the brief admission unit in emergency psychiatry

The Brief Admission Unit in Emergency PsychiatryÄ

Patrick Clarke, R. Julian Hafner, and Gwili HolmeDibden Research Unit, Glenside Hospital, Eastwood, Australia

The study evaluates a Brief Admission Unit for clients of an emergencyservice located within a comprehensive community psychiatric program.Eighty-five clients completed the Brief Symptom inventory and a struc-tured interview. Substance abuse disorder (n 5 29) and major depression(n 5 24) were the most common Axis I diagnoses, of which 30 subjectshad two or more. Sixty subjects had an Axis II diagnosis. Mean duration ofadmission was 3.9 days, compared with the average in other acute unitsof 11.5 days. At discharge, half the subjects were rated as moderately togreatly improved and client satisfaction was high. The unit was crucial tothe psychiatric emergency service and had a key role in relieving pressureon beds elsewhere within the system. © 1997 John Wiley & Sons, Inc.J Clin Psychol 53: 817–823, 1997

The first outcome study of a brief admission unit for emergency psychiatric treatment waspublished by Weisman, Feirstein and Thomas (1969), over 25 years ago. The seven bed unit’saims were to avoid the dependency linked with longer admissions and to facilitate rapid crisisresolution by providing intensive, skilled therapy. The mean length of stay was 3 days. Diag-nostically, 32% of patients had schizophrenia, 24% had “neurotic depression,” and 5% had acharacter disorder. Uncontrolled follow-up over 2 years showed that readmission rates werevery similar to those reported by units with much longer mean lengths of stay. In the firstcontrolled study, Herz, Endicott & Gibbon (1977) randomly allocated 175 patients living withtheir families to brief (mean 11 days) or standard (mean 60 days) hospital admission. During atwo-year follow-up, patients briefly admitted spent a mean of 37 days in hospital, comparedwith 115 days for those who had a standard admission. Diagnostically, 63% had schizophrenia;patients with alcoholism, drug abuse or “antisocial personality” were not admitted, adding tothe bias created by the requirement that patients lived with their families. Bryson et al. (1990)conducted a similar but uncontrolled study of 147 patients admitted to a 12–15 bed brief admis-sion unit for a mean of 9.9 days. Sixty-five percent had schizophrenia; patients with character-

We should like to acknowledge the invaluable contribution of Dr. David Ash to the establishment of the Brief Admis-sion Unit.Corresponding author and reprint requests to R. Julian Hafner, Dibden Research Unit, Glenside Hospital, PO Box 17,Eastwood SA 5063, Australia.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 53(8), 817–823 (1997)© 1997 John Wiley & Sons, Inc. CCC 0021-9762/97/080817-07

ological or primary substance abuse disorder were not admitted, because of initial negativeexperiences. The unit functioned as an adjunct to case-management in the community, its mainfocus being chronically ill patients with social or interpersonal crises. Informal evaluationshowed that both patients and case managers greatly valued ready access to a bed in the unit.

The two other studies that we located concerned units directly linked to an emergencyservice. Rhine and Mayerson (1971) reported outcome over 12 months follow-up for 200 patientsadmitted to an 11 bed unit with aims identical to those of Weisman, et al. (1969). Twenty-fivepercent of patients had a diagnosis of schizophrenia, 20% of “neurosis,” 14% of characterdisorder, and 13% of transient situational disturbance. Outcome was substantially better forthose patients (about 55%) admitted directly from the psychiatric emergency room. Breslow,Klinger and Erickson (1993) described 102 consecutive admissions to an eight bed unit with amaximum stay of 4 days. Twenty-nine percent of patients had schizophrenia and 69% had aprimary diagnosis of personality disorder. As well as avoiding dependency and facilitatingrapid crisis resolution, the unit clarified diagnoses, gave respite to carers and providers ofcommunity psychiatric services, and relieved pressure on adjacent inpatient units.

The present study describes a brief admission unit that is part of a psychiatric emergencyservice. It aims to assess the unit’s value in the context of a comprehensive community mentalhealth program.

METHOD

Setting and Subjects

The brief admission unit comprised six dedicated beds on the campus of a metropolitan psy-chiatric hospital, Glenside, located in Adelaide, a city of one million people. Campus facilitiesinclude a state-wide psychiatric emergency service with a “walk-in” facility open 24 hours.Nearly all admissions to the unit (about 60 a month during 1994) come through the emergencyservice, which also serves as the point of access to psychiatric inpatient services for communitytreatment teams unable to admit patients to facilities within their catchment area. About 18% ofall referrals to the emergency service are admitted to the brief admission unit, designed primar-ily for patients in crisis; those with an acute psychotic illness or in delirium are excluded.Patients were informed very early in their admission of a planned discharge date, and interven-tions were geared to this. After careful diagnostic assessment, a management plan was formu-lated which included medication for symptom relief, crisis intervention, counselling, involvementof family and support networks, and liaison with other health and social services. To achievethis, the unit was well staffed during the day, with two psychiatric nurses, a .4 time consultantpsychiatrist, a .5 time trainee psychiatrist, and a .5 time social worker all specially trained todeal with challenging behaviors such as splitting and acting out. The present study is based on85 consecutive admissions over a 6 week period; 44 subjects were women; mean age was33.96 10.9 (range 15–63).

Measures

The Brief Symptom Inventory (BSI)(Derogatis & Spencer, 1982). This self-report question-naire comprises 53 items reflecting a wide range of psychiatric symptoms. It is well-developedpsychometrically, and yields scores on 10 subscales, condensable to a single measure termedthe global severity index (GSI).

The Brief Admission Unit Assessment Schedule.This structured interview schedule was devel-oped specifically for the present study. It comprised 60 questions seeking demographic, bio-

818 Journal of Clinical Psychology, December 1997

graphical, social, interpersonal, occupational, treatment and outcome data. A mixture of open-ended and forced-choice questions was used, the latter employing three- or five-point equal-interval scales. The structured interviews were conducted by the first author. Diagnoses werebased on DSM-IV criteria; occasional diagnostic dilemmas were resolved through consultationwith experienced psychiatrists working within the service.

RESULTS

Demographic Data

Eighty subjects were Caucasian, 5 Aboriginal. Thirty-seven had never married; 25 were cur-rently married (including de facto); 21 were separated or divorced; 2 were widowed. Four hadonly primary education; 59 had achieved secondary level and 15 tertiary; 7 had trade certifi-cates. Only 11 were employed; 2 were students. Twenty-three received unemployment benefitsand 50 sickness benefits or disability support. Fifteen owned their dwellings; 38 rented (19alone and 19 sharing); 16 lived with friends or relatives; 4 lived in hostels; 12 had no fixedaddress.

Clinical and Biographical Data

Main Axis I Diagnoses.Major depression: 24 (12 women); adjustment disorder: 10 (4 women);polysubstance and alcohol abuse: 14 (6 women); bipolar disorder: 4; schizophrenia: 3; otherpsychoses: 6. Eight other diagnostic categories attracted only one or two subjects. Thirty sub-jects had a second Axis I diagnosis, of which by far the commonest was polysubstance andalcohol abuse (15; 4 women). Fourteen subjects (12 women) had no Axis I diagnosis; all ofthese had an Axis II diagnosis.

Axis II Diagnoses.Borderline personality disorder: 28 (25 women); antisocial personality dis-order: 18 (no women); dependent personality disorder: 14 (6 women). Twenty-five subjects (13women) had no Axis II diagnosis. The excess of borderline personality disorder in women, andof antisocial personality disorder in men, was highly significant (x2[5] 5 35.6;p , .0000).

Referral Source.Nineteen subjects were self-referred; 13 were referred by a general practi-tioner; 7 by relatives or friends, 5 by police, 10 by private psychiatrists, 16 from generalhospitals, 8 from community treatment teams, 6 from elsewhere on the campus, and 2 fromdrug and alcohol services. Fifty-nine subjects were voluntary and 26 detained (13 women); 3were currently under community treatment orders.

Psychiatric History.Mean age at onset of psychiatric disorder was 23.56 11.4 and mean ageat first admission to a psychiatric unit was 29.06 11.3. Fifty-nine subjects had been previouslyadmitted to a psychiatric unit (mean number of previous admissions was 4.36 7.4, of which1.6 6 3.6 were involuntary admissions). Nineteen subjects had only one previous admission;23 had between 2 and 6; 11 had between 7 and 24; and 6 had 25 or more. Fifty-seven subjectshad previously visited a psychiatrist in a public or private outpatient setting; 32 had previouslyattended a clinical psychologist. Fifty-nine subjects (29 women) reported a mean of 7.56 1.6previous attempts at suicide; 55 of these had either taken an overdose (n 5 28), cut themselves(n 5 7), or done both (n 5 20).

Substance Abuse and Forensic History.Only 10 men and 13 women reported a regular dailyalcohol intake of more than three standard drinks a day; 20 men and 12 women reported

Brief Admission Unit 819

occasional or regular use of marijuana; 9 men and 3 women reported occasional or regular useof amphetamines; and 6 men and 2 women reported some use of opiates. Thirty subjects (8women) admitted to at least one conviction for a criminal offense; 21 (4 women) had beenimprisoned; and 31 (10 women) reported a history of carrying out physical assaults.

Physical and Sexual Abuse.Forty-two subjects (23 women) reported significant childhoodphysical abuse or neglect; 33 subjects (23 women) reported significant childhood sexual abuse.Twelve subjects (10 women) said that they had experienced a significant physical assault withina week prior to their admission. Fifty-seven subjects (31 women) reported one or more signif-icant physical assaults over the previous 5 years. Of the women, 37% were assaulted by theirpartner and 7% by a stranger; of the men, 8% were assaulted by their partner, and 62% by astranger (x2[1] 5 12.2,p , .001).

Clinical Picture on Admission.Asked the main reason for their admission, 38 patients reportedacute depression or dangerously self-destructive feelings, usually because of interpersonal cri-ses. A further 41 needed help in coping with a wide range of crises, most commonly interper-sonal, but not infrequently of a practical kind relating to accommodation or finances. Staffjudged that only 15 admissions were inappropriate; 14 of these were transfers from generalhospitals.

On 1–5 scales measuring psychoticism, depression, anxiety, and dangerousness to self, 7subjects were rated as slightly psychotic (scale point 2) and 6 as moderately psychotic (scalepoint 3). Twenty-four were rated as slightly depressed, 29 as moderately, 15 as very (scalepoint 4) and 5 as acutely depressed (scale point 5). Seventeen were rated as slightly anxious, 54as moderately or very anxious, and 3 as acutely anxious. Twenty-five were rated as slightlydangerous to themselves, 17 as moderately or severely, and 4 as acutely.

Treatment, Attitudes and Outcome

Asked if they believed they had a psychiatric illness, 28 patients said definitely, 17 probably, 19“don’t know,” and 21 probably or definitely no. Asked to what extent they took responsibilityfor managing their mental health problems, 21 said all of the responsibility, 32 said at least half,11 said some, and 20 said very little.

Mean duration of admission was 3.9 days; 58 patients stayed 1–3 days; 13 stayed 4 days;and 14 stayed 5 or 6 days. Nineteen patients were transferred to beds elsewhere; 21 went to newaccommodation in the community. Thirty-four were referred to a community treatment teamand 21 to a private psychiatrist. In only three cases was disposal viewed as unsatisfactory,although many patients were not referred to an optimal service, usually because it was unavail-able. For example, 23 patients required cognitive-behavioral psychotherapy for specific prob-lems, but only seven could be referred.

Asked to rate the overall value of the admission, 12 patients said that it was unhelpful, 24said slightly helpful, 30 said fairly helpful, and 16 said very helpful (n 5 82). Based on con-sultation with staff, the first author made a global rating of the extent of each patient’s improve-ment on a 1–5 scale. Twelve patients were judged to be worse or unchanged, 28 as slightlyimproved, 36 as moderately improved, and 6 as greatly improved (n 5 82). None met thecriteria for scale point five, namely full recovery. Discharge medication is summarized inTable 1.

The Brief Symptom Inventory (BSI)

The BSI manual reports means and standard deviations for a general psychiatric inpatientsample of 310. These scores, reproduced in Table 2, are not given by sex. Patients in the present


study scored higher than the comparison sample on every subscale, and these differences werehighly statistically significant for the general severity index (males:t [348] 5 4.5; p , .001;females:t [350] 5 5.2,p , .001), and for the depression, phobic anxiety, hostility, interpersonalsensitivity, paranoid ideation and psychoticism subscales (allp , .001). None of the male-female differences was statistically significant.

DISCUSSION

According to both patients’ own ratings and those of staff, the unit achieved quite successfullyits main goal of facilitating rapid crisis resolution. Only 12 patients (14%) judged that theiradmission was unhelpful; the remainder made positive judgments about it. Twelve patientswere judged by staff to be unchanged or worse at discharge, the others improved. Althoughdisposal was not always optimal, usually because required treatment resources were not avail-able, in only three cases did staff judge it to be unsatisfactory. These results were obtained aftera mean stay of 3.9 days, compared with a mean of 11.5 days for adult acute inpatients serviceselsewhere on the campus. The absence of follow-up data precludes an assessment of the unit’svalue in helping to reduce patients’ dependency on inpatient hospital treatment.

It might be argued that the generally satisfactory short-term outcome of brief admissionwas a reflection of relatively mild psychiatric disorder. However, the mean Brief Symptom

Table 1. Medication on Discharge

MedicationNumber

of PatientsMean and Range

per 24 hours (mg)

Major Tranquilizers (Haloperidol equivalent) 20 3.8 (.5–20)Benzodiazepines (Diazepam equivalent) 25 17.0 (5–40)Tricyclics 16 85 (25–225)SSRI’s 15 —Moclobomide 6 625 (300–1200)Carbemazepine 5 560 (300–900)Lithium Carbonate 3 833 (750–1000)

Table 2. Brief Symptom Inventory Scores (n = 82)

Subscale Male M Female MInpatient Sample

(n = 310)

Depression 2.6 (1.3) 2.6 (1.1) 1.9 (1.2)Generalized Anxiety 2.0 (1.1) 2.2 (.9) 1.7 (1.2)Phobic Anxiety 1.6 (1.2) 1.8 (1.1) 1.1 (1.0)Somatization 1.2 (.8) 1.3 (.8) 1.0 (.9)Obsessive-Compulsive 2.0 (1.1) 2.2 (1.0) 1.6 (1.1)Hostility 1.7 (1.1) 1.6 (1.1) 1.0 (1.0)Interpersonal Sensitivity 2.3 (1.2) 2.4 (1.2) 1.5 (1.1)Paranoid Ideation 1.7 (.9) 2.0 (.9) 1.3 (1.2)Psychoticism 1.9 (1.1) 2.0 (1.0) 1.3 (1.0)General Severity Index 1.9 (.9) 2.0 (.8) 1.4 (.9)

Standard deviations in parentheses.


Inventor (BSI) scores were significantly and substantially higher than those reported by ageneral psychiatric inpatient sample, suggesting a greater than average severity of psychiatricdisorder. The high level of comorbidity is further evidence that the subjects were, at the time oftheir admission, suffering from relatively severe psychiatric disorder, and a majority had sev-eral previous admissions. Table 1 shows that even after crisis resolution, most patients requiredcontinuing medication, aimed usually at ameliorating residual symptoms of anxiety or depression.

In Adelaide, community psychiatric services are quite well developed, with key workersproviding case management for nearly all clients who require it, although there is a waiting listin some areas. Community services are supported by 200 beds for acute admissions, most ingeneral hospitals. This yields 20 beds per 100,000 adult population which, although within therecommended range, is rarely sufficient to meet demand. Case managers and community basedpsychiatrists greatly valued the unit as an alternative when beds within their own catchmentarea service were not available. Fourteen of the 15 admissions judged inappropriate were fromthe emergency rooms of general hospitals. These were rarely negotiated beforehand but basedon involuntary detention orders. This unsatisfactory state of affairs reflected the pressure onbusy emergency rooms to transfer psychiatric patients as quickly as possible.

Twenty-two percent of admissions to the unit were the result of self-referral to the campusbased emergency service. This proportion of referrals is unlikely to be reduced by furtherdevelopment of community psychiatric services, and neither are those from clients’ relatives,the police, private psychiatrists, or general hospitals. The emergency psychiatric service is amajor, highly visible interface between quality care for acute psychiatric disturbance and thegeneral public, clients and their relatives, the police, and other medical and social services. It isa very demanding area to work in, and emergency unit staff found the brief admission unitinvaluable, not only for those who obviously needed acute inpatient treatment, but to allowobservation of those whose diagnosis or levels of dangerousness to themselves (or, occasion-ally, to others) was uncertain. Knowing that their reasonable requests for admission were likelyto be met enhanced the morale of emergency staff, together with the quality of the service thatthey were able to provide.

The few significant sex differences between men and women that occurred among ourmeasures are of interest. Ten women, but only two men, reported a serious physical assaultwithin the week prior to admission, although almost equal proportions of men and womenreported serious assaults over the previous 5 years. Women were five times more likely thanmen to be assaulted by their partner, and men were nine times more likely than women to beassaulted by a stranger. Over half the women, but less than a quarter of the men, reported afamily background of both physical and sexual abuse. These data illustrate the role of domesticviolence in the women’s crises, and help to explain the huge excess of borderline personalitydisorder in women, and of antisocial personality disorder in men. It will be recalled that 18men, and no women, were given a diagnosis of antisocial personality disorder, the validity ofwhich was usually sustained by a long history of antisocial behavior, including imprisonmentin most cases.

Nearly two-thirds of subjects said that they took most or all of the responsibility for man-aging their mental health problems and it was generally from this group that a demand emergedfor specific treatment after discharge. Although this was often met, 14 clients who clearlyrequired cognitive-behavioral therapy could not be provided with it because of inadequateresources in this area. Improved training of case managers would allow them to treat selectedclients with cognitive-behavioral therapy (Gournay & Brooking, 1994; Linehan et al., 1991;Muijen et al., 1994), perhaps ultimately reducing the demand for inpatient beds.

To conclude, the brief admission unit was a crucial component of a comprehensive com-munity psychiatric service. Particularly important roles were relieving pressure on psychiatricbeds elsewhere within the system and facilitating the work of the emergency team. Overall, it


provided a service to a broad diagnostic range of seriously mentally ill clients, a service thatthey judged very favorably, and which involved admissions much shorter than the average. Itwas particularly helpful in treating clients who needed admission for acute crises, but who wereotherwise mainly free of psychiatric disorder (Suokas & Lönnqvist, 1995). Such clients are notgenerally suited for community treatment orders or case management. We hope that thesefindings will be of interest to those planning or developing comprehensive community psychi-atric services.

REFERENCES

Breslow, R.E., Klinger, B.I., & Erickson, B.J. (1993). Crisis hospitalization on a psychiatric emer-gency service.General Hospital Psychiatry, 15, 307–315.

Bryson, K.K., Naqvi, A., Callaghan, P., & Fontenot, D. (1990). Brief admission program. Analliance of inpatient care and outpatient case management.Journal of Psychosocial Nursing, 28,19–23.

Derogatis, L.R., & Spencer, B.S. (1982).The Brief Symptom Inventory (BSI). Administration, scoringand procedures manual.Baltimore: Clinical Psychometric Research.

Gournay, K., & Brooking, J. (1994). Community psychiatric nurses in primary health care.BritishJournal of Psychiatry, 165, 231–238.

Herz, M.I., Endicott, J., & Gibbon, M. (1977). Brief hospitalization: A two-year follow-up.AmericanJournal of Psychiatry, 134, 502–507.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients.Archives of General Psychiatry,48, 1060–1064.

Muijen, M., Cooney, M., Strathdee, G., Bell, R., & Hudson, A. (1994). Community psychiatricnurse teams: Intensive support versus generic care.British Journal of Psychiatry, 165, 211–217.

Rhine, M.W., & Mayerson, P. (1971). Crisis hospitalization within a psychiatric emergency service.American Journal of Psychiatry, 127, 1386–1391.

Suokas, J., & Lönnqvist, J. (1995). Suicide attempts in which alcohol is involved: A special group ingeneral hospital emergency rooms.Acta Psychiatrica Scandinavica, 91, 36–40.

Weisman, G., Feirstein, A., & Thomas, C. (1969). Three-day hospitalization—A model for intensiveintervention.Archives of General Psychiatry, 21, 620–629.


the brief admission unit in emergency psychiatry

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