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Ir Med J. 2009 May;102(5):137-8.
In 2008, the Inspector of Mental Health Services1 reported that “a significant number of local health areas continued to provide acute care in admission units in large psychiatric hospitals” and called for these to be “closed”. This idea was originally championed in Ireland by Dr Conolly Norman (1853-1908), resident medical superintendent of Grangegorman District Asylum (now St Brendan’s Hospital), who regarded “asylums” as “necessary and inevitable” but outlined “a great many objections” against them, including the risk of institutionalisation, the psychological and social distance between institutional inpatients and the general population, and difficulties with re-integration into broader society2. The move towards acute psychiatric units in general hospitals was recommended by the Commission of Enquiry on Mental Illness in 19663,4 and further emphasized in The Psychiatric Services - Planning For the Future5,6 which stated that “the provision of in-patient psychiatric services at general hospitals is accepted in most western countries”5. Planning for the Future recommended this policy be progressed in Ireland too and outlined seven distinct benefits it offered:
1. It brings to an end the isolation which has been so damaging to the concept and the practice of modern psychiatry;
2. It recognises psychiatry as a medical specialty to the advantage of both psychiatry and other areas of medical practice – in particular, it improves the treatment facilities in the many cases in which mental illness has a physical as well as a psychiatric basis;
3. It makes psychiatric treatment more acceptable to those who need it;
4. It increases the attractiveness of a career in psychiatry with consequential benefits in the recruitment of staff of a high calibre;
5. It brings psychiatric nurses into a closer working relationship with general nurses to their mutual advantage;
6. It enhances the development of specialist psychiatric out-patient care by linking it to the out-patient facilities which are already available for other specialties at the general hospital;
7. It makes long-term economic sense by enabling the psychiatric in-patient unit to share services and facilities at the general hospital5.
The first psychiatric unit at a general hospital in Ireland was established in Waterford in the mid-1960s and by the time Planning for the Future was published in 1984 there were already psychiatric units at ten general hospitals5. In 1981, the annual census of psychiatric inpatients revealed that only 2.7% of psychiatric inpatients were in psychiatric units at general hospitals as opposed to psychiatric hospitals; ten years later, in 1991, this had risen to a mere 4.4%3. By 1992, however, several more psychiatric units had been established at general hospitals3, ranging in size from 51 beds (St James’s Hospital, Dublin) to 22 beds (James Connolly Memorial Hospital, Blanchardstown and St Vincent’s Hospital, Elm Park, Dublin)7.
Over the past three decades, a number of studies have examined the effects of the establishment of psychiatric units in general hospitals in terms of length of stay, levels of medication prescription, levels of aggression, rates of involuntary admission and patients’ perception of stigma. O’Beirne and Fahy8, for example, reported that eleven years after the establishment of a new psychiatric unit at Galway Regional Hospital (in 1976), length of stay had become “very brief”, averaging at one month. In addition, the establishment of the new unit was associated with a substantial increase in “extra-mural activities” (such as day hospital care) and expansion of community facilities (such as day centres, hostels and out-patient clinics).
McGennis7 surveyed the medical directors of twelve psychiatric units in general hospitals and concluded that “the picture given of general hospital units in Ireland is a very encouraging one as it shows that the units are operating in a largely self-sufficient way”. Most significantly, length of stay had been reduced following the establishment of the new units: by 1988, 77.4% of patients admitted to general hospital units stayed for less than one month and only 2.2% stayed for more than three months; 0% remained as inpatients for more than one year, compared to 6.8% in old psychiatric hospitals9. There was, however a significant difference between Dublin and the rest of the country: in 1990, only 14% of psychiatric admissions in Dublin were to general hospital units, compared to 35% for the rest of the country7. More recently, Feeney et al10 provided further evidence to support the development of psychiatric units at general hospitals in Ireland, reporting that movement of inpatient facilities from an old psychiatric hospital setting to a new unit at a general hospital resulted in reduced levels of aggression (p=0.001), reduced levels of benzodiazepine prescription (p=0.003) and reduced numbers of patients leaving hospital against medical advice (p=0.027). There were also trends towards reduced antipsychotic prescribing, and reduced rates of involuntary admission, admission of intoxicated individuals and abuse of intoxicants by inpatients.
The location of new units at general hospitals appears to offer especially important benefits in terms of stigma. Lyons et al11 studied patients’ attitudes to the relocation of admission facilities from a general hospital setting to a new unit on the grounds of an old psychiatric hospital in the United Kingdom. Sixty-one per cent of inpatients felt that treatment at the general hospital was less stigmatising than treatment in a unit on the grounds of an old psychiatric hospital. Fifty-eight per cent felt that the stigma associated with the new unit was purely attributable to its location on the grounds of the old psychiatric hospital, and only a minority felt that any benefits associated with a new unit could possibly outweigh the stigma associated with a move back to the grounds of the old psychiatric hospital.
Overall, the four decades since the establishment of Ireland’s first general hospital psychiatric unit in Waterford have seen significant progress with the relocation of admission facilities from old psychiatric hospitals to general hospitals12,13: by 2006, there were twenty-two psychiatric units located at general hospitals in Ireland13. Also in 2006, the Department of Health and Children re-affirmed it’s commitment to this policy in A Vision for Change14,15 which recognized “the provision of a high-quality acute in-patient unit based in a general hospital” as “an important element of a community-based mental health service” and recommended that “a plan to bring about the closure of all mental hospitals should be drawn up and implemented”. There is now a critical body of evidence to support this policy in Ireland, demonstrating clearly that the relocation of admission facilities to general hospitals results in reduced length of stay, reduced need for medication, reduced levels of aggression, and – most importantly – a substantial reduction in stigma experienced by individuals with mental illness. It is to be hoped that policy-makers can see their way to pursuing this policy with the dedication and determination it so clearly merits, so that mental health service-users and their families are no longer denied the substantial, evidence-based, patient-centred benefits offered by inpatient treatment in psychiatric units located at general hospitals.
D Pillay, BD Kelly
Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, Eccles Street, Dublin 7
Tel: +353 1 803 4474
Fax: +353 1 830 9323
Email: [email protected]
References
1. Inspector of Mental Health Services. Report of the Inspector of Mental Health Services 2007. Dublin: Mental Health Commission, 2008.
2. Norman C. On the need for family care of persons of unsound mind in Ireland. Journal of Mental Science 1904; 50:461-73.
3. Walsh D. General hospital psychiatric units in Ireland. Irish Journal of Psychiatry 1992; 13: 6-11.
4. O’Neill A-M. Irish Mental Health Law. Dublin: First Law Limited, 2005.
5. Department of Health. The Psychiatric Services - Planning For the Future. Dublin: The Stationery Office, 1984.
6. Kelly BD. Mental health policy in Ireland, 1984-2004: theory, overview and future directions. Irish Journal of Psychological Medicine 2004; 21: 61-8
7. McGennis A. Psychiatric units in general hospitals – the Irish experience. Irish Journal of Psychological Medicine 1992; 9: 129-34.
8. O’Beirne M, Fahy TJ. The impact of a general hospital psychiatric unit on established patterns of psychiatric care. Irish Journal of Psychological Medicine 1988; 5: 85-8.
9. Health Research Board. Activities of Irish Psychiatric Hospitals and Units. Dublin: Health Research Board 1988.
10. Feeney L, Kavanagh A, Kelly BD, Mooney M. Moving to a purpose built acute psychiatric unit on a general hospital site – does the new environment produce change for the better? Irish Medical Journal 2007; 100: 391-3.
11. Lyons D, El Sayed OA, Matthew VM. New unit on old ground or general hospital – where do patients want inpatient treatment? Irish Journal of Psychological Medicine 2001; 18: 129-31.
12. Walsh D, Daly A. Mental Illness in Ireland, 1750-2002: Reflections on the Rise and Fall of Institutional Care. Dublin: Health Research Board, 2004.
13. Walsh D. A revolution in mental care – 50 years of Irish psychiatry. Irish Medical Times 2007; 41: 32.
14. Expert Group on Mental Health Policy. A Vision for Change: Report of the Expert Group on Mental Health Policy. Dublin: The Stationery Office, 2006.
15. Guruswamy S, Kelly BD. A change of vision? Mental health policy. Irish Medical Journal 2006; 99: 164-6.
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