugs after acute admission in schizophrenia: A prospective total-cohort study.

BACKGROUND: In society at large, it is debated whether use of antipsychotic drugs is associated with increased or decreased mortality among patients with schizophrenia. Large register studies have demonstrated an increased mortality risk associated with non-use of antipsychotic drugs, but prospective studies are missing. AIMS: To investigate the association between mortality and non-use of antipsychotics in patients with schizophrenia. METHOD: An open cohort study included and followed all patients with a discharge-diagnosis of schizophrenia consecutively admitted to a psychiatric acute unit at Haukeland University Hospital, Bergen, Norway during a 10 year period (n = 696). Cox multiple regression analyses were conducted with use of antipsychotic drugs as a time dependent variable, and periods of use and non-use were compared within individual patients. Adjustments were made for gender, age at index admission, number of acute psychiatric hospital admissions, excessive use of alcohol and illicit substances and use of benzodiazepines and antidepressants. RESULTS: A total of 68 (9.8%) deaths were registered during follow-up. Of these, 40 (59%) had natural causes, whereas 26 (38%) had unnatural causes. Non-use of antipsychotics was associated with 2.15 (p = .01, CI: 1.24-3.72) times higher mortality risk compared to use of antipsychotics. The difference in mortality risk between use and non-use of antipsychotic drugs was age dependent, with the largest risk difference in young patients. CONCLUSIONS: Non-use of antipsychotic drugs was associated with twofold increased mortality risk in patients with schizophrenia.

Suicidal and violent ideation in acute psychiatric inpatients: prevalence, co-occurrence, and associated characteristics.

OBJECTIVE: We studied the point prevalence of suicidal and violent ideation, as well as their co-occurrence and associated characteristics in inpatients with mental health disorders. METHODS: Data on suicidal and violent ideation, and sociodemographic and clinical information, were gathered from 1,737 patients when admitted to the acute psychiatric ward. RESULTS: The point prevalence was 51.9% for suicidal ideation and 19.8% for violent ideation. The point prevalence of co-occurring suicidal and violent ideation was 12.3%, which was significantly greater than expected by chance. Logistic regression analyses indicated that both suicidal and violent ideation were associated with young age and the absence of diagnoses of psychotic disorders; in addition, suicidal ideation was associated with female gender, violent ideation, and diagnoses of mood- neurotic and personality disorders, whereas violent ideation was associated with male gender, suicidal ideation, and diagnoses of mood and neurotic disorders. CONCLUSIONS: Overall, the findings highlight the need for further research on suicidal and violent ideation in people with mental health problems including, but not limited to, their association with adverse behavioral outcomes, as well as the need to routinely assess both suicidal and violent ideation in clinical practice.

Borderline Personality Disorder: What Predicts Acute Psychiatric Readmissions?

Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission.

Elderly patients with no previous psychiatric history: suicidality and other factors relating to psychiatric acute admissions.

BACKGROUND: The common recommendation that adults with onset of mental illness after the age of 65 should receive specialised psychogeriatric treatment is based on limited evidence. AIMS: To compare factors related to psychiatric acute admission in older adults who have no previous psychiatric history (NPH) with that of those who have a previous psychiatric history (PPH). METHOD: Cross-sectional cohort study of 918 patients aged ≥65 years consecutively admitted to a general adult psychiatric acute unit from 2005 to 2014. RESULTS: Patients in the NPH group (n = 526) were significantly older than those in the PPH group (n = 391) (77.6 v. 70.9 years P < 0.001), more likely to be men, married or widowed and admitted involuntarily. Diagnostic prevalence in the NPH and PPH groups were 49.0% v. 8.4% (P < 0.001) for organic mental disorders, 14.6% v. 30.4% (P < 0.001) for psychotic disorders, 30.2% v. 55.5% (P < 0.001) for affective disorders and 20.7% v. 13.3% (P = 0.003) for somatic disorders. The NPH group scored significantly higher on the Health of the Nation Outcome Scale (HoNOS) items agitated behaviour; cognitive problems; physical illness or disability and problems with activities of daily living, whereas those in the PPH group scored significantly higher on depressed mood. Although the PPH group were more likely to report suicidal ideation, those in the NPH group were more likely to have made a suicide attempt before the admission. CONCLUSIONS: Among psychiatric patients >65 years, the subgroup with NPH were characterised by more physical frailty, somatic comorbidity and functional and cognitive impairment as well as higher rates of preadmission suicide attempts. Admitting facilities should be appropriately suited to manage their needs.

Supported accommodation for people with schizophrenia.

Background: As a result of deinstitutionalization of psychiatric treatment and care, many people with severe mental illness have been offered supported accommodation. However, research on this costly intervention in Norway has been scarce. Aims: The aim of this study was to prospectively investigate the clinical and demographic factors associated with allocation to supported accommodation for people with schizophrenia. Methods: The study was a prospective cohort study of 334 people with schizophrenia acutely admitted to Haukeland University Hospital between 2005 and 2010. Information concerning allocation to supported accommodation in their residential municipalities was collected retrospectively. Univariate and multivariate statistical methods were used to assess the association of clinical and demographical variables with allocation to supported accommodation. Results: Supported accommodation was allocated to 29.6% of the participants during the study period. Age, gender, implementation of compulsory mental health care, substance abuse, symptom burden and suicidality were not associated with allocation to supported accommodation. Functional impairment, especially difficulties with activities of daily living, experiencing exacerbation in the course of chronic disease, being medicated and of Norwegian origin, favoured supported accommodation. Conclusions: Our results supported the hypothesis that people with severe mental illness presenting the greatest need for supported accommodation, based on functional difficulties and exacerbation of chronic disease were allocated supported accommodation. Symptom burden was not associated with allocation. Clinical implications: Further research is needed to examine the impact of supported accommodation on the outcomes for people with schizophrenia.

Borderline Personality Disorder and Posttraumatic Stress Disorder at Psychiatric Discharge Predict General Hospital Admission for Self-Harm.

We investigated whether posttraumatic stress disorder (PTSD) was predictor of suicidal behavior even when adjusting for comorbid borderline personality disorder (BPD) and other salient risk factors. To study this, we randomly selected 308 patients admitted to a psychiatric hospital because of suicide risk. Baseline interviews were performed within the first days of the stay. Information concerning the number of self-harm admissions to general hospitals over the subsequent 6 months was retrieved through linkage with the regional hospital registers. A censored regression analysis of hospital admissions for self-harm indicated significant associations with both PTSD (ß = .21, p < .001) and BPD (ß = .27, p < .001). A structural model comprising two latent BPD factors, dysregulation and relationship problems, as well as PTSD and several other variables, demonstrated that PTSD was an important predictor of the number of self-harm admissions to general hospitals(B = 1.52, p < .01). Dysregulation predicted self-harm directly (B = 0.28, p < .05), and also through PTSD [corrected]. These results suggested that PTSD and related dysregulation problems could be important treatment targets for a reduction in the risk of severe self-harm in high-risk psychiatric patients.

Time to discontinuation of antipsychotic drugs in a schizophrenia cohort: influence of current treatment strategies.

BACKGROUND: Rates of discontinuation of antipsychotic treatment for patients with schizophrenia are high and evidence is limited by selective inclusion and high attrition in randomized controlled trials. AIMS: To study time to discontinuation of antipsychotic treatment for patients with schizophrenia. METHOD: All patients with schizophrenia (n = 396) discharged between 2005 and 2011 were followed until discontinuation (clinician or patient decided) of antipsychotic treatment or other endpoints. Univariate and multivariate survival analyses (with time on antipsychotic treatment as the dependent variable) using time-dependent variables were performed. RESULTS: Clozapine displayed lower risk for all-cause (p < 0.001), clinician-decided (p = 0.012) and patient-decided (p = 0.039) discontinuation versus olanzapine oral treatment in the multivariate Cox regression. Second-generation long-acting injection antipsychotics (LAI) (p = 0.015) and first-generation long-acting injection antipsychotics (p = 0.013) showed significantly lower risks for patient-decided discontinuation than olanzapine oral. CONCLUSION: Higher effectiveness of clozapine and LAI treatment versus oral olanzapine were identified in a clinical cohort of patients with schizophrenia.

The suicide assessment scale: psychometric properties of a Norwegian language version.

BACKGROUND: Rating scales are valuable tools in suicide research and can also be useful supplements to the clinical interview in suicide risk assessments. This study describes the psychometric properties of a Norwegian language version of the Suicide Assessment Scale Self-report version (SUAS-S). METHODS: Participants were fifty-two patients (mean age = 39.3 years, SD = 10.7) with major depression (53.8%), bipolar disorder (25.0%) and/or a personality disorder (63.5%) referred to a psychiatric outpatient clinic. The SUAS-S, the screening section of the Beck Scale for Suicidal Ideation (BSS-5), the Beck Depression Inventory (BDI), Beck's Hopelessness Scale (BHS), the Symptom Check-List-90 R (SCL-90R) and the Clinical Global Impression for Severity of Suicidality (CGI-SS) were administered. One week later, the patients completed the SUAS-S a second time. RESULTS: Cronbach's alpha for SUAS-S was 0.88 and the test-retest reliability was 0.95 (95% CI: 0.93- 0.97). SUAS-S was positively correlated with the BSS-5 (r = 0.66; 95% CI: 0.47-0.85) for the study sample as a whole and for the suicidal (r = 0.52) and non-suicidal groups (r = 0.50) respectively. There was no difference between the SUAS-S and the BSS-5 in the ability to identify suicidality. This ability was more pronounced when the suicide risk was high. There was a substantial intercorrelation between the score on the SUAS-S and the BDI (0.81) and the BHS (0.76). The sensitivity and specificity of the SUAS-S was explored and an appropriate clinical cut-off value was assessed. CONCLUSIONS: The study revealed good internal consistency, test-retest reliability and concurrent validity for the Suicide Assessment Scale Self-report version. The discriminatory ability for suicidality was comparable to that of the BSS-5.

Admissions to a Norwegian emergency psychiatric ward: patient characteristics and referring agents. A prospective study.

BACKGROUND: In Norway, general practitioners serve as gatekeepers for specialist psychiatric care. Out-of-hours primary healthcare (i.e. casualty clinics) is responsible for the major part of acute psychiatric referrals. There are concerns regarding regular general practitioners' (rGPs') role in emergency psychiatric care of their enlisted patients. Also, the quality of casualty clinics' care and their gatekeeper function are questioned. AIMS: To investigate differences between acute admissions to a psychiatric hospital from casualty clinics, rGPs, specialist psychiatric services and other specialist services regarding characteristics of patients and circumstances of the referrals. METHODS: A prospective observational study. In the period of 1 May 2005 to 30 April 2008, anonymous information was recorded for all consecutive admissions (n = 5317) to the psychiatric acute unit (PAU) at a psychiatric hospital serving 400,000 inhabitants. The recorded information was: referring agent, circumstances of the referral, patient characteristics, and assessments by the receiving psychiatric resident and the therapist in charge of treatment at the PAU. RESULTS: There were only small differences between patients referred to PAU from casualty clinics, rGPs, specialist psychiatric services and other specialist services. The referrals from the different referring agents seemed equally well founded. However, the casualty clinics used more police assistance and coercion, and legal basis for admissions was more frequently converted than for other referring agents. CONCLUSION: Casualty clinics seem to function adequately as gatekeepers. The high proportion of casualty clinic referrals with converted legal basis might indicate unnecessary use of coercion.

Cardiovascular risk in patients admitted for psychosis compared with findings from a population-based study.

BACKGROUND: Schizophrenia and related psychoses are associated with excess morbidity and mortality from cardiovascular disease (CVD). Single-site studies on CVD-related risk factors in representative samples of acutely admitted inpatients are scarce. AIMS: To assess the levels of risk factors related to CVD in patients acutely admitted to hospital for symptoms of psychosis. METHODS: Eligible patients aged 18-65 years were included consecutively in the Bergen Psychosis Project (BPP). CVD-related risk factors were recorded at admittance and at discharge or after 6 weeks at the latest. The recordings of 218 patients with psychosis (BPP) were compared with the findings of 50,219 subjects from the population-based Nord-Trøndelag Health Study 1995-97 (HUNT2) survey. RESULTS: Diastolic blood pressures were higher for BPP women and men, whereas body mass indexes (BMIs) and total cholesterol levels were higher in HUNT2 women and men. On categorical measures, smoking was more prevalent in the patients compared with the HUNT2 subjects. Metabolic syndrome was present in 11.8% and 21.9% of BPP women and men, respectively. At discharge or 6 weeks from admission, 3.2% and 18.6% of BPP women and men, respectively, had metabolic syndrome. BMIs and total cholesterol levels had worsened during the inpatient treatment period. Only one patient had a diagnosis corresponding to the CVD risk found, and only four patients received antidiabetics, antihypertensives or lipid-lowering drugs. CONCLUSIONS: Some CVD-related risk factors were high in the patients at admission, some worsened and CVD risk factors seem to be suboptimally addressed, which should warrant increased awareness on the topic in clinical practice.

Suicide risk and acute psychiatric readmissions: a prospective cohort study.

OBJECTIVE: The objective was to improve knowledge of the role and functioning of psychiatric acute wards with respect to admissions because of suicide risk and factors associated with readmission. METHODS: Over one year, 1,245 consecutive psychiatric patients from a Norwegian catchment area were included at index admission and reassessed in cases of readmission. After a mean follow-up period of 562 days, a total of 1,234 readmissions were assessed. Time from discharge to readmission was analyzed with univariate and multivariate Cox regression analyses. Outcome variables included acute readmissions and readmissions for suicide risk. RESULTS: Fifty-four percent of the index admissions and 62% of the readmissions were related to suicide risk. Substance use disorders, personality disorders, prior psychiatric hospitalization, unemployment, and receipt of social benefits were significant predictors of any readmissions and readmissions because of suicide risk. At index admission suicidal ideation or suicide plans significantly predicted readmission because of suicide risk. A small subgroup of patients contributed disproportionately to the number of readmissions. A higher number of readmissions per individual patient was associated with greater tendency of admission because of suicide risk. CONCLUSIONS: The acute ward played an important role for patients with suicidal behavior. Care providers and clinicians should focus on staff training and supervision with regard to assessment and management of suicidal patients. Collaboration with referring physicians and aftercare providers is also important to help patients gain constructive coping strategies and break patterns of suicidal behavior and readmission.

Aggression on a psychiatric acute ward: a three-year prospective study.

The objectives of this 3-yr. prospective study of aggression on a Norwegian psychiatric acute ward serving a population of 170,000 were to monitor the rate and characteristics of aggressive behaviour, to identify possible interactional and situational precipitants to aggression, and to explore possible differences between aggressive and nonaggressive patients in terms of diagnosis, sex, age, numbers of admissions, admission type, and length of stay. Aggressive incidents were recorded on the Report Form for Aggressive Episodes (REFA). Severity of injuries was scored according to Fottrell's severity scale. Of the total 934 patients admitted, 98 (10.5%) accounted for a total of 981 aggressive episodes. About 55% of the aggressive incidents were assaults that resulted in 85 minor and 21 severe physical injuries. There was no evidence that diagnosis might be used to predict aggression in the clinical setting. Mean rate of admission per patient and length of stay was significantly higher in the aggressive group than in the nonaggressive group. However, several patients in the aggressive group also had admissions without being aggressive. About 13% of the aggressive patients accounted for nearly 50% of the aggressive incidents. There was no significant sex difference by total rate of aggression, but female patients tended to have higher rates of assaults and contributed to significantly more injuries than male patients. Nearly 20% of the aggressive episodes occurred during the first 24 hours of a stay and 54% during the first week. Limit setting, problems in communication, and physical contact, separately or in combinations, preceded nearly 90% of the aggressive episodes.