Minimum and optimal numbers of psychiatric beds: expert consensus using a Delphi process

An expert review of clozapine in Latin American countries: Use, monitoring, and pharmacovigilance

There is growing interest in clozapine clinical use, monitoring, and research, particularly adverse drug reactions (ADRs) other than agranulocytosis. In this study we focused on clozapine pharmacovigilance. Hence, we contacted clinicians and researchers in Latin America and requested information about local psychiatric services, clozapine availability, clinical use, and ADR monitoring with the VigiBase system. Only two countries have the minimum recommended number of psychiatric beds (15 per 100,000 residents): Uruguay (N = 34.9) and Argentina (N = 17). Bolivia is the only country where clozapine is unavailable. Nine out of twenty countries (45 %) reported ADRs to VigiBase. Argentina, Brazil, Chile, Colombia, and Mexico published national guidelines for schizophrenia treatment. Chile is the sole country with clozapine clinics with drug serum monitoring. Ethnicity-related drug titration in not described in package inserts in any country. We examined in detail the 9 most frequent and important clozapine ADRs in the worldwide database (pneumonia, sudden death, cardiac arrest, agranulocytosis, myocarditis, constipation, arrhythmia, seizure, and syncope). These 9 ADRs led to 294 reports with fatal outcomes in Argentina (N = 3), Brazil (N = 3), Chile (N = 2), and Peru (N = 1). Agranulocytosis was reported from 7 countries: constipation or seizures from 8 countries. Only two countries reported pneumonia and one country reported myocarditis. The number of clozapine reports in VigiBase has no relationship to the country's population. All Latin American countries underreport clozapine associated ADRs. Latin American governments, along with clinicians, researchers, and educators, should optimize clozapine use and monitoring for the benefit of people with severe mental and some neurological disorders.

Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal?

The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.

Types of Psychiatric Beds and Mental Health Services in 16 Latin American Countries, 1990-2020

OBJECTIVE

Latin America has undergone major changes in psychiatric services over the past three decades. The authors aimed to assess the availability of service data and changes in psychiatric services in this region during the 1990-2020 period.

METHODS

The authors formed a research network to collect data on psychiatric service indicators gathered between 1990 and 2020 from national registries in Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, and Uruguay. Indicators included psychiatric beds in psychiatric and general hospitals overall, for children and adolescents, and for forensic populations; residential beds for substance use treatment; treatment slots in residential facilities and day hospitals; and outpatient facilities.

RESULTS

Data availability varied among countries, service indicators, and time points. The median prevalence of psychiatric beds decreased in psychiatric hospitals from 5.1 to 3.0 per 100,000 people (-42%) and in general hospitals from 1.0 to 0.8 (-24%). The median prevalence estimates of specialized psychiatric beds for children and adolescents (0.18) and for forensic populations (0.04) remained unchanged. Increases in prevalence were observed for residential beds for substance use treatment (from 0.40 to 0.57, 43% increase), available treatment slots in residential facilities (0.67 to 0.79, 17%), treatment slots in day hospitals (0.41 to 0.54, 32%), and outpatient facilities (0.39 to 0.93, 138%).

CONCLUSIONS

The findings indicate that treatment capacity shifted from inpatient to outpatient and community care. Most countries had a bed shortage for acute psychiatric care, especially for children and adolescents and forensic patients. More comprehensive and standardized mental health service registries are needed.

Addressing the Knowledge Deficit in Hospital Bed Planning and Defining an Optimum Region for the Number of Different Types of Hospital Beds in an Effective Health Care System

Based upon 30-years of research by the author, a new approach to hospital bed planning and international benchmarking is proposed. The number of hospital beds per 1000 people is commonly used to compare international bed numbers. This method is flawed because it does not consider population age structure or the effect of nearness-to-death on hospital utilization. Deaths are also serving as a proxy for wider bed demand arising from undetected outbreaks of 3000 species of human pathogens. To remedy this problem, a new approach to bed modeling has been developed that plots beds per 1000 deaths against deaths per 1000 population. Lines of equivalence can be drawn on the plot to delineate countries with a higher or lower bed supply. This method is extended to attempt to define the optimum region for bed supply in an effective health care system. England is used as an example of a health system descending into operational chaos due to too few beds and manpower. The former Soviet bloc countries represent a health system overly dependent on hospital beds. Several countries also show evidence of overutilization of hospital beds. The new method is used to define a potential range for bed supply and manpower where the most effective health systems currently reside. The method is applied to total curative beds, medical beds, psychiatric beds, critical care, geriatric care, etc., and can also be used to compare different types of healthcare staff, i.e., nurses, physicians, and surgeons. Issues surrounding the optimum hospital size and the optimum average occupancy will also be discussed. The role of poor policy in the English NHS is used to show how the NHS has been led into a bed crisis. The method is also extended beyond international benchmarking to illustrate how it can be applied at a local or regional level in the process of long-term bed planning. Issues regarding the volatility in hospital admissions are also addressed to explain the need for surge capacity and why an adequate average bed occupancy margin is required for an optimally functioning hospital.

Understanding the mix of services for mental health care in urban DR Congo: a qualitative descriptive study

BACKGROUND

Mental health workers (MHWs) are exposed to conflicts of competence daily when performing tasks related to the provision of mental health services. This may be linked to a lack of understanding of their tasks as caregivers and providers. Furthermore, in most low-income settings, it is unclear how the available services are organized and coordinated to provide mental health care. To understand the above, this study aimed to identify the current mix of services for mental health care in the urban Democratic Republic of the Congo (DRC).

METHODS

A qualitative descriptive study was carried out in Lubumbashi from February to April 2021. We conducted 7 focus group discussions (FGDs) with 74 key informants (family members, primary care physicians, etc.) and 13 in-depth interviews (IDIs) with key informants (traditional healers, psychiatrists, etc.). We performed a qualitative content analysis, guided by an analytical framework, that led to the development of a comprehensive inventory of MHWs from the household level to specialized facilities, exploring their tasks in care delivery, identifying existing services, and defining their current organization.

RESULTS

Analysis of transcripts from the FGDs and IDIs showed that traditional healers and family caregivers are the leading providers in Lubumbashi. The exploration of the tasks performed by MHWs revealed that lifestyle, traditional therapies, psychotherapy, and medication are the main types of care offered/advised to patients. Active informal caregivers do not currently provide care corresponding to their competencies. The rare mental health specialists available do not presently recognize the tasks of primary care providers and informal caregivers in care delivery, and their contribution is considered marginal. We identified five types of services: informal services, traditional therapy services, social services, primary care services, and psychiatric services. Analyses pointed out an inversion of the ideal mix of these services.

CONCLUSIONS

Our findings show a suboptimal mix of services for mental health and point to a clear lack of collaboration between MHWs. There is an urgent need to clearly define the tasks of MHWs, build the capacity of nonspecialists, shift mental health-related tasks to them, and raise awareness about collaborative care approaches.

The 2023 New Zealand psychiatry of old age services and workforce survey

OBJECTIVE

The primary objective was to survey the Psychiatry of Old Age (POA) service resources in New Zealand: number of psychiatrists, inpatient beds, and community psychogeriatric beds. A secondary objective was to compare the POA service resources reported by frontline clinicians with official government data.

METHODS

The New Zealand Branch of Faculty of POA collected information from a POA representative in each of the 20 districts, along with official government data.

RESULTS

Information from 17 services were obtained. POA service resources varied greatly between districts. There were discrepancies between the New Zealand Branch of Faculty of POA and official government data. The number of old age psychiatrist FTEs per 10,000 older adults ranged from 0.3 to 1.1 (mean = 0.7). The number of inpatient beds per 10,000 older adults ranged from 0.0 to 4.1 (mean = 1.6); and the number of psychogeriatric beds per 10,000 older adults ranged from 0.0 to 22.7 (mean = 12.6).

CONCLUSIONS

There is an urgent need to address the official government data discrepancies and POA service resource inequalities. This can ensure the "postcode" system that determines psychiatric care for older adults can be effectively eliminated. We also found the number of POA inpatient beds is below the internationally recommended level.

Australian older persons mental health inpatient and ambulatory services in 2015-2020 - A descriptive analysis and commentary

OBJECTIVE

To provide a commentary on Australian state/territory older persons mental health service (OPMHS) expenditure, inpatient and outpatient services and key performance indicators (KPIs).

METHOD

Descriptive analysis of data from the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics and the World Health Organisation.

RESULTS

Between 2015-16 and 2019-20, annual expenditure on OPMHS in Australia increased by an average of only 2.3%, compared to 2.9% for all population groups, despite an increase in the number of over 65 year olds. Per capita recurrent expenditure on OPMHS decreased by an average of 1% annually. Australia's total mental health beds increased, whereas OPMHS beds decreased, mainly due to a reduction in non-acute beds. Outcomes for OPMHS admissions were similar to other age groups, except for a longer length of stay and reduced readmission rate. Older Australians accessed ambulatory mental health care at a lower rate and had a lower rate of improvement after a completed episode.

CONCLUSIONS

OPMHS expenditure has not increased at commensurate levels compared to other populations. The mental health of people aged over 65 appears to be a neglected policy priority in Australia. The Royal Commission into Aged Care Quality and Safety may herald service and expenditure changes.

Acquired Pedophilia: international Delphi-method-based consensus guidelines

Idiopathic and acquired pedophilia are two different disorders with two different etiologies. However, the differential diagnosis is still very difficult, as the behavioral indicators used to discriminate the two forms of pedophilia are underexplored, and clinicians are still devoid of clear guidelines describing the clinical and neuroscientific investigations suggested to help them with this difficult task. Furthermore, the consequences of misdiagnosis are not known, and a consensus regarding the legal consequences for the two kinds of offenders is still lacking. The present study used the Delphi method to reach a global consensus on the following six topics: behavioral indicators/red flags helpful for differential diagnosis; neurological conditions potentially leading to acquired pedophilia; neuroscientific investigations important for a correct understanding of the case; consequences of misdiagnosis; legal consequences; and issues and future perspectives. An international and multidisciplinary board of scientists and clinicians took part in the consensus statements as Delphi members. The Delphi panel comprised 52 raters with interdisciplinary competencies, including neurologists, psychiatrists, neuropsychologists, forensic psychologists, expert in ethics, etc. The final recommendations consisted of 63 statements covering the six different topics. The current study is the first expert consensus on a delicate topic such as pedophilia. Important exploitable consensual recommendations that can ultimately be of immediate use by clinicians to help with differential diagnosis and plan and guide therapeutic interventions are described, as well as future perspectives for researchers.

Penumbra of the pandemic workplace for psychiatrists and trainees in Australia

OBJECTIVE

A commentary on the workforce, infrastructure and health of psychiatrists and trainees providing psychiatric care during the COVID-19 pandemic in Australia.

CONCLUSIONS

The wide-ranging workplace, health system and societal changes necessitated by the SARS-CoV-2 virus have altered the practice and working lives of psychiatrists, trainees and other healthcare workers, as well as the general population. There have been workplace innovations, recalibrations and losses. There is a new baseline upon which to build better psychiatric services, as the pandemic's penumbra recedes.

Specialised psychiatric beds and 24-hour residential care in Australia 2018-2019 - Comparative analysis and commentary according to international benchmarking

OBJECTIVE

A commentary on Australian specialised private and public psychiatric acute and non-acute inpatient care, and 24-hour-staffed community residential care with regard to international benchmarks.

METHOD

Descriptive analysis of specialised psychiatric beds from the Australian Institute of Health and Welfare (AIHW) with the WHO Mental Health Atlas 2020, and an international Delphi consensus on optimal and minimal psychiatric beds per capita.

RESULTS

Australian private sector beds have shown a 3.8% annual growth rate from 2014-15 to 2018-19, in contrast to relatively static public sector bed numbers. Australia's national combined public and private psychiatric bed number (hospital acute and non-acute, and 24-hour-staffed community residential) of 48.8 per 100,000 population is lower than the WHO European (100.6) and World Bank High Income (69.2) medians, due to fewer community residential and non-acute beds. Australia's 40.9 general and stand-alone psychiatric beds per 100,000 are below the Delphi consensus optimal level of 60 beds per 100,000, but above the bed shortage threshold (30 per 100,000).

CONCLUSIONS

Rising bed numbers in private hospitals have contributed to Australian psychiatric inpatient capacity, although the level remains below comparable international medians. Recent initiatives to increase psychiatric bed numbers may signal a policy shift in the public sector, complementary to private and community care.

Changes in rates of psychiatric beds and prison populations in sub-Saharan Africa from 1990 to 2020

Background

Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020.

Methods

We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels.

Results

Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries.

Conclusions

SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.

Real-world performance of Victorian hospitals during the COVID-19 lockdowns

OBJECTIVE

Victoria has low numbers of general adult psychiatric beds per capita by Australian and international standards. Hospital key performance indicators (KPIs) such as bed occupancy rates, emergency department waiting times and inpatient lengths of stay are proximal measures of the effects any shortfall in beds. We investigate the real-world performance of Victorian hospitals during the first year of the COVID-19 pandemic and the extended lockdowns in 2020.

CONCLUSIONS

The Victorian inpatient psychiatric system is characterised by high bed occupancies in many regions, extended stays in emergency departments awaiting a bed, and short inpatient lengths of stay, except for patients with excessively long stays on acute units (over 35 days) who are unable to be admitted to non-acute facilities. At the end of 2020, bed occupancies were high (above 90%) in 10 regions, with three regions having bed occupancies over 100%. However, state-wide average bed occupancy improved between 2019 (94%) and 2020 (88%). Other KPIs remained steady because acute hospitals did not experience the expected pandemic mental health demand-surge. For a more complete picture of the impact of the pandemic, Australia needs interconnected, centralised data systems.