Real-world effectiveness of admissions to a tertiary treatment-resistant psychosis service: 2-year mirror-image study

Abstract

Background Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs. Aims This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures. Method Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system. Results Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = −8.099, P < 0.0001). Conclusions This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.

Effect of long-acting injectable antipsychotics on hospitalizations and global functioning in schizophrenia: a naturalistic mirror-image study

“…Also, in a mirror-image study, each patient serves as his or her own control, and observed changes from pre- to post-LAIs introduction may reflect regression to the mean. 57 Moreover, there are further biases in mirror-image studies, such as expectation biases, natural illness course, and time-effect. 25 …”

“…Fifth, owing to the nature of this study, we could not focus on the patients’ perspective or whether there was a specific component or components that yielded the positive outcome. 57 …”

Benign ethnic neutropenia: an analysis of prevalence, timing and identification accuracy in two large inner-city NHS hospitals

“…This can be likely attributed to differences in clinical practice, especially as previous studies have highlighted clinician knowledge, experience, and confidence as a significant barrier to clozapine treatment [26]. For example, SLaM hosts several specialist services, including the National Psychosis Service, a tertiary referral service with a special interest in clozapine rechallenge for whom this is deemed to be safe, often in close liaison with other medical specialities such as haematology [27]. Recent geographical data has demonstrated a substantial variation in clozapine prescription rates in the UK, with suggestions for a national training programme for clinicians and the implementation of a 'Hub and Spoke' model to improve clozapine management practices [28][29][30][31]..…”

“…Nevertheless, this estimate is likely to be confounded by other differentials such as BEN [19]. In the second half of the twentieth century, neutropenia was defined as an ANC value less than 1500/μL in individuals after the age of one [28], statistically determined as two standard deviations below the population mean at the time [27]. However, this classification system was originally developed in a largely Caucasian population and has consequently been recognised to preclude those with haematological variants such as BEN [27,37].…”

“…In the second half of the twentieth century, neutropenia was defined as an ANC value less than 1500/μL in individuals after the age of one [28], statistically determined as two standard deviations below the population mean at the time [27]. However, this classification system was originally developed in a largely Caucasian population and has consequently been recognised to preclude those with haematological variants such as BEN [27,37]. Such evidence led to the amending of clozapine guidelines in 2002 in the UK, which permitted more patients with BEN to have access to clozapine [1].…”